Pediatric scurvy MRI appearance

A comprehensive review on gelatinous transformation of the bone marrow

INTRODUCTION

Gelatinous transformation of the bone marrow (GTBM) represents a clinically significant but often underdiagnosed condition, emphasizing the pivotal role of accurate diagnosis in facilitating appropriate treatment strategies.

AREAS COVERED

This special report synthesizes insights gathered from a comprehensive appraisal of clinical and pathology publications on GTBM available on PubMed. By employing search terms such as 'gelatinous,' 'gelatinous transformation,' and 'bone marrow,' this report aims to provide a nuanced understanding of GTBM, elucidating distinctive pathological features while distinguishing it from similar pathologies. The review also discusses currently identified causes of GTBM, clinical, imaging, pathologic, and laboratory findings that are associated with GTBM, and treatment options available.

EXPERT OPINION

Contrary to popular belief, we suggest that nutrient deficiency is not solely responsible for the pathogenesis of GTBM and that malignancies, infection, and inflammatory conditions play a critical role in its pathogenesis. We propose that further research on the pathophysiology of GTBM should be performed to unravel the complex interplay of nutritional and inflammatory factors in hematopoiesis, paving the way for innovative treatment approaches in hematopoietic disorders. To better facilitate further research in GTBM, we suggest formulating a pooled patient database with nutritional, genetic, and cytokine markers in a prospective fashion.

An apple a day keeps the doctor away: pediatric scurvy case report and mini review

Scurvy is a rare nutritional disorder caused by deficiency of ascorbic acid (vitamin C). It is often under-diagnosed in clinical settings, especially in North America where population statistics are unavailable. However, scurvy is more common than previously thought and appears to be re-emerging in children with developmental delays. Here, we review the pertinent literature and present a case of a previously healthy, 5-year-old, non-verbal boy who presented with multiple, acute, and subacute spontaneous epidural hemorrhages managed by neurosurgical intervention. He remained in hospital for 17 days and was seen in follow-up 3 weeks post-operatively having returned to his neurological baseline. Our case suggests the importance of considering scurvy in patients who have developmental delays and poor nutritional status.

The Troubling Rise of Scurvy: A Review and National Analysis of Incidence, Associated Risk Factors, and Clinical Manifestations

INTRODUCTION

In the era of modern medicine, scurvy has been thought of as a rare disease of ancient times because of improved emphasis on diet and nutrition; however, isolated case reports are plentiful. This investigation presents a comprehensive review of scurvy, including an analysis on its rising incidence, with specific focus on its orthopaedic manifestations and commonly associated diagnoses.

METHODS

This comprehensive review includes a retrospective analysis of 19,413,465 pediatric patients in the National Inpatient Sample database from 2016 through 2020. Patients with scurvy were identified by the ICD-10 code, and an estimated incidence of scurvy in the inpatient pediatric population was calculated. Concurrent diagnoses, musculoskeletal reports, and demographic variables were collected from patient records. Comparisons were made using analysis of variance or chi-square with Kendall tau, where appropriate.

RESULTS

The incidence of scurvy increased over the study period, from 8.2 per 100,000 in 2016 to 26.7 per 100,000 in 2020. Patients with scurvy were more likely to be younger (P < 0.001), male (P = 0.010), in the lowest income quartile (P = 0.013), and obese (P < 0.001). A majority (64.2%) had a concomitant diagnosis of autism spectrum disorder. Common presenting musculoskeletal reports included difficulty walking, knee pain, and lower limb deformity. Burden of disease of scurvy was markedly greater than that of the average inpatient population, with these patients experiencing greater total charges and longer hospital stays.

CONCLUSION

Clinicians should be aware of the increasing incidence of scurvy in modern medicine. In cases of vague musculoskeletal reports without clear etiology, a diagnosis of scurvy should be considered, particularly if risk factors are present.

TRIAL REGISTRATION NUMBER

NA.

Pictorial review: challenges in distinguishing bilateral metaphyseal marrow abnormalities on magnetic resonance imaging

The paediatric metaphysis is afflicted by a wide range of pathological processes as it is the most metabolically active and well-vascularised part of the developing skeleton. This review focuses on metaphyseal marrow signal change detected with magnetic resonance imaging, which is most often occult on radiographs. When bilateral, these imaging appearances frequently present a diagnostic quandary. This review assists the radiologist to confidently dismiss physiological signal change and confidently work through the differential diagnosis. This is achieved by illustrating a practical method of classifying signal change into four categories: physiological red marrow, red marrow reconversion, marrow infiltration, and oedema-like marrow signal intensity. In doing so, various pathological entities are reviewed along with imaging pearls and next-step investigations.

