Scurvy and rickets masked by chronic neurologic illness: revisiting "psychologic malnutrition"

Unusual case of 'scorbutic proptosis'

Proptosis is a frequent presenting symptom/sign of many paediatric malignancies. Acute-onset proptosis is an ophthalmic emergency that can endanger vision if not treated promptly. Appropriate treatment must be instituted only after investigating for the underlying aetiology. Here, we report a developmentally delayed boy in middle childhood who presented with recent onset bilateral proptosis. Clinical examination followed by radiological evaluation suggested scurvy to be the underlying cause and vitamin C supplementation led to prompt reversal of proptosis. The relevant literature has been reviewed and presented here to apprise the paediatric oncologists about this rare but easily treatable cause of proptosis.

Pseudoparalysis Secondary to Vitamin C Deficiency: A Rare Presentation in a Toddler

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.

Scurvy in a 29-Month-Old Patient Presenting With a Gower Sign

Scurvy is a preventable condition caused by a severe vitamin C deficiency for prolonged periods. Most literature cases describe children with neurobehavioral disorders or extreme dietary restrictions. Vitamin C deficiency may be a rare clinical presentation in the developed world; hence, it is often overlooked and can lead to extensive workups when the history alone could have raised suspicion for the diagnosis. We report a previously healthy 29-month-old boy initially admitted to the hospital due to loss of ambulation over a three-week course. The patient had no history of fever, and the inflammatory parameters were normal. Blood workup, plain radiographs, and magnetic resonance imaging (MRI) of the right lower extremity were unremarkable. The patient was discharged home with antibiotics and anti-inflammatory medication but arrived a week later with worsening lower extremity weakness leading to complete loss of ambulation. Vitamin C deficiency was confirmed to be below normal levels (<0.4mg/dL), and a diagnosis of scurvy was confirmed and treated with oral ascorbic acid. Subsequently, his mother brought him to the orthopedic clinic with a positive Gower sign. CPK levels were normal. Within a month of ascorbic acid replacement, all symptoms disappeared. Our patient was a picky eater, which emphasizes the importance of early dietary screening to discover the underlying cause of symptoms. Vitamin C deficiency should be part of the differential diagnosis in patients with unremarkable laboratory workup for infection and other diseases presenting with a Gower sign.

Avoidant/restrictive food intake disorder and severe food selectivity in children and young people with autism: A scoping review

AIM

To assess the extent of the scientific literature on avoidant/restrictive food intake disorder (ARFID) in children and young people with autism in order to evaluate and synthesize the evidence on (a) the nature of feeding and eating difficulties in children and young people with autism; (b) the consequences of a severely restricted diet; and (c) what is known about effective treatment approaches.

METHOD

PubMed and PsycInfo databases were searched, identifying 56 studies and a narrative synthesis was effected.

RESULTS

The literature suggested that ARFID-like presentations are common in children and young people with autism, with severe consequences for physical and mental health. The three drivers mentioned in the DSM-5 criteria, namely a sensory-based avoidance, fear- or phobia-based restriction, and a lack of interest in eating, are present in this population, although sensory sensitivities are currently the most commonly described. Research suggests that ARFID symptoms in children and young people with autism can be amenable to treatment, with evidence that behavioural interventions are feasible and potentially effective in this population.

INTERPRETATION

ARFID is a common and impactful problem among young people with autism but is currently under researched. Work is required to (a) identify the prevalence of ARFID in children and young people with autism; (b) uncover the key drivers of ARFID in this population; (c) adapt currently available interventions for use with children and young people with autism; and (d) rigorously test these interventions in clinical trials.

WHAT THIS PAPER ADDS

Significant food restriction is common in children and young people with autism. Sensory sensitivities are frequently cited as a reason for food restriction. The prevalence and causes of avoidant/restrictive food disorders in children and young people with autism need further research.

A Narrative Review on Pediatric Scurvy: The Last Twenty Years

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.

Scurvy in children - A neglected disease?

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.

