Scurvy Due to Selective Diet in a Seemingly Healthy 4-Year-Old Boy Andrew Nastro, MD,A,G,H Natalie Rosenwasser, MD,A,B Steven P

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Scurvy Due to Selective Diet in a Seemingly Healthy 4-Year-Old Boy Andrew Nastro, MD,A,G,H Natalie Rosenwasser, MD,A,B Steven P Scurvy Due to Selective Diet in a Seemingly Healthy 4-Year-Old Boy Andrew Nastro, MD,a,g,h Natalie Rosenwasser, MD,a,b Steven P. Daniels, MD,c Jessie Magnani, MD,a,d Yoshimi Endo, MD,e Elisa Hampton, MD,a Nancy Pan, MD,a,b Arzu Kovanlikaya, MDf Scurvy is a rare disease in developed nations. In the field of pediatrics, it abstract primarily is seen in children with developmental and behavioral issues, fDivision of Pediatric Radiology and aDepartments of malabsorptive processes, or diseases involving dysphagia. We present the Pediatrics and cRadiology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York; bDivision of case of an otherwise developmentally appropriate 4-year-old boy who Pediatric Rheumatology and eDepartment of Radiology, developed scurvy after gradual self-restriction of his diet. He initially Hospital for Special Surgery, New York, New York; and d presented with a limp and a rash and was subsequently found to have anemia Division of Neonatal-Perinatal Medicine, University of Michigan, Ann Arbor, Michigan gDepartment of Pediatrics, and hematuria. A serum vitamin C level was undetectable, and after review of NYU School of Medicine, New York, New York hDepartment of the MRI of his lower extremities, the clinical findings supported a diagnosis of Pediatrics, Bellevue Hospital Center, New York, New York scurvy. Although scurvy is rare in developed nations, this diagnosis should be Dr Nastro helped conceptualize the case report, considered in a patient with the clinical constellation of lower-extremity pain contributed to writing the introduction, initial presentation, hospital course, and discussion, and or arthralgias, a nonblanching rash, easy bleeding or bruising, fatigue, and developed the laboratory tables while he was anemia. This case highlights the importance of carefully assessing a child’s a pediatric resident at NewYork-Presbyterian/Weill dietary and developmental status at well-child visits, which can help avoid Cornell Medical Center, and he is now a fellow in a more invasive workup. Academic General Pediatrics at the NYU School of Medicine/Bellevue Hospital Center; Dr Rosenwasser contributed to writing the introduction, initial presentation, and discussion, helped develop the laboratory tables, and provided editing for the case Scurvy is caused by a lack of dietary developmentally appropriate children. report; Drs Daniels and Kovanlikaya contributed to vitamin C intake, with early symptoms We present a case of a 4-year-old boy writing the discussion, annotated the images, and contributed editing to the case report; Drs Pan and including fatigue, weakness, and a lack with a restricted diet diagnosed with Hampton helped conceptualize the case report and of appetite. Later symptoms include scurvy and highlight many of the contributed editing to the case report; Dr Magnani follicular hyperkeratosis, gingival unique features of this case. contributed to writing the hospital course and bleeding, corkscrew hairs, petechiae, discussion and editing the case report while she purpura, arthralgias, myalgias, was a pediatric resident at NewYork-Presbyterian/ INITIAL PRESENTATION Weill Cornell Medical Center, and she is now hemarthrosis, microfractures, bone a neonatal-perinatal medicine fellow at the 1 pain, bone loss, and osteoporosis. The A seemingly healthy 4-year-old boy University of Michigan; Dr Endo provided the symptoms of scurvy are due to presented to our orthopedic clinic with radiologic images and performed their initial reads defective collagen production because right-leg pain and had been limping for and contributed to writing the initial presentation and discussion and editing the case report; and all vitamin C is essential for proper 3 weeks after a recent fall at school. He authors approved the final manuscript as submitted 1 collagen formation. had been diagnosed with streptococcal and agree to be accountable for all aspects of pharyngitis 2 weeks before his the work. In the pediatric population, scurvy symptoms and was treated with a full DOI: https://doi.org/10.1542/peds.2018-2824 occurs almost exclusively in children course of antibiotics. Plain radiographs Accepted for publication May 17, 2019 with autism, developmental and of the tibia, fibula, and knees bilaterally behavioral issues, malabsorptive Address correspondence to Andrew Nastro, MD, were unremarkable (Fig 1). On physical Department of Pediatrics, Bellevue Hospital Center, processes, or iron overload, and in examination, he had a marked limp Administration Building, 3rd Floor, Room A314, disorders causing dysphagia or favoring the right side and limited 462 1st Avenue, New York, NY 10016. E-mail: – impaired swallowing.1 5 Scurvy in an abduction and internal and external [email protected] otherwise healthy child is a rare rotation of the right hip. He did not occurrence and is not commonly cited have tenderness, erythema, or warmth To cite: Nastro A, Rosenwasser N, Daniels SP, in pediatric literature. Self-restrictive of either lower extremity. His et al. Scurvy Due to Selective Diet in a Seemingly diets due to “picky eating” could lead to neurologic examination result was Healthy 4-Year-Old Boy. Pediatrics. 