Nutritional deficiencies of the opioid epidemic: a story of scurvy masquerading as systemic lupus erythematosus

Introduction
Scurvy is uncommon in developed countries. Nevertheless, rare cases still do occur. Early recognition of scurvy can be difficult because symptoms may appear nonspecific and can mimic more common conditions. In any patient with spontaneous hematoma and purpura, in the context of a nutritional disorder, scurvy should be considered.

Case description
We describe a 49-year-old female with a history of systemic lupus erythematosus (SLE), irritable bowel syndrome (IBS) and opioid dependence with a three-week history of painless ecchymosis on the left hip and bleeding in her gums. Examination of the oral cavity showed mildly pale gums with oozing of blood on applying gentle pressure. There was also mild tenderness of the gums. Laboratory investigations were remarkable for vitamin C deficiency in the absence of anaemia. A coagulation panel was unremarkable. The patient was treated with oral vitamin C replacement, resulting in the resolution of her symptoms.

Commentary
Scurvy has been found to mimic symptoms of connective tissue disease. Patients’ social and family history needs to be explored in detail prior to the diagnosis of autoimmune disorders as these have different treatment approach and implications. The burden of nutritional deficiencies in dependence and the potential scope of nutrition services in drug detoxification programmes needs to be further investigated. Future directions include a more widespread study to determine the scope of various nutritional deficiencies in patients with opioid dependence.