Scurvy!! and CHF Exacerbation!!

Patient 1

Patient: 67-year-old female
Chief Complaint: Personality changes, bruises, skin rash
Source of History: Daughter (lives out of state) and limited input from patient

History of Present Illness

• Daughter noted increasing irritability, fatigue, generalized pain (arms/legs), rash, and bruising.

• Foul-smelling breath, unkempt appearance, withdrawn affect.

• Patient gives minimal responses, often single words.

• Lives alone, independent with shopping/cooking.

Past Medical History

• Depression (no current therapy)

• No known chronic medical conditions

• No medications, denies OTC or supplements

Social History

• Non-smoker, no alcohol or illicit drug use

• Recluse, lives alone

Review of Systems (from daughter + limited patient input)

• No recent infections

• No falls reported

• No visitors or caregivers involved

Exam

• Vitals: Stable

• General: Appears older than stated age, poorly groomed

• HEENT: Gingival swelling, red discoloration, halitosis

• Skin: Scattered bruising (forearms, buttocks), petechial rash on lower extremities

• Lungs/Abdomen: Normal

• Neuro: Alert, oriented, downcast affect

• No lymphadenopathy or splenomegaly

Differential Diagnosis (SPIT approach)

Serious:

• ITP/TTP

• Vasculitis

• Sepsis

• Leukemia

• DIC

• Intracranial bleed/trauma

• Non-accidental trauma/elder abuse

Probable:

• Vitamin deficiency (esp. Vitamin C deficiency)

• Depression with self-neglect

• Medication effect (undisclosed use, e.g., aspirin, phenytoin)

• Liver disease

Interesting/Teaching Pearls:

• Acute intermittent porphyria

• Scurvy

Workup

• Labs: CBC, CMP, coagulation studies, UA, toxicology screen, salicylate, acetaminophen, EtOH level, vitamin C level (rarely ordered, delayed result)

• Imaging: CT head (no acute findings, mild atrophy), CXR

• Other: Blood cultures

Results:

• Mild normocytic, normochromic anemia (Hgb 11.9)

• Normal platelets, normal CMP, normal UA

• Negative tox screen

• Normal CT head (aside from mild atrophy)

Impression

• High suspicion for scurvy (vitamin C deficiency) given: gingival inflammation, foul breath, bruising, petechiae, poor diet history, and social isolation.

Management

• Start high-dose vitamin C: 250 mg PO daily × 1 week, then maintenance (75 mg/day for women, 90 mg/day for men).

• Consider IV vitamin C if malabsorption suspected.

• Nutrition and psychosocial support.

• Admit for observation and further evaluation (elder abuse, malnutrition, depression).

Outcome:

• Bleeding stopped within 2 days of vitamin C supplementation.

• Discharged with daily supplementation and follow-up.

Patient 2

Patient: 45-year-old male
Chief Complaint: Shortness of breath × 5 days

History of Present Illness

• Gradual onset → now at rest.

• No chest pain, cough, or fever.

• Known congestive heart failure (secondary to chemotherapy for Hodgkin’s lymphoma 20 yrs ago).

• Medications: furosemide, lisinopril, potassium (reports adherence).

• Denies alcohol, tobacco, or illicit drugs.

Past Medical History

• Hodgkin’s lymphoma (treated with chemo + radiation, in remission)

• Asymptomatic mitral regurgitation

• CHF (chemo-related cardiomyopathy)

Exam

• Vitals: Stable except SpO₂ 95% RA (improved with O₂)

• Neck: JVD

• Lungs: Decreased breath sounds at bases

• CV: Loud holosystolic murmur

• Abdomen: Normal, no hepatosplenomegaly

• Extremities: Mild bilateral pitting edema

Differential Diagnosis (SPIT)

Serious:

• Acute decompensated CHF

• Cardiac tamponade

• Pulmonary embolism

• Myocarditis/endocarditis

Probable:

• Volume overload/medication noncompliance

• Recurrent malignancy

Interesting/Teaching Pearls:

• Chagas disease

• “Vanishing tumor” (pseudotumor due to fissural effusion)

Workup

• EKG

• CXR: Cardiomegaly, pleural effusions, apparent right-sided “mass”

• Bedside echo/ultrasound: Dilated heart, B-lines, pericardial effusion, fluid in fissure

• Labs: CMP, CBC, BNP, troponin, coagulation studies

Key History Additions

• No recent chest pain, weight loss, fevers, night sweats, IV drug use, or procedures.

• Later admits to self-adjusting furosemide dose (reduced to avoid nocturia).

Impression

• Acute decompensated heart failure with pleural effusion mimicking a mass (“vanishing tumor”).

Management

• Admit for inpatient care

• IV diuretics (adjust furosemide dosing)

• Oxygen as needed

• Monitor renal function and electrolytes

• Reassess imaging after diuresis

Outcome:

• Mass resolved after diuresis (confirmed by repeat imaging).

• Diagnosis: Phantom/vanishing tumor—loculated pleural effusion in interlobar fissure.

 These cases highlight:

• Importance of broad differential + structured SPIT approach.

• Value of considering uncommon but classic diagnoses (e.g., scurvy).

• Critical role of history (medication adherence, psychosocial context).

• Imaging pitfalls (pseudo-mass due to effusion).