Intensive multidisciplinary feeding intervention for patients with avoidant/restrictive food intake disorder associated with severe food selectivity: An electronic health record review

OBJECTIVE

Expert consensus increasingly recognizes intensive multidisciplinary intervention (IMI) as the standard of care to address chronic and severe feeding problems in pediatric populations. In this study, we examined the clinical presentation, intervention characteristics, and treatment outcomes for young children receiving IMI for avoidant restrictive rood intake disorder (ARFID) involving nutritional insufficiencies associated with severe food selectivity.

METHOD

We followed the Strengthening the Reporting of Observational Studies in Epidemiology statement to conduct this retrospective chart review. The review focused on consecutive patients (birth to age 21 years) admitted to the IMI program over a 5-year period (June 2014 to June 2019). Inclusion criteria required micronutrient insufficiencies (vitamins A, B12, C, D, E; folic acid; calcium; iron; and zinc) and chronic mealtime refusal behavior (e.g., turning head away from food/spoon, pushing or throwing spoon, crying, screaming, and leaving the table) associated with severe food selectivity.

RESULTS

Over the 5-year period, 63 of the patients met study entry requirements. Of these, 60 patients (50 boys and 10 girls; mean age = 72 ± 39 months; range = 23-181) completed intervention (95% treatment completion rate). At discharge, dietary diversity improved by 16 new therapeutic foods (range: 8-22), rapid acceptance and swallowing of new foods exceeded clinical benchmarks (80% or > bites), and risk for nutritional inadequacies declined for this patient cohort.

DISCUSSION

Results of the current study support the benefits of IMI to increase dietary variety, improve mealtime behaviors, and enhance nutritional intake for children with ARFID presenting with severe food selectivity.

Scurvy as a Sequela of Avoidant-Restrictive Food Intake Disorder in Autism: A Systematic Review

OBJECTIVE

To document the clinical presentation of scurvy in children with autism spectrum disorder (ASD) and summarize the contemporary approaches to assessment and management in this population. Scurvy is a disease caused by vitamin C deficiency most often detected in populations at high risk for nutrition insufficiency (e.g., extreme poverty). Children with ASD and severe food selectivity consistent with avoidant-restrictive food intake disorder may also be at risk for scurvy.

METHOD

We searched MEDLINE, CINAHL, and PsycINFO databases (1990-2018) in peer-reviewed journals for studies of children with ASD and scurvy. Inclusion criteria required confirmed diagnosis of ASD and scurvy in children (birth to 18 years) with a clear description of restrictive dietary patterns. Cases of scurvy due to other causes were excluded. We used a standardized protocol to independently code information; agreement between coders was high.

RESULTS

The systematic search identified 20 case reports involving 24 children (mean age = 9 ± 3.5; 22 boys/2 girls). The eventual diagnosis of scurvy followed a wide range of negative diagnostic testing; treatment with ascorbic acid and/or a multivitamin resulted in rapid improvement.

CONCLUSIONS

Symptoms of scurvy mimic other pediatric conditions (e.g., cancer). The range of diagnostic testing increased costs and healthcare risks (radiation, sedation) and delayed the diagnosis of scurvy. In children with ASD and severe food selectivity, a nutrition evaluation and laboratory testing are warranted before a more elaborate testing.

Vitamin A deficiency-associated corneal perforation in a boy with autism spectrum disorder: A case report and literature review

BACKGROUND

Malnutrition and vitamin deficiency are growing concerns in the clinical management of children with autism spectrum disorder (ASD). This case report presents a boy with ASD who developed vitamin A deficiency during follow-up.

CASE REPORT

A 7-y-old boy had been diagnosed with ASD and developmental delay at age 18 mo. He developed convulsions associated with hypocalcemia and vitamin D deficiency at 3 y of age. Although vitamin D supplementation was continued, he was only able to eat rice, green tea, and fried potatoes from 3 y of age to age 7 y. He had started rubbing his eyes and had refused to open his eyes 9 mo before. An ophthalmologic examination showed bilateral corneal ulcers and right corneal perforation. Vitamin A was immediately supplemented with a nasogastric tube; however, his right eye was surgically enucleated against the persistent infection.

