A Case Report

Scurvy May Occur Even in Children With No Underlying Risk Factors

Romina Gallizzi; Mariella Valenzise; Stefano Passanisi; Giovanni Battista Pajno; Filippo De Luca; Giuseppina Zirilli

Disclosures

J Med Case Reports. 2020;14(18) 

In This Article

Case Presentation

A 3-year-old white boy was admitted to our clinic due to the following symptoms that had presented some weeks earlier: asthenia, diffuse lower-extremity musculoskeletal pain, and refusal to walk. His past medical history was unremarkable for developmental delay, neurologic disorders, and/or other underlying diseases. He had received the recommended and compulsory vaccinations according to Italian regulations. There was no recent history of fever, weight loss, trauma, bruising, and/or arthropathies.

At the time of admission to our clinic, a physical examination evidenced normal growth parameters and blood pressure. He presented a stature of 92.1 cm (17th percentile of expected height for age and sex) and a weight of 11.9 kg (3rd percentile of expected weight for age and sex). No dysmorphic features and no neurological or cardiovascular abnormalities were noted. After 2 days, he developed a clinical picture characterized by severe pallor, petechial hemorrhages on his arms and legs, gum hypertrophy and bleeding, macroscopic hematochezia and, finally, tachycardia and dyspnea, which required oxygen therapy. He exhibited markedly swollen, purple, and spongy gingivae, which bled spontaneously. There were no hepatosplenomegaly or lymphadenopathies or joint effusions.

At that time laboratory investigations revealed hemoglobin of 5.4 g/L, reticulocyte count of 3.5%, white blood cell count of 8.75 × 109/L with a normal differential count, and a platelet count of 369 × 109/L. His C-reactive protein serum levels, coagulation profile, muscle enzyme and electrolyte levels, and liver and kidney function tests were all within reference ranges for our laboratory. Thus, the child underwent a blood transfusion due to his severe anemia.

A skeletal survey revealed a dense line at the distal right femoral metaphysis and a lucent metaphyseal band, two findings which were felt to be suggestive of scurvy (Figure 1). Such a diagnostic suspicion was, overall, supported by the constellation of gingival disease, purpura, anemia, hematochezia, musculoskeletal pain, and bone radiologic findings, as well as by the specific nutritional history. This revealed a strictly selective diet since the time of weaning, exclusively based on water, milk, and pasta, with complete avoidance of meat, fruit, vegetables, and fish for at least 2 years. Such inadequate eating habits derived from the boy's refusal to try new food. A psychological evaluation highlighted a food behavioral disorder as a possible cause of his selective diet. No vitamin supplementation was administered. A review of the nutritional content of his diet revealed no dietary source of vitamin C and limited amounts of iron and vitamin D (Table 1). Nutritional laboratory investigations showed low serum concentrations of ascorbic acid, ferritin, iron, 25-hydroxyvitamin D (25-OH-vitamin D), and 1,25-hydroxyvitamin D (1,25-OH-vitamin D) (Table 2). On the basis of his nutritional history, clinical examination, radiographic findings, and laboratory findings, a diagnosis of scurvy was definitively assessed and vitamin C supplementation was added, starting from 300 mg/day for 28 days, followed by 100 mg/day in a maintaining phase.

Figure 1.

Right leg X-ray showing dense line at the distal femoral metaphysis (green arrow) and a lucent metaphyseal band (red arrow)

During the subsequent weeks we recorded a progressive improvement in his general condition, with resolution of cutaneous and mucosal bleeding, weight gain, pain reduction, and amelioration in walking impairment. After 90 days of treatment with vitamin C, ascorbic acid levels increased to 59 μmol/L, which confirmed the diagnosis of scurvy. The subsequent normalization of radiologic findings corroborated this diagnosis (Table 3). Psychological support was mandatory in order to facilitate our patient's acceptance of the renewed nutritional regimen.

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