1
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Kassa HL, Singh S, Douglas-Jones M, Schermbrucker G, De Lange J, Phoya F, Butters C, Hlela C, Coetzee A, Banderker E, Webb K. Scurvy masquerading as IgA vasculitis. Pediatr Rheumatol Online J 2024; 22:56. [PMID: 38760753 PMCID: PMC11102241 DOI: 10.1186/s12969-024-00992-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 05/09/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Vitamin C deficiency, or scurvy, is rare but poses risks for children with poor diets, limited resources, or malabsorption issues. It may also be common in children with restrictive or selective dietary habits in children with global developmental delay, autism spectrum disorder, and physical disabilities. Symptoms include fatigue, irritability, joint and muscle pain, joint swellings, edema, swollen gums, easy bruising, and delayed wound healing. Early recognition and prompt intervention are essential to prevent the progression of symptomatic vitamin C deficiency in children. CASE PRESENTATION We present a case of a 13-year-old boy with developmental delay secondary to Lennox Gastaut syndrome referred for suspected recurrent, severe, and atypical IgA vasculitis. He presented with irritability, loss of appetite, petechial and ecchymotic lower limb lesions, unilateral gum swelling, severe arthritis, peripheral oedema, severe weight loss, anaemia, and raised inflammatory markers. Multiple investigations were performed before the diagnosis of scurvy was made. A surgical finding of friable gingival tissue with multiple loose teeth, a skin biopsy with follicular hyperkeratosis and extravasated perifollicular red blood cells, and a typical X-ray finding led to the diagnosis of scurvy. CONCLUSION Scurvy should be given careful consideration as a differential diagnosis in patients presenting with musculoskeletal issues, mucocutaneous complaints, and constitutional symptoms such as malaise, asthenia, irritability, and loss of appetite. A focused and detailed dietary history looking for a lack of good sources of vitamin C can be an easy indicator of this differential. Imaging studies revealing the typical features can also help make the diagnosis. Pathology of the skin revealing pathognomonic features can add to the certainty of the diagnosis. In the absence of all else, the rapid response to treatment with an appropriate dose of vitamin C has a diagnostic and therapeutic role.
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Affiliation(s)
- Hanna L Kassa
- Department of Pediatric Rheumatology, Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa.
| | - S Singh
- National Health Laboratory Service, Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - M Douglas-Jones
- Department of Maxillofacial and Oral Surgery, Groote Schuur and Red Cross Children's Hospital, University of the Western Cape, Cape Town, South Africa
| | | | - J De Lange
- Department of Maxillofacial and Oral Surgery, Groote Schuur and Red Cross Children's Hospital, University of the Western Cape, Cape Town, South Africa
| | - Frank Phoya
- Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Claire Butters
- Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Carol Hlela
- Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Ashton Coetzee
- Department of Paediatric Nephrology, Red Cross Childrens Hospital, University of Cape Town, Cape Town, South Africa
| | - Ebrahim Banderker
- Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Kate Webb
- Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
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2
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Sangaran LR, Smith JP, Menegotto F, Ramanan AV. Of oranges and lemons: you are what you eat. Arch Dis Child Educ Pract Ed 2024:edpract-2024-327057. [PMID: 38744456 DOI: 10.1136/archdischild-2024-327057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/20/2024] [Indexed: 05/16/2024]
Abstract
A young boy presented with increasing lower limb pain and swelling for a month. At the time of his hospitalisation, he was unable to walk. We report the patient's clinical journey with clinical commentary throughout, highlighting the importance that uncommon diseases may be diagnosed with a high index of suspicion and thorough history taking.
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Affiliation(s)
- La Reina Sangaran
- Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | | | - Flavia Menegotto
- Paediatric Radiology, Bristol Royal Hospital for Children, Bristol, UK
| | - Athimalaipet V Ramanan
- Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
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3
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Yu HNZ, Chia SY. Scurvy presenting as difficulty in walking in a child. BMJ Case Rep 2023; 16:e258819. [PMID: 38160038 PMCID: PMC10759024 DOI: 10.1136/bcr-2023-258819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Scurvy, a disease caused by ascorbic acid (vitamin C) deficiency, is a rare disease in the modern world. We report a case of a boy in middle childhood, with a background of autism, presenting bed-bound due to progressive bilateral lower limb pain, with concomitant rashes, bleeding gums and worsening lethargy. Detailed dietary history revealed a severely restricted diet. Physical examination showed bilateral lower limb ecchymoses, perifollicular hemorrhages, perifollicular hyperkeratosis and cockscrew hairs which are pathognomonic features of scurvy. A low serum ascorbic acid level confirmed the diagnosis. Therapy with oral vitamin C supplement and rehabilitation with multidisciplinary care was successful, with complete resolution of symptoms. This case emphasises the importance of thorough dietary evaluation in children with autism and food selectivity presenting with non-specific symptoms. Physician awareness of nutritional deficiencies avoids unnecessary extensive investigations and sub-specialty referrals and translates to savings in medical expenses.
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Affiliation(s)
| | - Shi Yun Chia
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore
- Department of Dermatology, KK Women's and Children's Hospital, Singapore
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4
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Paul AJ. Pseudoparalysis Secondary to Vitamin C Deficiency: A Rare Presentation in a Toddler. JBJS Case Connect 2023; 13:01709767-202312000-00016. [PMID: 37889997 DOI: 10.2106/jbjs.cc.23.00313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
CASE We present a 17-month-old girl with postencephalitic sequelae only on high-calorie cereal milk through a nasogastric tube. She presented with a 3-week history of swelling and decreased lower limb movements. Synovial fluid analysis ruled out septic arthritis. Plain radiograph and magnetic resonance imaging (MRI) were suggestive of scurvy. She was diagnosed to have pseudoparalysis secondary to scurvy. She was started on vitamin C supplements, after which she showed good clinical improvement. CONCLUSION This case report is to re-emphasize the need for awareness of the possibility of scurvy in children with poor nutritional status due to feeding difficulties.
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5
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Alhalabi R, Nasrallah B, Rahman R, Muad H, Qureshi A. Chronic Recurrent Multifocal Osteomyelitis Mimicking Scurvy in a Child: A Case Report. Cureus 2023; 15:e38880. [PMID: 37313111 PMCID: PMC10259692 DOI: 10.7759/cureus.38880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/15/2023] Open
Abstract
Scurvy is a rare clinical syndrome resulting from prolonged vitamin C deficiency and is uncommon in the Gulf area. It can present with non-specific symptoms, making diagnosis and treatment challenging. In pediatric patients, symptoms may include weight loss, lethargy, low-grade fever, anemia of varying degrees, easy bruising or bleeding, joint and muscle pain, and poor wound healing. Despite advances in healthcare in many Gulf countries, nutritional deficiencies can still occur in certain populations. Therefore, it is important for pediatricians, orthopedists, rheumatologists, and radiologists to consider scurvy in the evaluation of children with low-grade, multisystemic involvement. We report a case of a six-year-old boy who presented to the emergency department (ED) multiple times with progressive right (RT) leg pain. The clinical picture and imaging findings suggested chronic recurrent multifocal osteomyelitis (CRMO). Despite symptom progression, scurvy was ultimately diagnosed and treatment with vitamin C led to rapid resolution of his symptoms. This case highlights the importance of considering scurvy in the differential diagnosis of children with multisystemic involvement, especially in regions where nutritional deficiencies may be more prevalent.
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Affiliation(s)
- Rawan Alhalabi
- Department of Pediatrics, American Hospital Dubai, Dubai, ARE
| | - Basil Nasrallah
- Department of Pediatrics, American Hospital Dubai, Dubai, ARE
| | - Rizviya Rahman
- Department of Pediatrics, American Hospital Dubai, Dubai, ARE
| | - Hussein Muad
- Department of Pediatrics, American Hospital Dubai, Dubai, ARE
| | - Assad Qureshi
- Department of Orthopaedic Surgery, American Hospital Dubai, Dubai, ARE
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6
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Jafri A, Edwards O, Gupta P, Abdul-Aziz R. Scurvy in a Pediatric Patient Unable to Bear Weight: A Case Report. Cureus 2023; 15:e38687. [PMID: 37292550 PMCID: PMC10244491 DOI: 10.7759/cureus.38687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 06/10/2023] Open
Abstract
Pediatric scurvy is uncommon in the twenty-first century but cases have been reported in children with neurodevelopmental issues and restricted diets. We are reporting a two-year and nine-month-old boy who had a coronavirus disease (COVID) infection and then presented with a refusal to walk. By careful history-taking, he was found to have a restricted diet, speech delay, and gum bleeding suggestive of scurvy, which was confirmed by extremely low levels of ascorbic acid. In this case, the diagnosis of scurvy was established before establishing the diagnosis of neurodevelopmental delay. Treatment with ascorbic acid resulted in a remarkable improvement in his symptoms. This case highlights the importance of collecting a thorough history, connecting exam findings to the history, and including scurvy in differential diagnoses for the presentation of inability to bear weight.
