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Blaess M, Eliot K. A Framework for RDN and SLP Collaboration: A Missing Piece in Autism Spectrum Disorder Treatment. J Acad Nutr Diet 2024; 124:939-946. [PMID: 38615995 DOI: 10.1016/j.jand.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 04/08/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Martha Blaess
- Department of Nutrition and Dietetics, Department of Speech, Language, and Hearing Sciences, Saint Louis University, Saint Louis, MO.
| | - Kathrin Eliot
- Department of Nutritional Sciences, The University of Oklahoma Health Sciences, Oklahoma City, OK
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2
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Rittenhouse D, Daly A. Scurvy in a Child Presenting With a Limp and Elevated Inflammatory Markers: A Case Report. Cureus 2024; 16:e62101. [PMID: 38993395 PMCID: PMC11236488 DOI: 10.7759/cureus.62101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2024] [Indexed: 07/13/2024] Open
Abstract
Scurvy is a rare diagnosis in resource-rich countries, but cases have been documented in the United States in special populations of pediatric patients at increased risk of micronutrient deficiency such as those with autism spectrum disorder, developmental delay, or eating disorders. We discuss a seven-year-old female with autism spectrum disorder who presented with a limp and refusal to ambulate and elevated inflammatory markers on initial laboratory evaluation. Given her highly selective diet and malnutrition, we made a provisional diagnosis of scurvy and started treatment-dose vitamin C, which led to a significant improvement in her ambulatory function. Plasma vitamin C was ultimately undetectable. She was discharged with vitamin C supplementation and referred to a feeding clinic to address her malnutrition and selective eating.
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Affiliation(s)
| | - Alexander Daly
- Pediatrics, Penn State Health Children's Hospital, Hershey, USA
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3
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Du T, Kulkarni A. Scurvy in an Adolescent: A Case Report. Cureus 2024; 16:e58782. [PMID: 38784361 PMCID: PMC11112398 DOI: 10.7759/cureus.58782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Scurvy is a rare condition characterized by a deficiency in dietary vitamin C. Historically a disease taught in the context of long ocean voyages with limited vitamin intake, it is now rare in developed nations. The classical physical exam findings include gingival bleeding, perifollicular hemorrhages, and corkscrew hairs. We discuss the case of a 15-year-old female with scurvy whose initial presentation suggested more common diagnoses seen in the emergency department setting. Her course was complicated by a prior history of anorexia nervosa and a restrictive diet that lacked necessary vitamins. Once the patient's dietary habits were identified, a detailed physical exam revealed the characteristic findings. She was subsequently discharged with oral vitamin C supplements and was scheduled for outpatient follow-up to monitor symptoms.
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Affiliation(s)
- Tony Du
- Pediatric Emergency Medicine, Baylor College of Medicine, Houston, USA
| | - Abhay Kulkarni
- Pediatric Emergency Medicine, Baylor College of Medicine, Houston, USA
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4
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Haile A, Mara S, Belete Y, Dejene T. The Forgotten Disease in the 21st Century: Scurvy Outbreak in Hawassa Central Prison, Hawassa, Sidama, Southern Ethiopia, 2023. Int Med Case Rep J 2023; 16:847-866. [PMID: 38116464 PMCID: PMC10729832 DOI: 10.2147/imcrj.s438833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/05/2023] [Indexed: 12/21/2023] Open
Abstract
Background Dietary deficiencies in vitamin C lead to scurvy, an uncommon disease of nutritional deficiency in contemporary clinical practice. The inability of humans to synthesize vitamin C necessitates the regular consumption of vitamin C containing fruits, vegetables, or tablets. Objective To report a series of cases that came to HUCSH from May 25th up to the 18th of July, 2023, and to describe clinical features of scurvy from an observational study of on-site prison investigation. Methods A descriptive analysis of a case series of ten patients admitted to HUCSH between May 25th and July 18th, 2023, and on-site observational study of 67 patients over one month. A structured questionnaire was used to collect data, and SPSS version 25 was used for analysis. Results From the case series, all of the ten patients had either unilateral or bilateral leg swelling or pain as common compliant and all of them were male prisoners with mean age of 25.6±5.33 years and following admission, the hemoglobin value increased to 7.1±1.34 g/dL with treatment from 4.6±1.88 g/dL. From observational study of the prison, 67 cases were identified based on unilateral or bilateral leg swelling and/or pain, which was the presenting feature in the cluster of cases seen at HUCSH. The mean age was 23.57±6.4 years, and each patient got therapeutic doses of ascorbic acid 500mg PO daily using directly observed therapy and follow-up visit was after two and four weeks of ascorbic acid initiation and all patients showed significant improvement. Conclusion For clinicians in modern medicine, there should be a high index of suspicion for scurvy as a possible differential diagnosis when a patient presents with leg swelling in high-risk population, such as prisoners. Health-care providers in prison clinics need to be alert to such forgotten yet life-costly disease in resource constrained prison clinics.