LITERATURE REVIEW

A search of the relevant literature from 1993 to 2020 identified 11 cases of patients with ASD (5-17 y of age) who developed vitamin A deficiency owing to malnutrition. Only 4 cases (36%) had a full recovery in visual acuity.

CONCLUSION

Vitamin A deficiency frequently causes irreversible visual impairment in children with ASD. Vigilant monitoring of vitamin levels prevents unfavorable outcomes in children with ASD and difficulty in food intake.

Pediatric Scurvy: How an Old Disease Is Becoming a New Problem

Ascorbic acid (vitamin C) functions as a cofactor and antioxidant within the human body that enables tissue growth and repair, but vitamin C is not intrinsically produced. Scurvy, or ascorbic acid deficiency, has traditionally been viewed as a historical disease. With the incidence of autism spectrum disorder and food restriction on the rise, children's hospitals may see increasing cases of scurvy. This is a single-center, retrospective case series including patients aged 7 to 14 years who were admitted to the Kentucky Children's Hospital with scurvy in the 2018-2019 period. Although selective or restricted eating is not an uncommon behavior among children, especially toddlers, parents of autistic children frequently report their children to be exceedingly selective eaters. However, there currently are conflicting findings on whether this leads to nutritional inadequacy. Although no guidelines exist for the treatment of scurvy, the mainstay of therapy is reintroduction of vitamin C. Oral therapy is generally preferred, but vitamin C can be given parenterally when necessary. In conclusion, oral aversion is a symptom commonly seen in patients with autism spectrum disorder and other developmental delays, potentially leading to increased cases of scurvy. Treatment of scurvy includes reintroduction of vitamin C into the diet. However, oral supplementation may pose unique challenges in this patient population.

Nutritional Deficiency Disease Secondary to ARFID Symptoms Associated with Autism and the Broad Autism Phenotype: A Qualitative Systematic Review of Case Reports and Case Series

BACKGROUND

The demographics, weight statuses, and dietary patterns of people with autism or the broad autism phenotype who experience a severe nutrient deficiency disease due to symptoms of avoidant/restrictive food intake disorder have not been well established.

OBJECTIVE

The primary objective of this review was to examine the relationship between the demographics, weight statuses, dietary patterns, and nutrient deficiency diseases that characterize the most severe manifestations of avoidant/restrictive food intake disorder symptomology associated with autism or the broad autism phenotype.

METHODS

A systematic review of English and non-English articles published up to August 29, 2019, on the Scopus, PubMed, and Cumulative Index to Nursing and Allied Health Literature Plus electronic databases was conducted. Additional cases were identified through the reference list of all included articles. The search terms used were "autis^∗ AND (deficiency OR scurvy)". Only case reports or case series in which a person of any age who had been identified as having a formal diagnosis of autism or autism symptoms and a disease of nutritional deficiency due to self-imposed dietary restrictions were included. Data were independently extracted by 8 authors using predefined data fields.

RESULTS

A total of 76 cases (patients were aged 2.5 to 17 years) from 63 articles that were published from 1993 through 2019 were found. More than 85% cases (65 of 76 patients) were from articles published in the past 10 years. The largest percentage of published cases (69.7% [53 of 76]) involved scurvy, a vitamin C deficiency. The second-largest percentage of published cases (17.1% [13 of 76]) involved eye disorders secondary to vitamin A deficiency. Other primary nutrient deficiencies reported were thiamin, vitamin B-12, and vitamin D. In 62.9% (22 of 35) of the patients for which a body mass index or a weight percentile for age was provided, the patient was within normal weight parameters, per Centers for Disease Control weight status categories.

CONCLUSIONS

Based on the 63 articles extracted for this systematic review, nutritional deficiency diseases related to inadequate intakes of vitamin A, thiamin, vitamin B-12, vitamin C, and vitamin D were found in individuals with autism and the broad autism phenotype who had severe self-imposed dietary restrictions. When weight information was provided, most of the youth in these cases were not reported to be underweight. Individuals of any weight who present with symptoms of avoidant/restrictive food intake disorder can benefit from early and frequent screening for adequacy of micronutrient intake, regardless of whether they have a clinical diagnosis of autism.