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Affiliation(s)
- Aleena Jafri
- Pediatrics, State University of New York (SUNY) at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Olayinka Edwards
- Family Medicine, Jericho Road Community Health Center, Buffalo, USA
| | - Puneet Gupta
- Radiology, John R. Oishei Children's Hospital of Buffalo, Buffalo, USA
| | - Rabheh Abdul-Aziz
- Pediatric Rheumatology, State University of New York (SUNY) at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
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7
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Elouali A, El Haddar Z, Bouabdella Y, Rkain M, Babakhouya A. A Case of Scurvy in a Child: An Uncommon but Important Diagnosis to Consider. Cureus 2023; 15:e39369. [PMID: 37362528 PMCID: PMC10285571 DOI: 10.7759/cureus.39369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Scurvy is a rare disease resulting from a prolonged ascorbic acid deficiency. It commonly affects individuals with low incomes and limited access to fresh fruits and vegetables. The diagnosis of scurvy can be challenging for clinicians due to the non-specific symptoms, resulting in extensive investigations and a delayed diagnosis. We report the case of a 14-year-old girl who presented with symptoms of pallor, bone pain, inability to walk, petechiae, ecchymosis of the lower limbs, irritability, and swollen, bleeding gums. Initially, the symptoms raised suspicions of hematopoietic malignancies, such as leukemia, and the patient underwent a series of invasive diagnostic exams before arriving at the correct diagnosis. Following a detailed dietary anamnesis with the parents, it became evident that the patient had a limited intake of fresh fruits and vegetables. A vitamin C blood test confirmed the diagnosis of scurvy. The prompt resolution of the clinical symptoms after the administration of vitamin C provided further confirmation of the diagnosis. This case highlights the importance of considering a patient's medical history and symptoms rigorously to avoid unnecessary, expensive, and invasive medical procedures, as well as to prevent potential misdiagnosis.
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Affiliation(s)
- Aziza Elouali
- Pediatrics, Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, MAR
- Pediatrics, Mohammed VI University Hospital, Oujda, MAR
| | - Zohair El Haddar
- Pediatrics, Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, MAR
- Pediatrics, Mohammed VI University Hospital, Oujda, MAR
| | - Yasser Bouabdella
- Pediatrics, Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, MAR
- Pediatrics, Mohammed VI University Hospital, Oujda, MAR
| | - Maria Rkain
- Pediatrics, Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, MAR
- Pediatrics, Mohammed VI University Hospital, Oujda, MAR
| | - Abdeladim Babakhouya
- Pediatrics, Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, MAR
- Pediatrics, Mohammed VI University Hospital, Oujda, MAR
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8
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Ding TG, Goh F, Hayman R. Easily missed, easily treatable: A case of non-weight bearing, an MRI and scurvy. J Paediatr Child Health 2023; 59:395-397. [PMID: 36464998 DOI: 10.1111/jpc.16299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 12/07/2022]
Affiliation(s)
- Thomas G Ding
- Department of Paediatric, Kidz First Hospital, Te Whatu Ora, Auckland, New Zealand
| | - Fern Goh
- Radiology Department, Middlemore Hospital, Te Whatu Ora, Auckland, New Zealand
| | - Rebecca Hayman
- Department of Paediatric, Kidz First Hospital, Te Whatu Ora, Auckland, New Zealand
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9
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Adlakha V, Akhouri R, Andrake J. Healthy Toddler With Refusal to Walk. Clin Pediatr (Phila) 2023; 62:154-156. [PMID: 35912681 DOI: 10.1177/00099228221115244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Vaishali Adlakha
- Department of Pediatrics, SUNY Upstate Medical University, Upstate Golisano Children's Hospital, Syracuse, NY, USA
| | - Rohan Akhouri
- Department of Pediatrics, SUNY Upstate Medical University, Upstate Golisano Children's Hospital, Syracuse, NY, USA
| | - John Andrake
- Department of Pediatrics, SUNY Upstate Medical University, Upstate Golisano Children's Hospital, Syracuse, NY, USA
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10
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Ueki M, Sakamoto K, Nishioka N, Ohata H, Nobuta T, Takezaki S, Manabe A, Yamada M. Rheumatologic manifestations with elevated levels of IL-6, IL-17A, and IL-23 in a patient with scurvy. Mod Rheumatol Case Rep 2023; 7:302-306. [PMID: 35942728 DOI: 10.1093/mrcr/rxac059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/06/2022] [Accepted: 07/21/2022] [Indexed: 01/07/2023]
Abstract
Symptomatic vitamin C deficiency, scurvy, is a relatively rare disease in developed countries, but it has been reported in patients with autism spectrum disorder or developmental delay who tend to have selective diets. Patients with scurvy often demonstrate musculoskeletal manifestations with unknown pathophysiology. Herein, we report a case of scurvy in an 11-year-old boy who presented with iron-deficiency anaemia, systemic osteomyelitis, myositis predominantly in the lower extremities, and right ventricular volume overload with mild pulmonary hypertension and was diagnosed with scurvy. He had a mild developmental disorder and a selective diet, which resulted in severe vitamin C deficiency. He received intravenous and oral vitamin C supplementation, which relieved his arthralgia and muscle pain in a week. Following 4 months of vitamin C supplementation, he demonstrated no abnormal manifestations on laboratory or imaging examination and recovered without sequelae. Inflammatory cytokine and chemokine evaluations demonstrated elevated levels of interleukin (IL)-6, IL-17A, and IL-23, which are associated with T-helper (Th) 17 cell activation. This study is the first to suggest the association between the inflammation seen in scurvy, rheumatic manifestations in the patient, and Th17 cell activation. Further analysis of the association between the inflammation and vitamin C supplementation may contribute to new insights for the comprehension and treatment of other inflammatory diseases, such as rheumatic diseases.
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Affiliation(s)
- Masahiro Ueki
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | - Keita Sakamoto
- Department of Diagnostic Imaging, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaidô, Japan
| | - Noriko Nishioka
- Department of Diagnostic Imaging, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaidô, Japan
| | - Hiroki Ohata
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | - Takiko Nobuta
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | | | - Atsushi Manabe
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan.,Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaidô, Japan
| | - Masafumi Yamada
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan.,Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaidô, Japan.,Department of Food and Human Wellness, Rakuno Gakuen University, Ebetsu, Japan
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11
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Matijasic N, Kranjcec I, Jadrijevic-Cvrlje F, Tripalo Batos A, Sekelj Fures J, Stepan Giljevic J. Deep Tissue Hematomas-What Are We Forgetting? Clin Pediatr (Phila) 2023; 62:59-63. [PMID: 35848545 DOI: 10.1177/00099228221110116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Nusa Matijasic
- Department of Paediatric Oncology and Haematology, Children's Hospital Zagreb, Zagreb, Croatia
| | - Izabela Kranjcec
- Department of Paediatric Oncology and Haematology, Children's Hospital Zagreb, Zagreb, Croatia
| | - Filip Jadrijevic-Cvrlje
- Department of Paediatric Oncology and Haematology, Children's Hospital Zagreb, Zagreb, Croatia
| | - Ana Tripalo Batos
- Department of Paediatric Radiology, Children's Hospital Zagreb, Zagreb, Croatia
| | - Jadranka Sekelj Fures
- Department of Paediatric Neurology, Children's Hospital Zagreb, Zagreb, Croatia.,Faculty of Medicine, The Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Jasminka Stepan Giljevic
- Department of Paediatric Oncology and Haematology, Children's Hospital Zagreb, Zagreb, Croatia.,Medical School, University of Zagreb, Zagreb, Croatia
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12
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Barrette LX, Silverman BL, Lee C, Van Pelt AL. Sudden Refusal to Walk in a Child with Stickler Syndrome. Pediatr Rev 2022; 43:724-727. [PMID: 36450637 DOI: 10.1542/pir.2021-004997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
| | - Benjamin L Silverman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Clement Lee
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Children's Hospital of Philadelphia, Philadelphia, PA
| | - Amanda L Van Pelt
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Children's Hospital of Philadelphia, Philadelphia, PA
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13
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Patel N, Bessler S, Howard J, Cohen R, Doshi B. Bifrontal Epidural Hemorrhage Secondary to Scurvy in a 10-Year-Old Boy. Clin Pediatr (Phila) 2022; 61:745-748. [PMID: 35978474 PMCID: PMC9516601 DOI: 10.1177/00099228221103975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Neema Patel
- UCSF Benioff Children’s Hospital Oakland,
Oakland, CA, USA,Neema Patel, UCSF Benioff Children’s Hospital
Oakland, 747 52nd Street, Oakland, CA 94609, USA.
