Scurvy presenting as difficulty in walking in a child

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.

Mowat-Wilson syndrome presenting with Shone's complex cardiac anomaly

A female infant, who was diagnosed antenatally with complex heart disease, confirmed to be Shone's complex postnatally, underwent bilateral pulmonary artery banding, patent ductus arteriosus stent insertion and balloon aortic valvuloplasty soon after birth. She was found to have bilateral megaureters, left hydronephrosis and asplenia. She was on lifelong prophylactic antibiotics and extra vaccines. She had two episodes of pseudo-obstruction of the small bowel, but barium follow-through was normal. She also had a large bowel obstruction and work-up for Hirschsprung disease confirmed the diagnosis. It was noticed that she had developmental delay and hypotonia, together with subtle dysmorphism. She also had failure to thrive and difficulty feeding. Exome sequencing revealed a diagnosis of Mowat-Wilson syndrome (MWS). This case shows a previously undescribed association of Shone's complex, a complex left-sided obstructive heart defect, and MWS. It also highlights the usefulness of trio-exome sequencing in detecting such rare mutations.

Fatal SARS-CoV-2 and Mycobacterium tuberculosis coinfection in an infant: insights from Botswana

We report a fatal case of SARS-CoV-2 and Mycobacterium tuberculosis coinfection in an infant, Botswana’s first paediatric COVID-19-associated fatality. The patient, a 3-month-old HIV-unexposed boy, presented with fever and respiratory distress in the setting of failure to thrive. Both the patient and his mother tested positive for rifampin-sensitive M. tuberculosis (Xpert MTB/Rif) and SARS-CoV-2 (real time-PCR). Initially stable on supplemental oxygen and antitubercular therapy, the patient experienced precipitous clinical decline 5 days after presentation and subsequently died. Autopsy identified evidence of disseminated tuberculosis (TB) as well as histopathological findings similar to those described in recent reports of SARS-CoV-2 infections, including diffuse microthrombosis. TB remains a serious public health threat in hyperendemic regions like sub-Saharan Africa, and is often diagnosed late in infants. In addition to raising the question of additive/synergistic pathophysiology and/or immune reconstitution, this case of coinfection also highlights the importance of leveraging the COVID-19 pandemic response to strengthen efforts for TB prevention, screening and detection.

Premature thelarche in an infant girl with failure to thrive related to dietary soy exposure

A 7-month-old female infant presented with failure to thrive. She was breastfed till 3 months of age, thereafter switched to soy-based milk formula. There was no history to suggest excess energy losses, recurrent infections or chronic diarrhoea. Three months after switching to exclusive soy-based milk formula, parents noticed significant enlargement of both breasts. Clinical examination was unremarkable except for enlargement of both breasts. None of the other secondary sexual characteristics were present. Initial blood investigations showed hyponatraemic hypokalaemic hypochloraemic metabolic alkalosis, which corrected after 2 days with intravenous hydration. The patient subsequently maintained normal electrolyte balance with recommended intake of cow's milk-based standard formula milk.Further exploration of her soy-based milk revealed that it was low in sodium and calories, unsuitable for children. This was not a standard and approved infant soy-based formula milk. She achieved excellent weight gain and reduction of breast size on cessation of soy-based milk formula.

Respiratory symptoms in a child with IgE-non-dependent hypersensitivity to wheat

Food allergy (FA) is a serious health problem, and its incidence has been increasing especially in children. Wheat is one of the five most common foods that trigger allergic reactions in children. It is an increasingly recognised trigger for immune-mediated FAs, both Immunoglobulin E (IgE) and non-IgE mediated. We describe the case of a 4-year-old boy with a combination of symptoms due to IgE-mediated asthma worsened by IgE-non-dependent hypersensitivity to wheat demonstrated by a positive patch test. With the avoidance of wheat oral intake, we observed a progressive clinical improvement. To the best of our knowledge, this is the first report of a patient with IgE-non-dependent allergy to wheat presenting with chronic symptoms in one body system outside of the gastrointestinal tract and with negative skin prick test.

Late dumping syndrome in an infant on feeding jejunostomy

This article presents the case of a 3-month-old male child, who while on bolus jejunostomy tube feeds, developed recurrent episodes of hypoglycaemia. This infant had presented with failure to thrive with moderate gastroesophageal reflux necessitating a feeding jejunostomy. The infant was started on bolus feeds through the jejunostomy tube but developed recurrent episodes of hypoglycaemia. On evaluation, these episodes were hyperinsulinaemic and the baby was subsequently diagnosed with a late dumping syndrome. On changing the feeds to a continuous infusion and by eliminating added sugar from the feeds, the glucose fluctuations resolved. Dumping syndrome is a well-known complication in adults undergoing gastric surgeries. In the paediatric age group, dumping syndrome has been reported rarely, most commonly as a complication of Nissen fundoplication.

Childhood obesity in Mexico: social determinants of health and other risk factors

Approximately 50 million children and adolescents in Latin America are affected by the childhood obesity pandemic. We present the case of a 5-year-old Mexican girl with obesity and gastro-oesophageal reflux disease (GORD), in whom prenatal, lifestyle and environmental risk factors were identified. Here, we demonstrate how childhood obesity is rooted since pregnancy and the perinatal stage, and how the social determinants of health like unsafe outdoor conditions, lack of infrastructure to exercise and a suboptimal physical activity curriculum in government schools strongly influence the development and maintenance of childhood obesity and complicate management.

Food protein-induced enterocolitis syndrome: a challenging diagnosis

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated gastrointestinal food hypersensitivity triggered by food proteins. It may present acutely, with repetitive vomiting, diarrhoea and lethargy leading to dehydration and eventually shock or insidiously with intermittent emesis, chronic diarrhoea or failure to thrive. We describe a paediatric male patient with recurrent sepsis-like episodes of fever, lethargy, ashen-grey skin colouration and vomiting followed by diarrhoea. These episodes were triggered by cow's milk formula and grains. Laboratory tests revealed leucocytosis, thrombocytosis, metabolic acidosis and elevated C reactive protein. After exclusion of other differential diagnoses, the diagnosis of FPIES was established on clinical improvement with withdrawal of the offending food and positive oral food challenge. FPIES diagnosis requires a high index of suspicion and is frequently delayed, which contributes to an increased morbidity. This is due to the wide spectrum of clinical presentations and due to the absence of specific diagnostic tests.

Vitamin B12 deficiency: unusual cause of jaundice in an adolescent

Vitamin B₁₂ deficiency in vegans is a known cause of megaloblastic anaemia. We report an adolescent girl who presented with jaundice and weight loss for 6 months secondary to vitamin B₁₂ deficiency, leading to megaloblastic anaemia. Replacement with vitamin B₁₂ reversed her symptoms, resulting in weight gain, and normalised her haemoglobin, red blood cell morphology, bilirubin levels and serum vitamin B₁₂ levels.

Young girl with severe early-onset obesity and hyperphagia

This case report of an infant with severe early-onset obesity illustrates the societal condemnation of persons with obesity. In addition, it underlines the importance of diagnosing rare forms of monogenic obesity, even if no drug treatment is available. Here, we describe a 2-year-old girl with severe progressive obesity from birth onwards due to insatiable hunger. Genetic studies eventually reveal that the girl has a monogenic form of obesity caused by two mutations in the LEPR gene. No drug treatment is available (as yet) for this disease. Parents describe the stigmatic remarks they have to deal with every day. Diagnosing this rare genetic disorder was very important for understanding that satiety regulation is a complex system, of which willpower is only a small portion. In these patients, reduction of obesity can be achieved, but a different approach to lifestyle intervention is needed.