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Affiliation(s)
- Ashagrachew Haile
- Department of Internal Medicine, College of Medicine and Other Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Simeon Mara
- Department of Internal Medicine, College of Medicine and Other Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Yegzeru Belete
- School of Medicine, College of Medicine and other Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Tesfa Dejene
- School of Medicine, College of Medicine and other Health Sciences, Hawassa University, Hawassa, Ethiopia
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5
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Paul AJ. Pseudoparalysis Secondary to Vitamin C Deficiency: A Rare Presentation in a Toddler. JBJS Case Connect 2023; 13:01709767-202312000-00016. [PMID: 37889997 DOI: 10.2106/jbjs.cc.23.00313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
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.
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6
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Kidwell A, Kelly T, Humphrey SR, Kolinski J. Bilateral Lower Extremity Pain and Weakness in a 15-year-old Boy. Pediatr Rev 2023; 44:513-516. [PMID: 37653137 DOI: 10.1542/pir.2021-005222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Affiliation(s)
- Adam Kidwell
- Children's Wisconsin, Milwaukee, WI
- Medical College of Wisconsin, Milwaukee, WI
| | | | | | - Julie Kolinski
- Children's Wisconsin, Milwaukee, WI
- Medical College of Wisconsin, Milwaukee, WI
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7
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Upadhyaya JD, Mutalik VS. Oral Lesions Associated with Systemic Disease. Oral Maxillofac Surg Clin North Am 2023; 35:227-236. [PMID: 36805901 DOI: 10.1016/j.coms.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Oral manifestations may be the first sign of a systemic disease, or represent lesions associated with an established or recurrent disease. Oral health care providers are often the first to recognize these signs. Some lesions have characteristic features that allow for early detection and intervention. On the contrary, clinical manifestations may be diverse and require a comprehensive evaluation to establish a definitive diagnosis. This article reviews the oral manifestations of select systemic diseases to help clinicians develop a differential diagnosis that leads to early diagnosis and timely intervention.
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Affiliation(s)
- Jasbir D Upadhyaya
- Department of Applied Dental Medicine, Southern Illinois University School of Dental Medicine, 2800 College Avenue, Building 285, Alton, IL 62002, USA.