| | - Susan Bessler
- UCSF Benioff Children’s Hospital Oakland,
Oakland, CA, USA
| | - James Howard
- UCSF Benioff Children’s Hospital Oakland,
Oakland, CA, USA
| | - Ronald Cohen
- UCSF Benioff Children’s Hospital Oakland,
Oakland, CA, USA
| | - Bella Doshi
- UCSF Benioff Children’s Hospital Oakland,
Oakland, CA, USA
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14
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Quinn LA, Gilley SP, Ta AD, Frank BS, Foley CB, Moore JM. Case report: Pulmonary hypertensive crisis leading to cardiac arrest during endoscopic evaluation in a 6-year-old boy with autism, severe malnutrition, and undiagnosed scurvy. Front Pediatr 2022; 10:1008507. [PMID: 36389378 PMCID: PMC9650637 DOI: 10.3389/fped.2022.1008507] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/28/2022] [Indexed: 11/13/2022] Open
Abstract
Pediatric gastroenterologists are often responsible for the evaluation of malnutrition in the setting of selective eating. Endoscopic evaluation for conditions including eosinophilic esophagitis and celiac disease can help to identify and treat mucosal disease contributing to food selectivity. However, undiagnosed micronutrient deficiencies can cause cardiovascular derangements that significantly increase a patient's anesthetic risk. Vitamin C deficiency in particular, alone or in combination with severe malnutrition, is associated with a severe but reversible form of pulmonary arterial hypertension that, while life threatening in the acute phase, may significantly improve within days of starting ascorbic acid replacement therapy. Here we present a case of a 6-year-old boy with autism spectrum disorder (ASD), severe malnutrition, and undiagnosed chronic vitamin C deficiency who developed a pulmonary hypertensive crisis after induction of general anesthesia leading to cardiac arrest during endoscopic evaluation. While the association between food selectivity among youth with neurodevelopmental differences and vitamin C deficiency is well-described, and pulmonary hypertension is a recognized rare complication of scurvy, extant literature has not addressed next steps to improve patient outcomes. Using this case report as a foundation, we discuss specific patient populations to screen and treat for micronutrient deficiencies prior to anesthesia and propose a novel clinical algorithm for pre-anesthesia risk stratification and mitigation in patients specifically at risk for scurvy and associated pulmonary hypertension.
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Affiliation(s)
- Laura A. Quinn
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO, United States
| | - Stephanie P. Gilley
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO, United States
| | - Allison D. Ta
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO, United States
| | - Benjamin S. Frank
- Department of Pediatrics, Section of Cardiology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Carolyn B. Foley
- Department of Anesthesiology, Division of Pediatric Anesthesiology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Jaime M. Moore
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO, United States
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15
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Trapani S, Rubino C, Indolfi G, Lionetti P. A Narrative Review on Pediatric Scurvy: The Last Twenty Years. Nutrients 2022; 14:nu14030684. [PMID: 35277043 PMCID: PMC8840722 DOI: 10.3390/nu14030684] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 02/04/2023] Open
Abstract
Scurvy is a well-known clinical condition caused by vitamin C deficiency. Although considered a rare disease in high-income countries, it has been recently increasingly reported in children, especially in those with abnormal dietary habits, mental or physical disabilities. We performed an extensive review of the literature analyzing studies published in the last 20 years focusing on clinical features, differential diagnosis and diagnostic delay. Fifteen articles were selected, collectively reporting a total of 166 children. Because of the wide clinical spectrum (musculoskeletal complaints and/or mucocutaneous lesions or systemic symptoms), scurvy can mimic several conditions, including autoimmune diseases, infections, and neoplasia. In addition, frequent findings such as normal nutritional status, anemia or elevated inflammatory markers may guide clinicians towards the abovementioned misdiagnoses. Scurvy should be considered in patients presenting with musculoskeletal complaints, not only in those with risk factors but also in healthy children. A focused dietary history and a careful physical examination, assessing other signs of vitamin C deficiency, are mandatory in these patients. When suspected, the dosage of serum vitamin C is the diagnostic gold standard; furthermore, imaging studies, performed by an expert radiologist, can reveal the typical features of scurvy. Only early diagnosis can avoid unnecessary investigations and potentially fatal complications of the disease.
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Affiliation(s)
- Sandra Trapani
- Pediatric Unit, Department of Health Sciences, Meyer Children’s University Hospital, University of Florence, Viale Pieraccini 24, 50137 Florence, Italy
- Correspondence: ; Tel.: +39-055-5662480
| | - Chiara Rubino
- Pediatric Unit, Meyer Children’s University Hospital, Viale Pieraccini 24, 50137 Florence, Italy;
| | - Giuseppe Indolfi
- Pediatric Unit, Department of NEUROFARBA, Meyer Children’s University Hospital, University of Florence, Viale Pieraccini 24, 50137 Florence, Italy;
| | - Paolo Lionetti
- Gastroenterology Unit, Department of NEUROFARBA, Meyer Children’s University Hospital, University of Florence, Viale Pieraccini 24, 50137 Florence, Italy;
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16
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Goldfarb A, Breitling S, Amadasun O, Kiernan B, Gold-von Simson G, Sagalowsky ST. Chronic Non-infectious Osteomyelitis Mimicking Scurvy as the Presenting Sign of Crohn's Disease: Case Report. Front Pediatr 2022; 10:871993. [PMID: 35498788 PMCID: PMC9043343 DOI: 10.3389/fped.2022.871993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/18/2022] [Indexed: 12/05/2022] Open
Abstract
Chronic non-infectious osteomyelitis (CNO) is a rare, inflammatory process associated with pediatric inflammatory bowel disease (IBD). Signs and symptoms of CNO parallel scurvy, a nutritional deficiency that can affect children with autism spectrum disorder (ASD). This is the first report of a child initially thought to have scurvy, then subsequently diagnosed with CNO as the presenting manifestation of Crohn's disease. This case enhances the literature elucidating extra-intestinal manifestations of IBD and pediatric nutritional deficiencies.