"What can you C in a limping child?" Scurvy in an otherwise healthy "picky eater"

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.

Vitamin C Deficiency Presenting as an Acute Limp in Childhood

A previously well three-year-old boy attended with right knee pain and an antalgic gait. There was no history of fever and bloods including inflammatory markers were normal. A diagnosis of transient synovitis (irritable hip) was made and managed conservatively. One month later, he represented with increasing pain, now localising to his left hip, waking him at night with difficulty weight-bearing. No effusion was seen on ultrasound and bloods remained normal. He was discharged home but came back a week later with worsening polyarticular pain, a new maculopapular rash, significant bruising and new dental decay. A clinical diagnosis of vitamin C deficiency was made secondary to dietary insufficiency, and this was confirmed on blood testing. Within six weeks, his symptoms had fully improved on oral ascorbic acid (vitamin C) and he was engaging in dietetic input and reward systems to maintain a more balanced diet.

Increases in Acute Phase Reactants in a Patient with Scurvy Despite No Inflammation: Review of Literature

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.

Scurvy: a rare case in an adult

A 69-year-old man presented with unilateral calf pain, swelling, and erythematous rash. He was initially treated with antibiotics for suspected cellulitis. A venous duplex ultrasound, performed to exclude deep venous thrombosis, revealed multiple heterogeneous hypoechoic foci of unknown etiology throughout the calf musculature. His condition did not improve with antibiotics, instead progressing to a necrotic ulcer along the medial malleolus. Clinical suspicion of vascular insufficiency or vasculitis prompted an extensive imaging work-up. CT and MRI revealed the intramuscular abnormalities observed on previous ultrasound represented foci of intramuscular hemorrhage. Marrow signal abnormality was also noted in the proximal tibia. A punch biopsy of the skin rash ultimately demonstrated distorted hair follicles with perifollicular inflammation and hemorrhage concerning for scurvy. The diagnosis was confirmed by low vitamin C levels and dietary history. A resurgence of scurvy has occurred in the pediatric population in recent years. However, this diagnosis remains uncommon in adults, with limited reports of the potential advanced imaging findings in the current literature.

Is vitamin C enough? A case report of scurvy in a five-year-old girl and review of the literature

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.

Lessons in early identification and treatment from a case of disabling vitamin C deficiency in a child with autism spectrum disorder

BACKGROUND

Autism spectrum disorder is a heterogenous neurodevelopmental condition accompanied by a variety of associated features. Case reports suggest one such associated feature, food selectivity, increases risk for nutritional deficiencies; however, little attention has been given to prevent and treat nutritional deficiencies in youth with autism spectrum disorder.

METHOD

Single case report.

RESULTS

This single case report presents a child with autism spectrum disorder and food selectivity difficulties that resulted in severe vitamin C deficiency. Although eventually corrected, the nutritional deficiency was debilitating, required invasive interventions, and resulted in significant social/emotional and economic costs.

CONCLUSIONS

We review the course of treatment and highlight strategies to prevent and more effectively treat nutritional deficiencies in youth with autism spectrum disorder.

Epilepsy and vitamin D: a comprehensive review of current knowledge

Vitamin D has been considered as neurosteroid, and its pivotal role in neuroprotection, brain development, and immunomodulation has been noticed in studies; however, our knowledge regarding its role in neurological disorders is still developing. The potential role of vitamin D in the pathophysiology and treatment of epilepsy, as one the most prevalent neurological disorders, has received less attention in recent years. In this article, we review the possible relationship between vitamin D and epilepsy from different aspects, including the action mechanism of vitamin D in the central nervous system and ecological and epidemiological findings. We also present the outcome of studies that evaluated the level of vitamin D and the impact of administrating vitamin D in epileptic patients or animal subjects. We also review the current evidence on interactions between vitamin D and antiepileptic drugs.

Scurvy: When it is a Forgotten Illness the Surgery Makes the Diagnosis

BACKGROUND

Unlike most of animal species, human beings lack the enzymatic process for the conversion of glucose to ascorbic acid (vitaminC), and therefore getting the vitamin from food sources is essential. The association of the various signs caused by a deficiency of vitamin C is called scurvy or Barlow's disease, an easily treatable disease but can be fatal. It is rare in the developed countries and even economically underdeveloped societies in which the basic diet is already rich in ascorbate.

