This 82 year old man had not seen a doctor for 13 years, so when he presented with haemorrhagic discolouration on his legs and vague aches and pains, Dr Keith Hopcroft suspected some significant pathology.
The patient
A visit request for an elderly man, living alone, who has ‘gone off his legs' wouldn't set the average GP's pulse racing.
But in this case, it was intriguing to note that my 82-year-old patient had managed to steer completely clear of the medical profession for the past 13 years – which obviously raised the chances of some significant pathology.
The story turned out to be frustratingly vague: increasing malaise over the last few months with some joint aches and pains.
He had no significant past medical history and was on no treatment. But two things were immediately apparent: the squalid surroundings suggested he'd been neglecting himself and the empty whisky bottles indicated that alcohol had played a significant part.
Examination revealed a thin, unkempt man, though he protested that he had always been on the skinny side. There were no obvious physical signs – until I finally revealed his legs. These showed dramatic, haemorrhagic discolouration, worse on the right side.
First instinct
I immediately thought of chronic alcoholism as the underlying problem. He fitted the typical demographic, admitted to more than 56 units per week – and the empty bottles were a bit of a giveaway.
The dramatic appearance of his legs, I guessed, was part of a bleeding diathesis, probably secondary to liver failure. There was no jaundice, no enlarged liver and no other obvious signs of hepatic failure – but the fact that he also complained of gum swelling and bleeding reinforced my gut feeling that he had a blood disorder linked to his alcohol intake.
Differential diagnosis
• Bleeding diathesis – secondary to chronic liver disease
• Other cause for bleeding diathesis such as blood dyscrasia
• Trauma
• Cellulitis
• Varicose or stasis eczema
• Scurvy.
Everything pointed rather neatly towards liver failure secondary to alcoholism. This would explain his slow decline as well as his leg discolouration and bleeding gums.
There are, however, many other possible causes for a bleeding diathesis in an elderly male – such as an underlying blood dyscrasia. Or it could simply have been that he had traumatised his legs in a fall. He denied this, but I doubted his memory was that reliable – or he might have been in denial for fear of being transferred to hospital. Other possibilities included cellulitis or eczema of the legs, both of which sometimes produce a haemorrhagic appearance – but the absence of fever, pain or itch made these unlikely.
I had seen pictures of scurvy similar to this in medical textbooks, but never in practice. So, given its rarity, this seemed a long shot – although, given the state of the house and his own appearance of neglect, it did seem likely that he hadn't been eating much in the way of fruit and vegetables for a while.
The hidden clue
To my amazement, the blood tests I arranged – including LFTs, clotting screen and platelets – were virtually normal. The only positive finding, in fact, was a mild normochromic, normocytic anaemia. This meant a rethink. I'd assumed the bleeding gums – the only other symptom he'd volunteered – was a reflection of his bleeding diathesis, now disproven. Failing that, I'd dismissed it as gingivitis, part of his overall neglect. But now the scenario was ringing big bells for scurvy, rare or not.
Getting on the right track
Predictably, he declined further investigation or hospital intervention – though he would accept vitamin C tablets and some social service input to help out at home. So we agreed on empirical treatment – and within a few weeks he was back on his feet, with much improved legs and gums. The final diagnosis, then, was scurvy – hopefully something he can avoid in future with an improved diet and reduced alcohol intake.
Dr Keith Hopcroft is a GP in Laindon, Essex
Haemorrhagic patches on leg Haemorrhagic patches on leg