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Affiliation(s)
- Alexa Goldfarb
- Department of Pediatrics, New York University Langone Health, New York, NY, United States
| | - Stefan Breitling
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, United States
| | - Owen Amadasun
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, United States
| | - Bridget Kiernan
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, United States
| | - Gabrielle Gold-von Simson
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, United States
| | - Selin T Sagalowsky
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, United States
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17
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Masci D, Rubino C, Basile M, Indolfi G, Trapani S. When the limp has a dietary cause: A retrospective study on scurvy in a tertiary Italian pediatric hospital. Front Pediatr 2022; 10:981908. [PMID: 36186634 PMCID: PMC9519129 DOI: 10.3389/fped.2022.981908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
The limping child frequently represents a diagnostic challenge. The differential diagnosis is broad and should include vitamin C deficiency. Scurvy, resulting from vitamin C deficiency, is the oldest-known nutritional disorder. Despite its rarity in developed countries, scurvy has been increasingly reported in recent years in pediatric patients, particularly those with autism or neurological disabilities. In the present retrospective study, we describe the clinical, laboratory, and radiological features of 8 patients diagnosed with scurvy in the Pediatrics Unit of Meyer Children's University Hospital, between January 2016 and December 2021. The majority (87%) were males, and the median age was 3.7 years. Half of the patients had comorbidities known to be risk factors for scurvy, while the remaining patients were previously healthy. All the children were admitted for musculoskeletal symptoms, ranging from lower limb pain (87%) to overt limping (87%). Mucocutaneous involvement was observed in 75% cases. Microcytic anemia and elevated inflammatory markers were common laboratory findings. Bone radiographs, performed on all patients, were often interpreted as normal at first, with osteopenia (62%) as the most frequent finding; notably, after re-examination, they were reported as consistent with scurvy in four patients. The most common magnetic resonance imaging findings were multifocal symmetrical increased signal on STIR sequence within metaphysis, with varying degrees of bone marrow enhancement, adjacent periosteal elevation and soft tissue swelling. Differential diagnosis was challenging and frequently required invasive diagnostic procedures like bone marrow biopsy, performed in the first three patients of our series. The median time frame between clinical onset and the final diagnosis was 35 days. Notably, the interval times between admission and diagnosis become progressively shorter during the study period, ranging from 44 to 2 days. Treatment with oral vitamin C led to improvement/resolution of symptoms in all cases. In conclusion, scurvy should be considered in the differential diagnosis in a limping child, performing a detailed dietary history and careful physical examination, looking for mucocutaneous lesions. A quick and correct diagnostic path avoids invasive diagnostic procedures and reduces the risk of long-term complications.
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Affiliation(s)
- Daniela Masci
- Post-graduate School of Pediatrics, University of Florence, Florence, Italy
| | - Chiara Rubino
- Pediatric Unit, Meyer Children's University Hospital, Florence, Italy
| | - Massimo Basile
- Radiology Unit, Meyer Children's University Hospital, Florence, Italy
| | - Giuseppe Indolfi
- Pediatric Unit, Meyer Children's University Hospital, Florence, Italy.,Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Sandra Trapani
- Pediatric Unit, Meyer Children's University Hospital, Florence, Italy.,Department of Health Sciences, Meyer Children's University Hospital, University of Florence, Florence, Italy
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18
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Iamopas O, Ratanachu-Ek S, Kaewnimee S. Scurvy in children - A neglected disease? Pediatr Int 2022; 64:e15324. [PMID: 36331236 DOI: 10.1111/ped.15324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 07/30/2022] [Accepted: 08/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The incidences of pediatric scurvy has decreased substantially, particularly in developed countries, but there are still reports of it from developing countries. Unusual manifestations have led to delays in diagnosis and treatment. Nevertheless, there are few publications regarding misdiagnosis of scurvy. The objective is to determine dietary factors, clinical manifestations, laboratory and radiologic findings, treatment, and outcomes of scurvy cases. The occurrence of misdiagnosis and its associated factors are also explored. METHOD The medical records of 0-18 year-old children from 2003 to 2016, diagnosed with scurvy, were included and reviewed. Clinical data, and data regarding feeding history, nutritional status, laboratory and radiologic findings, and misdiagnosis were collected. Univariate and logistic regression analysis were used for identification of the independent associated factors. RESULTS The study consisted of 106 children. The boys-to-girls ratio was 2.2:1, and their mean age was 44.65 months ± 30.50 months. The common manifestations were refusal to walk, tenderness, and swelling at the lower extremities. Four participants had unusual manifestations including proptosis and scalp hematoma. Low serum vitamin C level and abnormal radiologic findings were detected in most patients. All of them fully recovered after receiving vitamin C supplementation. Misdiagnosis was identified in 74 cases (69%). Logistic regression analysis revealed that temperature higher than or equal to 38 °C, participants aged 3 years or below, and swelling at lower extremities were independently associated with misdiagnosis (adjusted OR 5.91, 3.78, and 3.56 respectively). CONCLUSIONS Scurvy still exists, and misdiagnosis often occurs. Taking a careful medical history and conducting a physical examination are still the best way to diagnose scurvy.
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Affiliation(s)
- Orawan Iamopas
- Division of Nutrition, Department of Pediatrics, Queen Sirikit National Institute of Child Health, Bangkok, Thailand.,College of Medicine, Rangsit University, Mueang Pathum Thani, Thailand
| | - Suntaree Ratanachu-Ek
- Division of Nutrition, Department of Pediatrics, Queen Sirikit National Institute of Child Health, Bangkok, Thailand.,College of Medicine, Rangsit University, Mueang Pathum Thani, Thailand
| | - Suranat Kaewnimee
- Division of Nutrition, Department of Pediatrics, Queen Sirikit National Institute of Child Health, Bangkok, Thailand.,College of Medicine, Rangsit University, Mueang Pathum Thani, Thailand
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19
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Kow RY, Nik Abdul Adel NA, Abdul Razak AH, Low CL, Awang MS. Scurvy: A Neglected Cause of Muscle Pain and Weakness in a Child With Picky Eating Behavior. Cureus 2021; 13:e16289. [PMID: 34405060 PMCID: PMC8352794 DOI: 10.7759/cureus.16289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2021] [Indexed: 12/30/2022] Open
Abstract
Ascorbic acid (vitamin C) is an essential micronutrient that the human's body cannot synthesize endogenously. Scurvy, a disease of ascorbic acid deficiency, can manifest in a myriad of presentations. Due to its rarity in the modern world, scurvy is considered as a disease of the past. We present a paediatric case of scurvy with musculoskeletal manifestations as a result of picky eating behavior. We report a previously healthy nine-year-old boy who presented with unexplained progressive bilateral lower limb generalized weakness and pain for two months. All initial biochemical and radiological investigations were unremarkable. Upon further history taking, he had severe picky eating behavior which raised the suspicion of scurvy. The diagnosis was confirmed with a serum ascorbic acid test. After ascorbic acid supplementation, his symptoms resolved immediately. Further food behavioral modification counselling to his family members helped to change his diet in a lasting way. As a result, he had no recurrence of symptoms. This case highlights the importance of having a high index of suspicion for an uncommon disease and emphasizes the need for a detailed dietary history upon patient’s presentation.
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Affiliation(s)
- Ren Yi Kow
- Department of Orthopaedics, Traumatology & Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
| | - Nik Alyani Nik Abdul Adel
- Department of Orthopaedics, Traumatology & Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
| | - Ardilla Hanim Abdul Razak
- Department of Orthopaedics, Traumatology & Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
| | - Chooi Leng Low
- Department of Radiology, International Islamic University Malaysia, Kuantan, MYS
| | - Mohd Shukrimi Awang
- Department of Orthopaedics, Traumatology & Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
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20
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Liuzzo Scorpo M, Corsello G, Maggio MC. Scurvy as an Alarm Bell of Autistic Spectrum Disorder in the First World: A Case Report of a 3-Year-Old Girl. Am J Case Rep 2021; 22:e930583. [PMID: 34339404 PMCID: PMC8349570 DOI: 10.12659/ajcr.930583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Scurvy secondary to deficiency of vitamin C is a rare condition in children. The polymorphism of clinical signs and symptoms makes scurvy diagnosis a challenge for the pediatrician. CASE REPORT A 3-year-old girl came to our observation because she refused to walk and to stand, she showed petechiae, follicular hyperkeratosis on the limbs, and bleeding gums. After a physical exam, laboratory tests, and X-ray examinations, we suspected scurvy disease and started treatment with vitamin C. During the hospitalization, some relationship difficulties of the little girl emerged such as absence of eye contact, smiling and laughter without reason, solitary play activities, poor interaction with strangers, non-communicative language, and gestural stereotypes. Therefore, we suspected an autism spectrum disorder, which is often associated with vitamins intake deficiency secondary to food selectivity. After the administration of vitamins, there was a clinical improvement. Due to the suspicion of autism spectrum disorder, the neuropsychiatric team started neuro-psychomotor and speech therapy. CONCLUSIONS This case shows that although the incidence of scurvy has been greatly reduced in Western Europe, this pathology can still manifest itself, especially in vulnerable children, and its prompt diagnosis and therapy are important considering the excellent response to treatment.