METHODS

We describe here the case of a 4-year-old girl with cerebral palsy, in whom diagnosis concerns were oriented for osteomyelitis, based upon clinical presentation, ultrasonic and magnetic resonance imaging, led to a surgery revealing subperiosteal hematomas that argues in favor of scurvy.

RESULTS

After vitamin C therapy, the symptoms are gone and the general condition of the patient improved despite persistent radiological signs.

CONCLUSION

Recent studies of sporadic cases report a high incidence of scurvy in children with autism or psychomotor retardation and the fact that musculoskeletal manifestations are more common. The mosaics of the symptoms of scurvy are varied and include dermatological, dental, bone and systemic manifestations, making it a forgotten and misdiagnosed illness. A heightened awareness is needed to avoid an unnecessary surgery, unnecessary tests and procedures and to be able to start treatment for a potentially fatal but easily curable disease.

Brief Report: Scurvy as a Manifestation of Food Selectivity in Children with Autism

Scurvy was diagnosed in seven children at Boston Children's Hospital. All of the children had a developmental disorder and autism was the most common. They had a long-standing history of food selectivity with diets devoid of fruits and vegetables, and none of the children were supplemented with a multivitamin. They presented with limp, and an elaborate panel of tests and procedures were undertaken before the diagnosis of scurvy was made. Treatment with vitamin C led to rapid recovery of symptoms. This report emphasizes the importance of considering nutritional causes of musculoskeletal symptoms in children with autism and restrictive diets.

[Infantile scurvy: Two cases]

BACKGROUND

Scurvy is the classic and most severe form of vitamin C deficiency. This condition has become extremely rare among children in the industrialized countries.

PATIENTS AND METHODS

We report the case of two boys presenting bone pain associated with haemorrhagic gingivitis, with perifollicular purpura of the lower limbs in one boy. The children had an unbalanced diet. Scurvy was associated with vitamin D and iron deficiency. The dermatological and radiological abnormalities seen were characteristic and a favourable outcome was rapidly obtained following supplementation.

DISCUSSION

The possibility of this forgotten historical illness should not be overlooked in the presence of these dermatological and rheumatologic signs, since this can help avoid unnecessary or excessively aggressive investigations.

Childhood scurvy: an unusual cause of refusal to walk in a child

Scurvy, or vitamin C deficiency, is rarely presented to a rheumatology clinic. It can mimic several rheumatologic disorders. Although uncommon, it may present as pseudovasculitis or chronic arthritis. Scurvy still exists today within certain populations, particularly in patients with neurodevelopmental disabilities, psychiatric illness or unusual dietary habits.Scurvy presentation to the rheumatologist varies from aches and mild pains to excruciating bone pain or arthritis. Musculoskeletal and mucocutaneous features of scurvy are often what prompts referrals to pediatric rheumatology clinics. Unless health care providers inquire about nutritional habits and keep in mind the risk of nutritional deficiency, it will be easy to miss the diagnosis of scurvy. Rarity of occurrence as compared to other nutritional deficiencies, combined with a lack of understanding about modern-day risk factors for nutritional deficiency, frequently leads to delayed recognition of vitamin C deficiency. We report a case of scurvy in a mentally handicapped Saudi child, who presented with new onset inability to walk with diffuse swelling and pain in the left leg. Skin examination revealed extensive ecchymoses, hyperkeratosis and follicular purpura with corkscrew hairs, in addition to gingival swelling with bleeding. Clinical diagnosis of scurvy was rendered and confirmed by low serum vitamin C level. The patient did extremely well with proper nutritional support and vitamin C supplementation. It has been noticed lately that there is increased awareness about scurvy in rheumatology literature. A high index of suspicion, together with taking a thorough history and physical examination, is required for diagnosis of scurvy in patient who presents with musculoskeletal symptoms. Nutritional deficiency should also be considered by the rheumatologist formulating differential diagnosis for musculoskeletal or mucocutaneous complaints in children, particularly those at risk.

