Milk and honey: how skin changes reveal the deeper dangers of nutritional deficiencies

INTRODUCTION: The wide-reaching consequences of a restrictive diet are often underestimated or poorly recognized both by the public and many physicians. Deficiency symptoms may go unnoticed leading to unnecessary investigations and ineffective treatments, and a delay in a simple and directed treatment: suppletion of the missing nutrients. CASE PRESENTATION: This case-report describes a 68-year-old man in a high-income country who presented with a 3-week history of painful, indurated edema of the lower legs, immobility due to pain, and dyspnea. Treatment with antibiotics and LMWH was ineffective. Laboratory tests showed anemia (Hb 7.7 g/dL), elevated C-reactive protein (48 mg/L) and elevated D-dimers. He was hospitalized for further investigation. Folate and iron deficiencies were found. Pulmonary embolism and deep venous thrombosis were ruled out, as were systemic inflammatory diseases and infectious causes. PET-CT revealed lung changes suggestive of pulmonary hemorrhage and findings suspicious for bilateral lower leg fasciitis. Detailed dietary history revealed a severely restricted intake (limited to bread, white rice, butter, honey and coffee) for over 20 years. Skin biopsy and exclusion of differential diagnoses confirmed the clinical suspicion of scurvy due to vitamin C deficiency. Nutritional supplementation and dietary expansion led to rapid clinical improvement. CONCLUSIONS: Although scurvy is more common in low- and middle-income countries, it still occurs in high-income settings. It should be considered in at-risk patients presenting with suggestive symptoms.