Scurvy hits Australia: Could New Zealand be next?
Scurvy is something many of us associate with nautical misadventures and famine of years past, and for good reason: in the developed world, it has been all but eradicated.
That's why it was so surprising when a patient in Sydney turned up with unusual and unhealed wounds.
Penelope Jackson became the first of a number of people in western Sydney to be diagnosed with the scourge of the seas.
"I couldn't believe it. I thought, hang on a minute, scurvy hasn't be around for centuries," Ms Jackson said.
"It's something you associate with the First Fleet and the days of Arthur Phillip and Captain Cook. You don't expect it to be around in the 21st century," she said.
Ms Jackson had become a human anachronism. She had all the signs; an ulcer wound that had not healed for months, bleeding gums, sore muscles and loose teeth.
But it wasn't until her endocrinologist decided to investigate her diet that her scurvy was discovered.
She ate very little fruit and cooked her vegetables until they disintegrated to the touch, essentially straining out the nutrients.
"The thought of having such an old disease was scary. I couldn't believe you could be obese and malnourished," she said.
Her doctor, Professor Jenny Gunton, found several patients in her diabetes clinic in Sydney's Westmead Hospital had developed the severe vitamin C deficiency and believes the condition could be going undiagnosed in countless more people.
Seven of the 11 patients screened had a significant vitamin C deficiency, Professor Gunton reported in a research paper published on Tuesday in Diabetic Medicine.
"I've found another six or seven additional patients [with the condition]," said Professor Gunton, an endocrinologist and Director of the Centre for Diabetes and Obesity Research at the Westmead Institute for Medical Research.
Professor Gunton said diabetes patients would often avoid fruit because they were concerned their glucose levels could spike.
"In people who do not eat fresh fruit and vegetables, it is unfortunately possible to achieve vitamin C deficiency even in the presence of overweight or obesity," she said.
The telltale symptoms of severe vitamin C deficiency are wounds that won't heal, bleeding gums, loose teeth, or teeth that are falling out, corkscrew-shaped hairs on the legs and weak bones and muscles.
Vitamin C is essential to the body's healing process, acting as a stabiliser for collagen, which supports the skin's structure.
Though scurvy could kill sailors aboard the tall ships of centuries past, vitamin C deficiency is very easy to treat, and its effects are rapidly reversed after about a week of taking vitamin C tablets.
"They also need to make sure they eat enough fruit and vegetables … it's just about following basic healthy eating advice, and not overcooking vegetables" she said.
Capsicum, particularly yellow capsicum, broccoli, spinach, kale, berries and citrus fruit were all rich in vitamin C.
Professor Gunton suspected vitamin C deficiency may be going undiagnosed in other clinical settings across the country, but patients and doctors don't know to look for it.
In most cases, patients were probably being inadvertently treated for scurvy when they were admitted to hospital for their wounds or other illnesses.
"There's a lot of not so complimentary things said about hospital food ... but it will give you your dose of vitamin C," she said.
DermNet New Zealand observed the disease is most likely to manifest in alcoholics, the elderly, men who live alone, children, people with mental illnesses pertaining to food, or people with medical conditions that may prevent the absorption of Vitamin C - essentially those most likely to be malnourished.
Poverty is also considered a factor in outbreaks of the disease.
Incidences are rare in developed countries because fortified food products and supplements are widely available.
The last major documented outbreak occurred in 2002 in Afghanistan, following a drought and crops being ravaged by civil warfare.
Side-effects include bruising, bleeding, teeth falling out and fatigue.
According to Dr Marion Poore, Southern DHB Officer of Health, "Patients develop anaemia, debility, exhaustion, swelling in some parts of the body, and sometimes ulceration of the gums and loss of teeth."
However, she noted that in New Zealand, the disease is "extremely rare".
"It's prevented by ensuring a diet that contains green vegetables and citrus fruits."
There have been no recorded instances of Scurvy in New Zealand since 2013, which saw one case of the disease.
Treatment, meanwhile, is as simple as prescribing a Vitamin C pill.