MRI findings in pediatric patients with scurvy

In modern times scurvy is a rarely encountered disease caused by ascorbic acid (vitamin C) deficiency. However, sporadic cases of scurvy persist, particularly within the pediatric population. Recent individual case reports highlight an increased incidence of scurvy among patients with autism or developmental delay, with isolated case reports detailing the magnetic resonance imaging (MRI) findings of scurvy in these pediatric populations. We present the MRI findings of scurvy in four patients with autism or developmental delay, and review the literature on MRI findings in pediatric patients with scurvy. Despite its rarity, the radiologist must consider scurvy in a pediatric patient with a restricted diet presenting with arthralgia or myalgia.

Scurvy in an autistic child: MRI findings

Scurvy results from a deficiency of vitamin C and is rarely seen in the United States. We describe the MRI findings of a case of scurvy in an autistic child with food-avoidant behavior. Advanced imaging is rarely performed in clinically well-understood disease entities such as scurvy. Typical radiographic findings are well described leading to definitive diagnosis, although the findings can be missed or misinterpreted given the rarity of scurvy in daily practice. To our knowledge, MRI features of scurvy in children in the US have been described in only one case report. This case of scurvy in an autistic child with food-avoidant behavior emphasizes that classic nutritional deficiencies, despite their rarity, must be included in the differential diagnosis of at-risk populations.

Historic condition in a modern child with autism

Haven is an 11-year-old primary care patient who you have followed since her birth. She was the 9 lb 6 oz product of a 38-week gestation complicated by maternal hypertension and seizure disorder treated with tegretol. Her delivery and neonatal course were uneventful. She was diagnosed with austistic disorder at age 2 years, at which time she used no functional language or gestures, had repetitive motor mannerisms, and limited eye contact. She had strong tactile sensory aversions. Her diet was very restricted including only banana yogurt and drinking milk and apple juice for the first several years of life. She was followed by a developmental-behavioral pediatrician approximately annually through age 8 years and then more frequently. She was healthy other than lead exposure (maximum serum level 18 at age 3 years) and multiple febrile seizures with other possible absence episodes. Her development remained very delayed with use of single words and short phrases. She developed multiple repetitive, anxious, obsessive behaviors (picking up lint, organizing, cleaning, and freezing in certain postures) that were treated with a selective serotonin reuptake inhibitors fluvoxamine. Sensory issues were ongoing, with restrictive eating (primarily peanut butter and jelly sandwiches, cereal bars, milk, and a kiwi-strawberry drink). She took a liquid multivitamin until age 8.At age 11 years, 3 weeks prior to admission, Haven developed acute loss of ambulation over the course of 1 day, initially dragging her right leg, and then refusing to walk and her parents brought her in to see you. She had fever, vomiting, and general weakness. She developed extensive bruising over her legs, especially in the popliteal fossae. She was also noted to have friability and dark discoloration of her gums. Initially, you suspected a post-viral syndrome and close monitoring. She was seen twice in the next 2 weeks in a local emergency room where her erythrocyte sedimentation rate was reported to be elevated and juvenile rheumatoid arthritis or a reaction to fluvoxamine were suspected. Antibiotics were also prescribed for gingivitis. She was seen by an orthopedist who felt it was not an orthopedic issue and leg films were unremarkable. With her second emergency room visit, she was transferred to a tertiary medical center and admitted for further evaluation. Where would you go from here?

Nutrition, physical activity, and bone mineral density in youth with autistic spectrum disorders

OBJECTIVE

Fractures and pain, secondary to low bone mineral density (BMD), have been reported in pediatric patients with autistic spectrum disorders (ASD). The purpose of this study was to assess the BMD of a clinical sample of 10- to 18-year olds with ASD, and the nutrition and physical activity correlates of skeletal health in this population.

METHODS

Twenty-six patients with ASD were recruited from an outpatient multidisciplinary child-development clinic. Lumbar bone density was measured using dual-energy x-ray absorptiometry. Data collection included anthropometries, serum nutrient levels, parent interview, and 72-hour diet, screen-time, and physical activity records.