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Affiliation(s)
| | - Giovanni Corsello
- Department PROMISE "G. D'Alessandro", University of Palermo, Palermo, Italy
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21
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Nazeer M, Ravindran R, Katragadda BC, Muhammed EN, Titus S, Muhammed MN. Slipped Capital Femoral Epiphysis Associated With Vitamin C Deficiency in a 7-year-old Boy. J Am Acad Orthop Surg Glob Res Rev 2021; 5. [PMID: 33961586 DOI: 10.5435/JAAOSGlobal-D-21-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/18/2021] [Indexed: 11/18/2022]
Abstract
Scurvy is rare in the present world and is mostly found in children with abnormal dietary habits and physical and mental disabilities. Scurvy can present in various forms, mimicking several common diseases, thus making the diagnosis difficult. Spontaneous epiphyseal separation is known to occur in scurvy, although rarely reported. The usual locations of these epiphyseal separations are distal femur and proximal humerus. Our case is unique in that scurvy in a seemingly normal child resulted in proximal femur epiphyseal separation which was not reported previously. We report a case of a 7-year-old boy presenting with pain and swelling in multiple joints for 6 months and later inability to walk. Pseudoparalytic frog-leg posture, dietary history of selective eating, and typical radiologic features made us consider a diagnosis of scurvy which was confirmed by a low serum vitamin C level. He developed epiphyseal separation of proximal femur and was treated with percutaneous screw fixation. Vitamin C supplementation resulted in prompt improvement clinically and radiologically.
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22
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Musa H, Ismail II, Abdul Rashid NH. Paediatric scurvy: frequently misdiagnosed. Paediatr Int Child Health 2021; 41:158-161. [PMID: 32937094 DOI: 10.1080/20469047.2020.1816285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Paediatric scurvy is uncommon in the modern age but cases have been reported in children with neurodevelopmental issues and restricted dietary habits. The broad clinical picture is frequently overlooked as primarily other systemic diseases are considered first leading to extensive investigations and delay in diagnosis. A 4-year-old boy with autism and bilateral lower limb pain and refusal to walk is reported. His restricted diet and radiographic findings were highly suggestive of scurvy which was confirmed by the extremely low levels of ascorbic acid. Treatment with ascorbic acid replenishment and maintenance resulted in remarkable improvement. This case highlights the importance of a high index of suspicion in at-risk children so as to avoid unnecessary invasive investigations and procedures.
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Affiliation(s)
- Husna Musa
- Department of Paediatrics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia.,Department of Paediatrics, Serdang Hospital, Ministry of Health, Serdang, Malaysia
| | - Imma Isniza Ismail
- Department of Orthopaedics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Nurul Hazwani Abdul Rashid
- Department of Paediatrics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia.,Department of Paediatrics, Serdang Hospital, Ministry of Health, Serdang, Malaysia
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23
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Abstract
INTRODUCTION Scurvy, or vitamin C deficiency, is rare. The goal of this study is to highlight the common risk factors and identify the orthopaedic presentation of scurvy in children. METHODS A retrospective chart and radiograph review was performed of all patients consulted to the pediatric orthopaedic service from 2010 to 2019 who ultimately had the diagnosis of scurvy confirmed by an abnormally low serum vitamin C level. Data extracted included: patient age, sex, neurological conditions, prematurity, psychiatric conditions, dietary abnormalities, bone pain, arthritis, limb swelling, inability to walk, skin changes, child abuse evaluations, radiographic findings, additional vitamin deficiencies, lab studies, additional tests, response to treatment. Descriptive statistics were performed. RESULTS Nine patients (7 males, 2 females) with scurvy were studied. The average age was 7 years (range 3 to 13 y). The average body mass index was 21.4 (range, 14 to 30). Five had autism, 2 had a neurological disorder. Two had been born premature. Two had a psychiatric disorder. Seven had an abnormal diet. One presented with bone pain. Four presented with limb swelling. Seven had unilateral and 2 had bilateral leg symptoms. Five presented with inability to walk. Six demonstrated skin changes with ecchymosis or petechiae. Three presented with gingival bleeding. Radiographic findings included subperiosteal hematoma in 2, ring epiphysis in 3, Pelkan spurs in 1, metaphyseal white lines (Frankel sign) in 6, and a metaphyseal zone of rarefaction (Trummerfeld zone) in 3. Seven had additional vitamin deficiencies including: A, B1, B6, B9, D, E, K, iron and zinc. Four had a bone marrow biopsy and 1 had lumbar puncture. All were anemic. The average erythrocyte sedimentation rate was 25.7 (range 6 to 35) and C-reactive protein was 1.5 (range 0.55 to 5.64). Six had a computed tomography, 3 had a magnetic resonance imaging. After treatment with vitamin C lasting 3.4 months (range, 2 wk to 7 mo), all symptoms gradually resolved, including leg pain and swelling. All children began to walk. CONCLUSION The pediatric orthopaedic surgeon should have an increased awareness about the diagnosis of scurvy when consulted on a child with bone pain or inability to walk. The most common orthopaedic presentation was the refusal to bear weight, the most common radiographic finding was the metaphyseal line of increased density (Frankel sign) and treatment with vitamin c supplementation was excellent in all cases.
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24
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Murakami Y, Omata T, Aoyama H, Kodama K. Scurvy preceded by hematuria and gait difficulties in two pediatric patients. Pediatr Int 2021; 63:358-360. [PMID: 33638223 DOI: 10.1111/ped.14430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/27/2020] [Accepted: 08/04/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Yoshimi Murakami
- Division of Child Neurology, Chiba Children's Hospital, Chiba, Japan
| | - Taku Omata
- Division of Child Neurology, Chiba Children's Hospital, Chiba, Japan
| | - Hiromi Aoyama
- Division of Child Neurology, Chiba Children's Hospital, Chiba, Japan
| | - Kazuo Kodama
- Division of Child Neurology, Chiba Children's Hospital, Chiba, Japan
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25
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Ravi NS, Gandhi N, Noel S, Commissaris C, Michalski A, Chang YK. Visual Diagnosis: Petechiae, Gingival Hyperplasia, Metaphyseal Lucencies, and Refusal to Ambulate in a 5-year-old Boy. Pediatr Rev 2020; 41:e46-e49. [PMID: 33262159 DOI: 10.1542/pir.2018-0080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Nithin S Ravi
- University of Michigan Medical School, Ann Arbor, MI
| | | | - Stacey Noel
- Department of Pediatric Emergency Medicine, and
| | | | - Austin Michalski
- Patient Food and Nutrition Services, CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI
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26
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Luckow C, Thomas AA. Scurvy in a Pediatric Patient With Autism and Limp: A Case Report. J Emerg Med 2021; 60:e53-6. [PMID: 33109434 DOI: 10.1016/j.jemermed.2020.09.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/09/2020] [Accepted: 09/12/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Limping is a common chief complaint in the pediatric emergency department (ED) and can be difficult to assess in pediatric patients, particularly if they have developmental delay. CASE REPORT We present a case of a 5-year-old male with nonverbal autism who presented with a progressive limp, weakness, pain, and rash over the course of 1 month. A magnetic resonance imaging scan of the pelvis performed while the patient was sedated revealed multifocal osseous marrow signal abnormalities, ultimately consistent with vitamin C deficiency or scurvy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Scurvy can present with nonspecific limp, rash, and bony pain and should be considered in pediatric patients with developmental/sensory delay who may restrict their diets. Emergency physicians should broaden their differential diagnoses to nutritional deficiencies such as scurvy in the evaluation of pediatric patients with limp.
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27
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Diab Shehade K, Lamdan R, Aharoni D, Yeshayahu Y. "What can you C in a limping child?" Scurvy in an otherwise healthy "picky eater". Nutrition 2021; 82:111019. [PMID: 33109452 DOI: 10.1016/j.nut.2020.111019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/31/2020] [Accepted: 09/04/2020] [Indexed: 11/23/2022]
Abstract
We present a case of an otherwise healthy 3-year-old child who presented with limping, bone pain, fatigue, and agitation. Differential diagnosis included an infection of the bone, malignancy, an inflammatory bone disease, and metabolic bone disease. Magnetic resonance imaging of the lower limbs and the spine was consistent with scurvy, and the diagnosis was confirmed by very low levels of vitamin C. Further history taking revealed a diet based entirely on dairy pudding, with no fruits or vegetables, and being a "picky eater" was the sole reason. Intravenous treatment with vitamin C led to full recovery. Previous reports of scurvy were in patients with other medical conditions, such as malabsorption, or behavioral conditions as in autism. This case demonstrates that scurvy, an almost forgotten condition from past centuries, can occur in otherwise healthy children and should raise awareness regarding the importance of a balanced diet and proper nutritional history taking. Following growth charts as the only screening tool for balanced and inclusive nutrition may not be sufficient.