| | - Vimi Sunil Mutalik
- Department of Dental Diagnostic and Surgical Sciences, University of Manitoba Dr. Gerald Niznick College of Dentistry, 780 Bannatyne Avenue, Winnipeg, Manitoba R3E 0W2, Canada
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8
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Barrette LX, Silverman BL, Lee C, Van Pelt AL. Sudden Refusal to Walk in a Child with Stickler Syndrome. Pediatr Rev 2022; 43:724-727. [PMID: 36450637 DOI: 10.1542/pir.2021-004997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
| | - Benjamin L Silverman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Clement Lee
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Children's Hospital of Philadelphia, Philadelphia, PA
| | - Amanda L Van Pelt
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Children's Hospital of Philadelphia, Philadelphia, PA
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9
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Gehle SC, Zwemer EK, Harrison WN. Limping Toward Improvement: The Value of Communicating Diagnostic Uncertainty. Hosp Pediatr 2022; 12:e288-e290. [PMID: 35851918 DOI: 10.1542/hpeds.2022-006625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Stephanie C Gehle
- Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Eric K Zwemer
- Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Wade N Harrison
- Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
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10
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Trapani S, Rubino C, Indolfi G, Lionetti P. A Narrative Review on Pediatric Scurvy: The Last Twenty Years. Nutrients 2022; 14:nu14030684. [PMID: 35277043 PMCID: PMC8840722 DOI: 10.3390/nu14030684] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Sandra Trapani
- Pediatric Unit, Department of Health Sciences, Meyer Children’s University Hospital, University of Florence, Viale Pieraccini 24, 50137 Florence, Italy
- Correspondence: ; Tel.: +39-055-5662480
| | - Chiara Rubino
- Pediatric Unit, Meyer Children’s University Hospital, Viale Pieraccini 24, 50137 Florence, Italy;
| | - Giuseppe Indolfi
- Pediatric Unit, Department of NEUROFARBA, Meyer Children’s University Hospital, University of Florence, Viale Pieraccini 24, 50137 Florence, Italy;
| | - Paolo Lionetti
- Gastroenterology Unit, Department of NEUROFARBA, Meyer Children’s University Hospital, University of Florence, Viale Pieraccini 24, 50137 Florence, Italy;
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11
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Masci D, Rubino C, Basile M, Indolfi G, Trapani S. When the limp has a dietary cause: A retrospective study on scurvy in a tertiary Italian pediatric hospital. Front Pediatr 2022; 10:981908. [PMID: 36186634 PMCID: PMC9519129 DOI: 10.3389/fped.2022.981908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Daniela Masci
- Post-graduate School of Pediatrics, University of Florence, Florence, Italy
| | - Chiara Rubino
- Pediatric Unit, Meyer Children's University Hospital, Florence, Italy
| | - Massimo Basile
- Radiology Unit, Meyer Children's University Hospital, Florence, Italy
| | - Giuseppe Indolfi
- Pediatric Unit, Meyer Children's University Hospital, Florence, Italy.,Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Sandra Trapani
- Pediatric Unit, Meyer Children's University Hospital, Florence, Italy.,Department of Health Sciences, Meyer Children's University Hospital, University of Florence, Florence, Italy
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12
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Rubino C, Mastrangelo G, Bartolini E, Indolfi G, Trapani S. The Pitfall in Differential Diagnosis of Musculoskeletal Symptoms in Children: A Case Series of Pediatric Scurvy. J Clin Rheumatol 2021; 27:S362-S367. [PMID: 32897996 DOI: 10.1097/rhu.0000000000001562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Kow RY, Nik Abdul Adel NA, Abdul Razak AH, Low CL, Awang MS. Scurvy: A Neglected Cause of Muscle Pain and Weakness in a Child With Picky Eating Behavior. Cureus 2021; 13:e16289. [PMID: 34405060 PMCID: PMC8352794 DOI: 10.7759/cureus.16289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2021] [Indexed: 12/30/2022] Open
Abstract
Ascorbic acid (vitamin C) is an essential micronutrient that the human's body cannot synthesize endogenously. Scurvy, a disease of ascorbic acid deficiency, can manifest in a myriad of presentations. Due to its rarity in the modern world, scurvy is considered as a disease of the past. We present a paediatric case of scurvy with musculoskeletal manifestations as a result of picky eating behavior. We report a previously healthy nine-year-old boy who presented with unexplained progressive bilateral lower limb generalized weakness and pain for two months. All initial biochemical and radiological investigations were unremarkable. Upon further history taking, he had severe picky eating behavior which raised the suspicion of scurvy. The diagnosis was confirmed with a serum ascorbic acid test. After ascorbic acid supplementation, his symptoms resolved immediately. Further food behavioral modification counselling to his family members helped to change his diet in a lasting way. As a result, he had no recurrence of symptoms. This case highlights the importance of having a high index of suspicion for an uncommon disease and emphasizes the need for a detailed dietary history upon patient’s presentation.
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Affiliation(s)
- Ren Yi Kow
- Department of Orthopaedics, Traumatology & Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
| | - Nik Alyani Nik Abdul Adel
- Department of Orthopaedics, Traumatology & Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
| | - Ardilla Hanim Abdul Razak
- Department of Orthopaedics, Traumatology & Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
| | - Chooi Leng Low
- Department of Radiology, International Islamic University Malaysia, Kuantan, MYS
| | - Mohd Shukrimi Awang
- Department of Orthopaedics, Traumatology & Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
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14
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Abstract
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.