RESULTS

Four patients (15%) met criteria for pediatric low BMD with z scores less than or equal to -2.0; another 4 were at risk with z scores less than or equal to -1.0. Approximately 54% of participants had insufficient serum 25-hydroxy vitamin D. Mean electronic media use was 251 minutes/day; mean physical activity 69 minutes/day. Fewer than 50% of participants met daily reference intake of vitamins A, B3, D, E, K, zinc, calcium, folate, potassium, and fiber. Bone density correlated positively with body mass (r = .47), calcium intake (r = .46), and calorie intake (r = .58).

CONCLUSIONS

Children aged 10 to 18 years old with ASD are at risk for occult low bone density. In this study, those with low body mass index and insufficient calcium and calorie intake were at greater risk. Other unhealthy behaviors in this population included a high screen-time to physical activity ratio and multiple nutrient deficiencies.

Vitamin D and autism: clinical review

BACKGROUND

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder with multiple genetic and environmental risk factors. The interplay between genetic and environmental factors has become the subject of intensified research in the last several years. Vitamin D deficiency has recently been proposed as a possible environmental risk factor for ASD.

OBJECTIVE

The aim of the current paper is to systematically review the research regarding the possible connection between ASD and vitamin D, and to provide a narrative review of the literature regarding the role of vitamin D in various biological processes in order to generate hypotheses for future research.

RESULTS

Systematic data obtained by different research groups provide some, albeit very limited, support for the possible role of vitamin D deficiency in the pathogenesis of ASD. There are two main areas of involvement of vitamin D in the human body that could potentially have direct impact on the development of ASD: (1) the brain (its homeostasis, immune system and neurodevelopment) and (2) gene regulation.

CONCLUSION

Vitamin D deficiency--either during pregnancy or early childhood--may be an environmental trigger for ASD in individuals genetically predisposed for the broad phenotype of autism. On the basis of the results of the present review, we argue for the recognition of this possibly important role of vitamin D in ASD, and for urgent research in the field.

Bilateral proptosis in a child with vitamin C deficiency

Scurvy is one of the oldest diseases known to mankind, caused by vitamin C deficiency. Nowadays it exists primarily in certain vulnerable populations such as patients with neurodevelopmental disabilities. Proptosis due to orbital haemorrhage is a rare complication of scurvy. Here we describe a case of diaplegic cerebral palsy presented with sudden onset of bilateral proptosis and swollen and tender knee joints. Subsequent computed tomography of the orbit revealed hematoma in the superior aspect of both orbits in the extraconal position. X-ray of the knee joints revealed bony changes consistent with scurvy. After 6 weeks of treatment with vitamin C orally, the proptosis and the bony changes returned to normal. Although scurvy is a rare disease in the general pediatric population, it still exists in certain vulnerable populations like neurologically disabled ones, and this uncommon cause for proptosis should be considered in such children.

Infantile scurvy: two case reports

Background. Ascorbic acid (vitamin C) is necessary for the formation of collagen, reducing free radicals, and aiding in iron absorption. SCURVY, a disease of dietary ascorbic acid deficiency, is uncommon today. It still exists in high risk groups including economically disadvantaged populations with poor nutrition. The incidence of SCURVY in the pediatric population is very low. Cases Report. Here we report two cases of SCURVY revealed by subperiosteal hematoma in children with cerebral palsy and developmental delay. Conclusion. SCURVY is extremely rare in children. Musculoskeletal manifestations are prominent in pediatric SCURVY. Multiple subperiosteal hematomas are an important indicator for diagnosis.

Scurvy: forgotten but definitely not gone

Scurvy, a disease of vitamin C deficiency, is purportedly rare in the United States yet frequently may be misdiagnosed. Presenting symptoms include bone pain, limping, rashes, or spongy bleeding gingiva. These symptoms mimic many other disorders, which often results in numerous unnecessary, invasive, and expensive procedural investigations. The strongest indication of a scurvy diagnosis is the dramatic response to the administration of vitamin C. This case report demonstrates the complexities involved in determining the cause of one child's symptoms. A thorough nutritional history and a shrewd clinician are essential to the early diagnosis and treatment of scurvy.