Pediatric scurvy case report: a novel presentation with deep vein thrombosis secondary to large bilateral spontaneous iliac subperiosteal hematomas

BACKGROUND

Scurvy is an uncommon disease in developed countries caused by deficiency of vitamin C. We present a case of scurvy in a 14-year-old male with autism with both novel presentation and imaging findings. This case had the novel presentation of lower limb deep vein thrombosis (DVT) secondary to compression of the external iliac vein from large bilateral iliac wing subperiosteal hematomas. Subperiosteal hematoma is a well-recognised feature of scurvy but large and bilateral pelvic subperiosteal hematoma causing DVT has not previously been described.

CASE PRESENTATION

A 14 year old Caucasian male with background of autism and severe dietary restriction presented with lower limb swelling and immobility. He was diagnosed with lower limb DVT. Further investigation revealed an iron deficiency anaemia, and he was found on MRI to have large bilateral subperiosteal iliac hematomata causing compression of the iliac vessels. He improved following treatment with vitamin C replacement and follow-up imaging demonstrated resolution of the DVT and hematoma.

CONCLUSION

DVT is rare in children and when diagnosed should prompt investigation as to the underlying cause. This case demonstrates an unusual cause of DVT and as an unusual presentation of paediatric scurvy.

Scurvy: old disease, new lessons

Scurvy, the condition associated with severe vitamin C deficiency, is believed to be one of the oldest diseases in human history. It was particularly prevalent during the Age of Sail, when long sea voyages without access to fresh food resulted in an epidemic which claimed millions of lives; however, scurvy has existed across time and geography, occurring whenever and wherever diets are devoid of vitamin C. Young children, specifically, were affected by the emergence of 'infantile scurvy' in the 19th century owing to the use of heated milk and manufactured infant foods of poor nutritional quality. Scurvy continues to occur in at-risk groups. In children and youths, it is primarily observed in the context of autism spectrum disorder and feeding problems such as a limited food repertoire and high-frequency single food intake. Diagnosis may be delayed and invasive testing undertaken owing to clinicians' lack of familiarity with the disease, or the mistaken assumption that it is exclusively a disease of the past. The aetiology, clinical manifestations and treatment of scurvy are described. Its long history and current epidemiology are also reviewed, demonstrating that scurvy is very much a disease of the present. It is suggested that future efforts should focus on (i) anticipatory guidance and early nutritional intervention, informed by an understanding of scurvy's epidemiology, with the aim of preventing the disease in those at risk, and (ii) prompt recognition and treatment to minimise morbidity and healthcare costs.Abbreviations: ASD: autism spectrum disorder.

Scurvy, abnormal MRI, and gelatinous bone marrow in an adolescent with avoidant restrictive food intake disorder

BACKGROUND

Although medical literature describes pediatric scurvy as "rare", a growing number of case reports suggests otherwise. Patients often undergo costly and unnecessary workup due to unfamiliarity with the presentation of scurvy. This case report further supports the small yet growing literature documenting scurvy and its manifestations in patients with eating disorders.

CASE PRESENTATION

A 15-year-old female presented to the emergency department with bilateral knee and ankle swelling and pain in the setting of chronic lower limb rash and BMI of 16.3. For years, she had restricted her diet to carbohydrates. Exam showed perifollicular petechial hemorrhagic rash with corkscrew hairs, knee edema, ankle edema with restricted range of motion, and antalgic gait. She was admitted for severe malnutrition from avoidant restrictive food intake disorder. Her hospital course was complicated by recurrent normocytic anemia and fever. Hematology workup revealed anemia from iron deficiency, vitamin K deficiency, and anemia of chronic disease. Rheumatology workup was negative. MRI findings showed dark T1 and bright T2 signals and were read as consistent with leukemia/lymphoma, chronic multifocal osteomyelitis, or Langerhans cell histiocytosis. However, bone marrow biopsy showed gelatinous transformation secondary to malnutrition. She was treated with vitamin C and a nutrition plan and her symptoms improved.

CONCLUSIONS

Although this patient had common manifestations of scurvy, including perifollicular petechial hemorrhagic rash, joint effusions, anemia, and recurrent fevers, she still underwent an extensive workup. Clinicians should be aware that scurvy can present with multiple symptoms that mimic infectious, rheumatic, oncologic and hematological disease. Clinicians should have a high index of suspicion for scurvy in patients with malnutrition and eating disorders.

