A 79-year-old woman comes to the office for evaluation of difficulty walking due to fatigue and bilateral leg pain. The pain started in her lower legs 3 weeks ago and progressed to involve the muscles of her thighs also. In addition, she has noted red spots on her legs. The patient has lived alone since her husband died 3 years ago and is largely homebound. Her diet consists mostly of bread and canned meat products. On examination, the gums are swollen and tender. The patient's skin findings are shown in the exhibit.
Muscles of the lower limbs are tender to palpation. Imaging studies reveal a tibial subperiosteal hematoma. Which of the following nutrient deficiencies is most likely responsible for this patient's symptoms?

Question

A 79-year-old woman comes to the office for evaluation of difficulty walking due to fatigue and bilateral leg pain.  The pain started in her lower legs 3 weeks ago and progressed to involve the muscles of her thighs also.  In addition, she has noted red spots on her legs.  The patient has lived alone since her husband died 3 years ago and is largely homebound.  Her diet consists mostly of bread and canned meat products.  On examination, the gums are swollen and tender.  The patient's skin findings are shown in the exhibit. 
 Muscles of the lower limbs are tender to palpation.  Imaging studies reveal a tibial subperiosteal hematoma.  Which of the following nutrient deficiencies is most likely responsible for this patient's symptoms?

Quizplus · Accepted Answer

This patient with perifollicular hemorrhages, myalgias, subperiosteal hematoma, and gingivitis has typical features of scurvy. Scurvy, which is due to a deficiency of ascorbic acid (vitamin C), is uncommon in developed countries as this vitamin is widely available in fruits, vegetables, and a variety of other foods. However, it may occasionally be seen in patients with abnormal eating patterns, including the elderly, patients with alcohol use disorder, and persons who live alone. Other possible signs of scurvy include hemarthrosis, petechial hemorrhages, impaired wound healing, and weakened immune responses to local infections. Ascorbic acid is a cofactor in a number of reactions but is especially important in the hydroxylation of proline and lysine residues. In particular, synthesis of collagen requires extensive formation of hydroxyproline in the procollagen polypeptide, and ascorbic acid deficiency leads to reduced production of collagen with lower tensile strength. Collagen defects in blood vessel walls lead to widespread microvascular bleeding. (Choice B) Biotin plays a role in a number of carboxylation reactions. Deficiency is rare but can present with rash, hair loss, and neuropsychiatric defects. (Choice C) Folic acid deficiency is characterized by megaloblastic anemia and fetal neural tube defects. (Choice D) Linoleic acid is an essential fatty acid used in the synthesis of arachidonic acid. Deficiency is not well characterized, but reported features include growth deficiency and neurovisual defects. (Choice E) Pyridoxine (vitamin B₆) deficiency is characterized by cheilosis, glossitis, dermatitis, and peripheral neuropathy. (Choice F) Vitamin B₂ (riboflavin) deficiency is characterized by angular stomatitis, cheilitis, glossitis, seborrheic dermatitis, eye changes (eg, keratitis, corneal neovascularization), and anemia. (Choice G) Vitamin B₁ (thiamine) deficiency causes beriberi (peripheral neuropathy, muscle wasting, and heart failure), Wernicke syndrome (nystagmus, ataxia, and ophthalmoplegia), and Korsakoff psychosis. (Choice H) Vitamin K deficiency is characterized by a bleeding diathesis (but not painful gums). (Choice I) Zinc deficiency is characterized by acrodermatitis enteropathica, growth retardation, and infertility. Educational objective: Ascorbic acid (vitamin C) is a cofactor in the hydroxylation of proline and lysine residues and is important in the synthesis of collagen. Deficiency (scurvy) is characterized by microvascular bleeding, gingivitis, and impaired wound healing.

A 79-Year-Old Woman Comes to the Office for Evaluation of Difficulty