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28
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Kothari P, Tate A, Adewumi A, Kinlin LM, Ritwik P. The risk for scurvy in children with neurodevelopmental disorders. Spec Care Dentist 2020; 40:251-259. [PMID: 32330999 DOI: 10.1111/scd.12459] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/06/2020] [Accepted: 03/20/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Scurvy, the disease resulting from vitamin C deficiency, is perceived as being rare and occurring predominantly in the past. However, scurvy continues to exist and may be encountered in children with medical/developmental conditions and/or restricted diet. Diagnosis can be challenging given the perceived rarity of the condition and nonspecific symptoms, including gingival disease. METHODS We present a series of two cases of scurvy in which the affected children presented to medical attention with dental complaints. Additional cases of scurvy are described, based on the literature review of case reports/series published in the last 10 years. RESULTS Literature review yielded 77 relevant case reports published in the English language since 2009. Most affected children had a previous diagnosis of a medical or developmental condition (especially autism spectrum disorder). Intraoral features (gingival swelling, pain, and bleeding) were noted in most of the identified cases of scurvy. Improvement in the oral features of scurvy occurred within days of vitamin C therapy initiation. CONCLUSIONS Recognizing classic signs and symptoms of scurvy enables prompt diagnosis and avoids invasive investigations. Dentists may be in a unique position to facilitate prompt and accurate diagnosis of a condition that is relatively easy and safe to treat once identified.
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Affiliation(s)
- Priya Kothari
- Kidsworld Pediatric Dentistry, Aurora, Ontario, Canada
| | - Anupama Tate
- Children's National Hospital, Washington, DC, USA.,George Washington University, Washington, DC, USA
| | - Abimbola Adewumi
- Department of Pediatric Dentistry, University of Florida College of Dentistry, Gainesville, Florida, USA
| | - Laura M Kinlin
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Priyanshi Ritwik
- Department of Pediatric Dentistry, The University of Texas Health Science Center at Houston, School of Dentistry, Houston, Texas, USA
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29
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Abstract
Scurvy is seldom encountered in modern day clinical practice. Children can present with nonspecific features which can mimic several other common conditions. We describe here a four-year-old child who presented with severe pain and weakness of bilateral lower limbs and found to be severely malnourished. The diagnosis of scurvy was suspected in the context of underlying malnutrition after excluding other ominous pathologies. Pathognomic radiological changes clinched the diagnosis, and the best supportive evidence was the dramatic response to vitamin C supplementation.
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Affiliation(s)
- Neeraj Gupta
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan 342001, India
| | - Nisha Toteja
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan 342001, India
| | - Rohit Sasidharan
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan 342001, India
| | - Kuldeep Singh
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan 342001, India
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30
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Abstract
We regularly face primary challenges in deciding what to eat to maintain young and healthy skin, defining a healthy diet and the role of diet in aging. The topic that currently attracts maximum attention is ways to maintain healthy skin and delay skin aging. Skin is the primary barrier that protects the body from external aggressions. Skin aging is a complex biological process, categorized as chronological aging and photo-aging, and is affected by internal factors and external factors. With the rapid breakthrough of medicine in prolonging human life and the rapid deterioration of environmental conditions, it has become urgent to find safe and effective methods to treat skin aging. For diet, as the main way for the body to obtain energy and nutrients, people have gradually realized its importance to the skin. Therefore, in this review, we discuss the skin structure, aging manifestations, and possible mechanisms, summarize the research progress, challenges, possible directions of diet management, and effects of foodborne antioxidants on skin aging from the perspective of food and nutrition.
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Affiliation(s)
- Changwei Cao
- Livestock Product Processing Engineering and Technology Research Center of Yunnan Province, Yunnan Agricultural University, Kunming 650201, China; (C.C.); (Z.X.)
- College of Food Science, Sichuan Agricultural University, Ya’ an, Sichuan 625014, China;
| | - Zhichao Xiao
- Livestock Product Processing Engineering and Technology Research Center of Yunnan Province, Yunnan Agricultural University, Kunming 650201, China; (C.C.); (Z.X.)
- College of Food Science and technology, Yunnan Agricultural University, Kunming, Yunnan 650201, China
| | - Yinglong Wu
- College of Food Science, Sichuan Agricultural University, Ya’ an, Sichuan 625014, China;
| | - Changrong Ge
- Livestock Product Processing Engineering and Technology Research Center of Yunnan Province, Yunnan Agricultural University, Kunming 650201, China; (C.C.); (Z.X.)
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31
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Perkins A, Sontheimer C, Otjen JP, Shenoi S. Scurvy Masquerading as Juvenile Idiopathic Arthritis or Vasculitis with Elevated Inflammatory Markers: A Case Series. J Pediatr 2020; 218:234-237.e2. [PMID: 31843213 DOI: 10.1016/j.jpeds.2019.10.059] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 11/19/2022]
Abstract
Ten patients with scurvy were evaluated by rheumatology; we review their clinical, laboratory, and dietary presentations. Eight patients had developmental delay or autism. All had elevated inflammatory markers. These clinical and laboratory features with imaging findings can mimic rheumatic conditions such as arthritis, vasculitis, and chronic nonbacterial osteomyelitis (CNO).
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Affiliation(s)
- Alexandra Perkins
- School of Public Health, University of Washington School of Medicine, Seattle, WA
| | | | - Jeffrey P Otjen
- Department of Radiology, Seattle Children's Hospital and Research Center, Seattle, WA
| | - Susan Shenoi
- Department of Pediatric Rheumatology, Seattle Children's Hospital and Research Center, Seattle, WA.
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32
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Gallizzi R, Valenzise M, Passanisi S, Pajno GB, De Luca F, Zirilli G. Scurvy may occur even in children with no underlying risk factors: a case report. J Med Case Rep 2020; 14:18. [PMID: 31973768 PMCID: PMC6979388 DOI: 10.1186/s13256-020-2341-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 01/02/2020] [Indexed: 11/10/2022] Open
Abstract
Background Since ancient times, scurvy has been considered one of the most fearsome nutritional deficiency diseases. In modern developed countries, this condition has become very rare and is only occasionally encountered, especially in the pediatric population. Underlying medical conditions, such as neuropsychiatric disorders, anorexia nervosa, celiac disease, Crohn disease, hemodialysis, and severe allergies to food products may enhance the risk of developing scurvy. Case presentation We report the case of an otherwise healthy 3-year-old white boy who developed scurvy due to a selective restrictive diet derived from his refusal to try new food. He presented to our clinic with asthenia and refusal to walk. During hospitalization he developed severe anemia and hematochezia. A diagnosis of scurvy was assessed on the basis of nutritional history, clinical features, radiographic findings, and laboratory findings. Supplementation of ascorbic acid enabled a prompt resolution of symptoms. Conclusions Scurvy is caused by vitamin C deficiency. Cutaneous bleeding, mucosal bleeding, and anemia represent typical manifestations of the disease. These symptoms are directly connected to ascorbic acid involvement in collagen biosynthesis. Some radiographic findings can be useful for the diagnosis. Treatment aims to normalize serum levels of vitamin C in order to counteract the deprivation symptoms. The present case report demonstrates that scurvy may sporadically occur in pediatric patients, even in individuals with no predisposing medical conditions and/or potential risk factors.
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Affiliation(s)
- Romina Gallizzi
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, Italy.
| | - Mariella Valenzise
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, Italy
| | - Stefano Passanisi
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, Italy
| | - Giovanni Battista Pajno
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, Italy
| | - Filippo De Luca
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, Italy
| | - Giuseppina Zirilli
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, Italy
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Abstract
The US Surgeon General's report Oral Health in America highlighted ways in which oral health and systemic conditions are associated with each other. An oral examination can reveal signs and symptoms associated with systemic diseases. In this article, multiple systemic diseases including but not limited to viral and immune modulated conditions and associated oral symptoms are discussed.