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15
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Abstract
INTRODUCTION Scurvy, or vitamin C deficiency, is rare. The goal of this study is to highlight the common risk factors and identify the orthopaedic presentation of scurvy in children. METHODS A retrospective chart and radiograph review was performed of all patients consulted to the pediatric orthopaedic service from 2010 to 2019 who ultimately had the diagnosis of scurvy confirmed by an abnormally low serum vitamin C level. Data extracted included: patient age, sex, neurological conditions, prematurity, psychiatric conditions, dietary abnormalities, bone pain, arthritis, limb swelling, inability to walk, skin changes, child abuse evaluations, radiographic findings, additional vitamin deficiencies, lab studies, additional tests, response to treatment. Descriptive statistics were performed. RESULTS Nine patients (7 males, 2 females) with scurvy were studied. The average age was 7 years (range 3 to 13 y). The average body mass index was 21.4 (range, 14 to 30). Five had autism, 2 had a neurological disorder. Two had been born premature. Two had a psychiatric disorder. Seven had an abnormal diet. One presented with bone pain. Four presented with limb swelling. Seven had unilateral and 2 had bilateral leg symptoms. Five presented with inability to walk. Six demonstrated skin changes with ecchymosis or petechiae. Three presented with gingival bleeding. Radiographic findings included subperiosteal hematoma in 2, ring epiphysis in 3, Pelkan spurs in 1, metaphyseal white lines (Frankel sign) in 6, and a metaphyseal zone of rarefaction (Trummerfeld zone) in 3. Seven had additional vitamin deficiencies including: A, B1, B6, B9, D, E, K, iron and zinc. Four had a bone marrow biopsy and 1 had lumbar puncture. All were anemic. The average erythrocyte sedimentation rate was 25.7 (range 6 to 35) and C-reactive protein was 1.5 (range 0.55 to 5.64). Six had a computed tomography, 3 had a magnetic resonance imaging. After treatment with vitamin C lasting 3.4 months (range, 2 wk to 7 mo), all symptoms gradually resolved, including leg pain and swelling. All children began to walk. CONCLUSION The pediatric orthopaedic surgeon should have an increased awareness about the diagnosis of scurvy when consulted on a child with bone pain or inability to walk. The most common orthopaedic presentation was the refusal to bear weight, the most common radiographic finding was the metaphyseal line of increased density (Frankel sign) and treatment with vitamin c supplementation was excellent in all cases.
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16
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Yule S, Wanik J, Holm EM, Bruder MB, Shanley E, Sherman CQ, Fitterman M, Lerner J, Marcello M, Parenchuck N, Roman-White C, Ziff M. 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. J Acad Nutr Diet 2020; 121:467-492. [PMID: 33221247 DOI: 10.1016/j.jand.2020.10.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/05/2020] [Accepted: 10/14/2020] [Indexed: 12/13/2022]
Abstract
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.
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17
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Kothari P, Tate A, Adewumi A, Kinlin LM, Ritwik P. The risk for scurvy in children with neurodevelopmental disorders. SPECIAL CARE IN DENTISTRY 2020; 40:251-259. [PMID: 32330999 DOI: 10.1111/scd.12459] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/06/2020] [Accepted: 03/20/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Scurvy, the disease resulting from vitamin C deficiency, is perceived as being rare and occurring predominantly in the past. However, scurvy continues to exist and may be encountered in children with medical/developmental conditions and/or restricted diet. Diagnosis can be challenging given the perceived rarity of the condition and nonspecific symptoms, including gingival disease. METHODS We present a series of two cases of scurvy in which the affected children presented to medical attention with dental complaints. Additional cases of scurvy are described, based on the literature review of case reports/series published in the last 10 years. RESULTS Literature review yielded 77 relevant case reports published in the English language since 2009. Most affected children had a previous diagnosis of a medical or developmental condition (especially autism spectrum disorder). Intraoral features (gingival swelling, pain, and bleeding) were noted in most of the identified cases of scurvy. Improvement in the oral features of scurvy occurred within days of vitamin C therapy initiation. CONCLUSIONS Recognizing classic signs and symptoms of scurvy enables prompt diagnosis and avoids invasive investigations. Dentists may be in a unique position to facilitate prompt and accurate diagnosis of a condition that is relatively easy and safe to treat once identified.