2019;144(3): e20182824 nutritional deficiencies in otherwise normal. He was referred to Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 144, number 3, September 2019:e20182824 CASE REPORT laboratory workup was notable for an Nephrology was consulted for his elevated erythrocyte sedimentation microscopic hematuria. Complement rate (ESR) of 17 mm per hour component 3 and 4 levels were found (Table 1). Antistreptolysin O antibody to be within normal limits. Hepatic and anti-DNase B antibody levels transaminases, thyroid function, and were found to be within normal serum calcium were also noted to be limits. Naproxen was prescribed within normal limits (Table 1). for pain. Additional laboratories showed iron- deficiency anemia and vitamin D On follow-up in the rheumatology deficiency (Tables 1 and 2). His fi FIGURE 1 of ce, he was noted to have serum vitamin C level result was Anteroposterior radiographs of both knees worsening limp with refusal to bear returned 48 hours after it was sent demonstrate no fracture or periosteal reaction. weight and a new rash on his lower in our rheumatology office as ,5 Subtle growth-arrest lines are noted in the extremities, which was follicular with m fi mol/L, which led to a diagnosis of distal femurs bilaterally, which are nonspeci c. nonblanching pinpoint lesions. L, left; R, right. scurvy. The reference range for Further history revealed some easy vitamin C is 24 to 114; levels .24 bleeding with brushing of his teeth, are considered normal, levels 11 rheumatology clinic because of and he was found to have mild to 23 are mild to moderate concern for poststreptococcal gingivitis on examination. deficiency, and levels ,11 are severe reactive arthritis or transient Considering his evolving physical deficiency.2 A detailed dietary fi synovitis. At the rheumatology clinic, examination ndings, including history revealed that the patient a review of systems was notable for a petechial rash and not being able to had a limited diet consisting of an intermittent rash (Fig 2) over the bear weight, our differential was primarily of waffles, yogurt, pasta arms and legs for the past 2 years, broadened to include malignancy, with butter, goldfish crackers, peanut with little improvement seen with the vasculitidies, and vitamin C butter, chicken nuggets, and water. fi use of topical emollients. His de ciency. Further laboratory work The parents reported that the developmental history was notable was sent, which showed an ESR of 39, patient’s diet had always been picky for speech delay, which had resolved hemoglobin of 7.9, and microscopic and had gradually narrowed from without intervention. He was doing hematuria (Table 1). Given his age 18 months through 4 years. well in prekindergarten and meeting progression of symptoms to the point Celiac disease was considered as all developmental milestones at the of acutely not bearing weight, a possible malabsorptive cause of time of presentation. He was found to additional imaging was done. An scurvy; however, his tissue fl be at the 10th percentile for weight ultrasound showed trace joint uid in transglutaminase immunoglobulin and 18th percentile for height, and the right hip, which was symmetric A (IgA) and total IgA levels were there was no history of weight loss or when compared with the left hip. An within normal limits. reduced height velocity. On MRI of the pelvis and femurs was examination, he did not have any ordered because of the persistent The patient was started on vitamin C rashes other than mild atopic clinical suspicion for an infectious or supplementation at 100 mg every fl dermatitis and petechiae around his in ammatory process (Fig 3), which 8 hours for 1 week followed by venipuncture site. His initial did not show any abnormality of the 100 mg daily along with iron, vitamin hips but did show bilateral symmetric D, and a multivitamin. His bone marrow edema in the distal femoral culture results were negative, and his metaphyses with periostitis and bone biopsy showed evidence of prominent surrounding soft-tissue chronic inflammation and no edema that were concerning for evidence of malignancy. His pain and multifocal osteomyelitis or ambulation quickly improved. On malignancy. A surgical bone biopsy hospital day 8, he was discharged with culture and pathology was with follow-up appointments,
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