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Affiliation(s)
- Natasha Bhalla
- Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA.
| | - Yoav Nudell
- Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA
| | - Jaykrishna Thakkar
- Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA
| | - Harry Dym
- Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA
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Abstract
So far, little attention has been paid to the increase in acute phase reactants (APRs) in patients with scurvy. We report that elevated levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and serum amyloid A were shown in a pediatric patient with scurvy despite the absence of inflammation. These peculiar findings are important to discriminate scurvy from other rheumatic diseases.
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Affiliation(s)
- Kaori Kimura
- Pediatrics, Nihon University School of Medicine, Tokyo, JPN
| | - Yasuji Inamo
- Pediatrics, Nihon Uniiversity School of Medicine, Tokyo, JPN
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Farquhar B, Gonzalez A, Lee CC, Jones KS. A Boy Refusing to Walk. Clin Pediatr (Phila) 2019; 58:1140-1143. [PMID: 31271043 DOI: 10.1177/0009922819861282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Adam Gonzalez
- 2 Virginia Commonwealth University, Richmond, VA, USA
| | - Clifton C Lee
- 1 Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Kathryn S Jones
- 3 Virginia Commonwealth University Health System, Richmond, VA, USA
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Abstract
Background Scurvy is one of the oldest diseases known to mankind. Although presently rare in the developed world, scurvy was a common potentially fatal disease. In recent times, the most common risk factors for scurvy include alcoholism, low socioeconomic status, and severely poor nutrition or dietary restriction secondary to psychiatric illness or developmental disorders. Our case demonstrates the importance of having a high index of clinical suspicion of an uncommon disease in developed countries and emphasizes the necessity of a dietary screening that could potentially reduce extensive work-up in patients with nonspecific complaints. Case presentation We report a case of a 3-year-old previously healthy female originally seen in the rheumatology clinic for limp. She developed weakness and was admitted to the hospital for further evaluation. She underwent extensive diagnostic testing including blood work, magnetic resonance imaging, lumbar puncture, electromyogram, and nerve conduction studies. Ultimately, her vitamin C level returned undetectable. She had immediate and complete improvement upon starting vitamin C supplementation. Conclusions Despite being developmentally appropriate, our patient’s refusal to eat fruits or vegetables had limited her diet, emphasizing the importance of obtaining a diet history in a child presenting with an unknown diagnosis. In addition, our patient had no other characteristic features of scurvy, which further supports the need to consider this diagnosis in a child presenting with lower extremity weakness or abnormal gait.
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Affiliation(s)
- Robin M Lund
- University of Louisville School of Medicine, 571 S. Floyd Street, Suite 412, Louisville, KY, 40202, USA
| | - Mara L Becker
- Duke Clinical Research Institute, 200 Morris Street, Durham, North Carolina, 27701, USA
| | - Steven Shapiro
- Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Tyler Allison
- Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Julia G Harris
- Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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37
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Abstract
Background Numerous cases of scurvy secondary to diet limitations have been reported in the literature with most being boys with special needs. To date, the focus of the literature describing vitamin C deficiency has been the medical sequelae of the deficiency. There has been little attention given underlying diet limitations causing the vitamin C deficiency. Case presentation A five-year-old female with typical development initially presented with rash, then later for pain in both lower extremities. After evaluation revealed vitamin C deficiency, she was admitted into an intensive day treatment feeding program. A feeding assessment found she had life-long problems with eating and had a diet that never exceeded ten foods. Across the course of treatment, she learned to eat 29 new foods. At six-month follow-up her body mass index had increased from the 1st to the 61st percentile. At one-year follow-up her body mass index was at the 85th percentile. All sequalae of her deficiency resolved. Conclusions This case is unusual as most reported studies describe males with special needs. The severity of her eating issues suggest providers may consider referral to allied health professionals to address diet limitations for both children identified with nutrient deficiencies as well as children whose selective eating places them at risk for nutritional deficiencies or problems with growth. The child we described was anemic, like 42% of children described in the case literature on scurvy and like 32% of the children in this literature, our patient was underweight. In the literature, comorbid nutrient deficiencies were reported in 22% of the scurvy case studies. We suggest vitamin C supplementation is a necessary component for addressing vitamin C deficiency, but insufficient for addressing the diet limitations causing the nutrient deficiency. Electronic supplementary material The online version of this article (10.1186/s12887-019-1437-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Timothy Hahn
- Feeding Program, Penn State Hershey Medical Center, 905 W. Governor Road, Hershey, PA, 17033, USA
| | - Whitney Adams
- Feeding Program, Penn State Hershey Medical Center, 905 W. Governor Road, Hershey, PA, 17033, USA
| | - Keith Williams
- Feeding Program, Penn State Hershey Medical Center, 905 W. Governor Road, Hershey, PA, 17033, USA.
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Abstract
PURPOSE OF REVIEW Childhood malnutrition is a major global health issue. It is often thought of as a developing world problem and therefore, underdiagnosed or misdiagnosed in developed countries. The delay in diagnosis and treatment can lead to increased morbidity and mortality. Cutaneous manifestations are often the initial presenting signs of nutritional deficiency. Early recognition is essential in timely initiation of the necessary interventions. This article will review pertinent cutaneous findings and systemic manifestations associated with common nutritional deficiencies. RECENT FINDINGS Malnutrition has historically been associated with poverty in developing countries. However, recent literatures suggest that the incidence of nutritional deficiencies continuous to rise among infants from developed countries, as a result of dietary restrictions because of perceived food allergies or intolerance. It is also an emerging finding in children with complicated medical problems. SUMMARY It is very important to raise awareness about cutaneous manifestations of nutritional deficiency as early and appropriate treatment results in excellent prognosis.
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Pérez-Sánchez A, Barrajón-Catalán E, Herranz-López M, Micol V. Nutraceuticals for Skin Care: A Comprehensive Review of Human Clinical Studies. Nutrients 2018; 10:nu10040403. [PMID: 29587342 PMCID: PMC5946188 DOI: 10.3390/nu10040403] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 12/18/2022] Open
Abstract
The skin is the body’s largest organ, it participates in sensitivity and offers protection against microorganisms, chemicals and ultraviolet (UV) radiation. Consequently, the skin may suffer alterations such as photo-ageing, immune dysfunction and inflammation which may significantly affect human health. Nutraceuticals represent a promising strategy for preventing, delaying, or minimising premature ageing of the skin and also to alleviate certain skin disorders. Among them, bioactive peptides and oligosaccharides, plant polyphenols, carotenoids, vitamins and polyunsaturated fatty acids are the most widely used ingredients. Supplementation with these products has shown evidence of having an effect on the signs of ageing and protection against UV radiation ageing in several human trials. In this review, the most relevant human studies on skin nutraceuticals are evaluated and the statistical resolution, biological relevance of their results, and, the trial protocols are discussed. In conclusion, quality and rigorousness of the trials must be improved to build credible scientific evidence for skin nutraceuticals and to establish a cause-effect relationship between the ingredients the beneficial effects for the skin.
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Affiliation(s)
- Almudena Pérez-Sánchez
- Instituto de Biología Molecular y Celular (IBMC), Universidad Miguel Hernández (UMH), Edificio Torregaitán, 03202 Elche, Spain.
| | - Enrique Barrajón-Catalán
- Instituto de Biología Molecular y Celular (IBMC), Universidad Miguel Hernández (UMH), Edificio Torregaitán, 03202 Elche, Spain.
- Ilice Effitech, UMH Scientific Park, 03202 Elche, Spain.
| | - María Herranz-López
- Instituto de Biología Molecular y Celular (IBMC), Universidad Miguel Hernández (UMH), Edificio Torregaitán, 03202 Elche, Spain.
- Ilice Effitech, UMH Scientific Park, 03202 Elche, Spain.
| | - Vicente Micol
- Instituto de Biología Molecular y Celular (IBMC), Universidad Miguel Hernández (UMH), Edificio Torregaitán, 03202 Elche, Spain.
- Ilice Effitech, UMH Scientific Park, 03202 Elche, Spain.
- CIBER: CB12/03/30038, Fisiopatología de la Obesidad y la Nutrición, CIBERobn, Instituto de Salud Carlos III (ISCIII), 07122 Palma Sola, Spain.