Gait Disturbance … of Red Herrings, Oranges, and Lemons - A Case of Missed Vitamin C Deficiency and Lessons Learnt

Vitamin C deficiency resulting in scurvy, is considered to be a rare nutritional disorder in developed countries, thus leading to underdiagnosis with exposure to unnecessary investigations and delay in appropriate treatment. The wide myriad of clinical signs and symptoms with which vitamin C deficiency can present (including haematological, musculoskeletal and vague constitutional symptoms that overlap with other common medical conditions), also contributes to this diagnostic challenge. Despite scurvy being habitually thought to be present in children with neurodevelopmental conditions such as autism spectrum disorder, other important at-risk groups that frequently tend to be forgotten include children with persistent fussy eating behaviour, and children with abnormal vitamin C metabolism. We hereunder present a case of a 10-year-old boy who presented to an acute general hospital for further investigation with gait disturbance. The lack of detailed nutritional assessment on presentation in the first instance led to a missed diagnosis of vitamin C deficiency, thus exposing the child to a wide array of unnecessary investigations and treatments. The added perplexity to the case resulting from false positive results of investigations performed as part of this child's workup, is also discussed.

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.

When the limp has a dietary cause: A retrospective study on scurvy in a tertiary Italian pediatric hospital

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.

Clinical Analysis of Improved Particle Swarm Algorithm-Based Magnetic Resonance Imaging Diagnosis of Placenta Accreta

The magnetic resonance imaging (MRI) image processing capabilities were investigated based on the improved particle swarm optimization (IPSO) algorithm, and the clinical application analysis of MRI images in the diagnosis of placenta accreta (PA) was evaluated in this study. The MRI uterine images were detected on the basis of IPSO. Besides, the clinical data of 89 patients with PA were selected and collected, who were diagnosed by clinical cesarean section surgery and pathological comprehensive diagnosis in hospital from January 2018 to July 2020. Then, all of them underwent the ultrasound (US) and MRI examinations, and the differences of sensitivity, specificity, and accuracy between MRI and US under IPSO in the diagnosis of PA were compared, as well as the differences in the diagnosis of adhesive, implantable, and penetrated PA. The results showed that the difference in detection between IPSO-based MRI images and US images was not statistically substantial (p > 0.05), but the number of initial detections was higher than the number of US examination. MRI examination had higher sensitivity and specificity in the diagnosis of PA during pregnancy, especially for implantable PA, compared with US examination (p < 0.05). In conclusion, MRI images based on the improved particle swarm optimization algorithm showed a good application effect in the diagnosis of placental implantation diseases, which was worthy of further promotion in clinical practice.

Magnetic Resonance Imaging Artifact Elimination in the Diagnosis of Female Pelvic Abscess under Phase Correction Algorithm

In order to explore the effect of magnetic resonance imaging (MRI) based on phase correction algorithm in diagnosing female pelvic abscess, firstly, the effect of phase correction algorithm on eliminating MRI image motion artifacts was studied, then it was applied to 71 female pelvic cases admitted to our hospital in the diagnosis of abscess patients with magnetic resonance imaging technology, and the results were compared with the results of multislice spiral CT and laparoscopy to explore the accuracy of MRI and CT. It was found that the results of MRI examination were close to those of laparoscopy, and the difference was not statistically significant (P > 0.05); the results of CT examination and laparoscopy were significantly different, and the difference was statistically significant (P < 0.05); in addition, the results of CT examination, the number of bacterial cysts (43 cases) and tuberculous cysts (12 cases), were significantly lower than the results of MRI (50 cases, 18 cases), and the difference was statistically significant (P < 0.05). The size of the mass shown by the MRI examination (4.1  cm × 4.2  cm × 3.9 cm～13.9  cm × 9.5  cm × 8.7 cm) was larger than the size of the mass revealed by the CT examination (5.2  cm × 4.3  cm × 4.1 cm～15.5  cm × 10.1  cm × 9.6 cm), the difference between the two was statistically significant (P < 0.05), and it was closer to the results of laparoscopic pathology (4.1  cm × 4.3  cm × 3.9 cm～14.1  cm × 9.3  cmP < 0.058.7 cm). In short, the phase correction algorithm could eliminate the motion artifacts of MRI images. In the imaging diagnosis of female pelvic abscess, the MRI diagnosis based on the phase correction algorithm is more ideal than the diagnosis of multislice spiral CT. It can be used as a reference basis for clinical disease treatment.