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Brambilla A, Pizza C, Lasagni D, Lachina L, Resti M, Trapani S. Pediatric Scurvy: When Contemporary Eating Habits Bring Back the Past. Front Pediatr 2018; 6:126. [PMID: 29780794 PMCID: PMC5946015 DOI: 10.3389/fped.2018.00126] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/16/2018] [Indexed: 11/17/2022] Open
Abstract
Vitamin C deficiency is anecdotal in developed countries, mainly associated with underling clinical morbidities as autism or neurological impairment. Chronic insufficient dietary supply is responsible for vascular fragility and impaired bone formation, resulting in gingival bleeding, petechial lesions, articular and bone pain or limb swelling. Children may present anorexia, irritability, failure to thrive, limping or refusal to walk. Accordingly, pediatric scurvy is frequently misdiagnosed with osteomyelitis, septic arthritis, bone and soft tissue tumor, leukemia, bleeding disorders, and rheumatologic conditions. We report the case of a 3-years old child developing scurvy as consequence of strict selective diet; extensive and invasive investigations were undertaken before the correct diagnosis was considered. Despite being considered a rare condition, scurvy still exists nowadays, even in children with no apparent risk factors living in wealthy families. The increasing popularity of dietary restriction for children, especially those with allergies, may potentially enhance the occurrence of scurvy in apparently healthy children. Appropriate dietary anamnesis is fundamental in order to highlight potential nutritional deficit and to avoid unnecessary invasive diagnostic procedures. Patients without considerable risk factors may benefit from psychological support in order to investigate possible eating disorders.
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Affiliation(s)
- Alice Brambilla
- Pediatric Department, University of Florence, Anna Meyer Children Hospital, Florence, Italy
| | - Cristina Pizza
- Pediatric Department, University of Florence, Anna Meyer Children Hospital, Florence, Italy
| | - Donatella Lasagni
- Clinical Pediatric Department, Anna Meyer Children Hospital, Florence, Italy
| | - Lucia Lachina
- Clinical Pediatric Department, Anna Meyer Children Hospital, Florence, Italy
| | - Massimo Resti
- Clinical Pediatric Department, Anna Meyer Children Hospital, Florence, Italy
| | - Sandra Trapani
- Pediatric Department, University of Florence, Anna Meyer Children Hospital, Florence, Italy.,Clinical Pediatric Department, Anna Meyer Children Hospital, Florence, Italy
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Abstract
RATIONALE Scurvy is often diagnosed at the state of well-established signs as, for example, skin and visceral purpura, gums involvement, loss of healthy teeth, which derive mostly from disturbance of collagen metabolism. Little is known about the state of latent scurvy, which symptoms are nonspecific and may mimic more common conditions such as weakness, leg pain, and muscle aching. PATIENT CONCERNS We report 3 cases of extreme lassitude and leg pain in alcoholics. In 2 of the 3 cases, discreet classic symptoms such as petechiae or hyperkeratosis of the legs involving collagen metabolism were also present. DIAGNOSES Latent scurvy has been diagnosed thanks to historical experimental data reporting and undetectable ascorbic acid levels. INTERVENTIONS In addition to the treatments recommended by the French Alcohol Society, patients were given oral vitamin C 500 mg to 1000 mg per day for at least three months. OUTCOMES Vitamin C supplementation allowed the regression of the symptoms, greatly improved the quality of life, and gave the possibility to return to work. Cartinine, requiring vitamin C for its hydroxylation, is an essential cofactor in the transport of long-chain fatty acid into mitochondrial matrix. Therefore, it plays an important role in energy production via beta-oxidation. It is thought that carnitine metabolism impairment is responsible for weakness or muscle aching. LESSONS We recommend being aware of the possibility of latent scurvy in chronic alcohol abusers. The vitamin C supplementation and dietetic recommendation eating fresh fruit and vegetables may help to cure tiredness and to return more easily to socialization and to work.
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42
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Abstract
The primary function of the skin is to act as a barrier against insults from the environment, and its unique structure reflects this. The skin is composed of two layers: the epidermal outer layer is highly cellular and provides the barrier function, and the inner dermal layer ensures strength and elasticity and gives nutritional support to the epidermis. Normal skin contains high concentrations of vitamin C, which supports important and well-known functions, stimulating collagen synthesis and assisting in antioxidant protection against UV-induced photodamage. This knowledge is often used as a rationale for the addition of vitamin C to topical applications, but the efficacy of such treatment, as opposed to optimising dietary vitamin C intake, is poorly understood. This review discusses the potential roles for vitamin C in skin health and summarises the in vitro and in vivo research to date. We compare the efficacy of nutritional intake of vitamin C versus topical application, identify the areas where lack of evidence limits our understanding of the potential benefits of vitamin C on skin health, and suggest which skin properties are most likely to benefit from improved nutritional vitamin C intake.
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Affiliation(s)
- Juliet M Pullar
- Department of Pathology, University of Otago, Christchurch, P.O. Box 4345, Christchurch 8140, New Zealand.
| | - Anitra C Carr
- Department of Pathology, University of Otago, Christchurch, P.O. Box 4345, Christchurch 8140, New Zealand.
| | - Margreet C M Vissers
- Department of Pathology, University of Otago, Christchurch, P.O. Box 4345, Christchurch 8140, New Zealand.
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Golriz F, Donnelly LF, Devaraj S, Krishnamurthy R. Modern American scurvy - experience with vitamin C deficiency at a large children's hospital. Pediatr Radiol 2017; 47:214-220. [PMID: 27778040 DOI: 10.1007/s00247-016-3726-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 09/08/2016] [Accepted: 10/04/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Until recently scurvy has been viewed in developed countries as a disease of the past. More recently there have been reports of case series of children with scurvy who have had a delayed diagnosis after an extensive diagnostic workup that included imaging. Most of these children have had underlying neurologic conditions such as autism. OBJECTIVE To review the medical records of children diagnosed with vitamin C (ascorbic acid) deficiency based on serum ascorbic acid levels at a large pediatric health care system, to determine imaging findings and utility of imaging in management, and to identify at-risk pediatric populations. MATERIALS AND METHODS We retrospectively identified cases of vitamin C deficiency in children tested for serum ascorbic acid levels during the last 5 years. We used the criteria of normal ascorbic acid >23 μmol/L and included children with ascorbic acid levels <23 μmol/L. We evaluated their clinical history, underlying medical condition, imaging studies obtained and imaging findings. RESULTS We identified 32 children with vitamin C deficiency. All of these children had underlying medical conditions, most commonly iron overload from multiple transfusions related to sickle cell anemia or thalassemia (20), neurologic disorders (4) and bone marrow transplant/chemotherapy (3). No cases of scurvy from dietary deficiency in otherwise normal children were identified. All except two children had multiple imaging studies, primarily related to their underlying conditions. Three of these children had extensive imaging workups related to diffuse musculoskeletal pain. Imaging findings included ill-defined sclerotic and lucent metaphyseal bands (mainly at the knee) on radiography and MRI studies that showed diffuse increased T2-weighted signal in the bilateral lower-extremity long-bone metaphyses, periosteal reaction and adjacent soft-tissue edema. CONCLUSION Vitamin C deficiency is not uncommon in large pediatric health care facilities, and it is frequently missed on clinical evaluation and diagnostic imaging. At-risk populations include those with iron overload, neurologic conditions and history of chemotherapy. Scurvy related to dietary deficiency in otherwise normal children was not encountered. When characteristic MRI findings are seen, particularly in children with a predisposing condition for vitamin C deficiency, scurvy should be considered and a serum ascorbic acid level checked to potentially confirm a diagnosis prior to further invasive tests.
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Affiliation(s)
- Farahnaz Golriz
- Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA
| | - Lane F Donnelly
- Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.
| | - Sridevi Devaraj
- Department of Pathology and Laboratory Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Raj Krishnamurthy
- Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA
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44
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Seya M, Handa A, Hasegawa D, Matsui T, Nozaki T. Scurvy: From a Selective Diet in Children with Developmental Delay. J Pediatr 2016; 177:331. [PMID: 27426835 DOI: 10.1016/j.jpeds.2016.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/01/2016] [Accepted: 06/06/2016] [Indexed: 11/24/2022]
Affiliation(s)
| | - Atsuhiko Handa
- Department of Radiology St. Luke's International Hospital Tokyo, Japan; MassGeneral Hospital for Children Harvard Medical School Boston, Massachusetts
| | | | | | - Taiki Nozaki
- Department of Radiology St. Luke's International Hospital Tokyo, Japan
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