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Affiliation(s)
- Priya Kothari
- Kidsworld Pediatric Dentistry, Aurora, Ontario, Canada
| | - Anupama Tate
- Children's National Hospital, Washington, DC, USA.,George Washington University, Washington, DC, USA
| | - Abimbola Adewumi
- Department of Pediatric Dentistry, University of Florida College of Dentistry, Gainesville, Florida, USA
| | - Laura M Kinlin
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Priyanshi Ritwik
- Department of Pediatric Dentistry, The University of Texas Health Science Center at Houston, School of Dentistry, Houston, Texas, USA
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18
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Perkins A, Sontheimer C, Otjen JP, Shenoi S. Scurvy Masquerading as Juvenile Idiopathic Arthritis or Vasculitis with Elevated Inflammatory Markers: A Case Series. J Pediatr 2020; 218:234-237.e2. [PMID: 31843213 DOI: 10.1016/j.jpeds.2019.10.059] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 11/19/2022]
Abstract
Ten patients with scurvy were evaluated by rheumatology; we review their clinical, laboratory, and dietary presentations. Eight patients had developmental delay or autism. All had elevated inflammatory markers. These clinical and laboratory features with imaging findings can mimic rheumatic conditions such as arthritis, vasculitis, and chronic nonbacterial osteomyelitis (CNO).
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Affiliation(s)
- Alexandra Perkins
- School of Public Health, University of Washington School of Medicine, Seattle, WA
| | | | - Jeffrey P Otjen
- Department of Radiology, Seattle Children's Hospital and Research Center, Seattle, WA
| | - Susan Shenoi
- Department of Pediatric Rheumatology, Seattle Children's Hospital and Research Center, Seattle, WA.
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Gallizzi R, Valenzise M, Passanisi S, Pajno GB, De Luca F, Zirilli G. Scurvy may occur even in children with no underlying risk factors: a case report. J Med Case Rep 2020; 14:18. [PMID: 31973768 PMCID: PMC6979388 DOI: 10.1186/s13256-020-2341-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 01/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Since ancient times, scurvy has been considered one of the most fearsome nutritional deficiency diseases. In modern developed countries, this condition has become very rare and is only occasionally encountered, especially in the pediatric population. Underlying medical conditions, such as neuropsychiatric disorders, anorexia nervosa, celiac disease, Crohn disease, hemodialysis, and severe allergies to food products may enhance the risk of developing scurvy. CASE PRESENTATION We report the case of an otherwise healthy 3-year-old white boy who developed scurvy due to a selective restrictive diet derived from his refusal to try new food. He presented to our clinic with asthenia and refusal to walk. During hospitalization he developed severe anemia and hematochezia. A diagnosis of scurvy was assessed on the basis of nutritional history, clinical features, radiographic findings, and laboratory findings. Supplementation of ascorbic acid enabled a prompt resolution of symptoms. CONCLUSIONS Scurvy is caused by vitamin C deficiency. Cutaneous bleeding, mucosal bleeding, and anemia represent typical manifestations of the disease. These symptoms are directly connected to ascorbic acid involvement in collagen biosynthesis. Some radiographic findings can be useful for the diagnosis. Treatment aims to normalize serum levels of vitamin C in order to counteract the deprivation symptoms. The present case report demonstrates that scurvy may sporadically occur in pediatric patients, even in individuals with no predisposing medical conditions and/or potential risk factors.
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Affiliation(s)
- Romina Gallizzi
- Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Mariella Valenzise
- Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Stefano Passanisi
- Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Giovanni Battista Pajno
- Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Filippo De Luca
- Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Giuseppina Zirilli
- Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
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Ristori MV, Quagliariello A, Reddel S, Ianiro G, Vicari S, Gasbarrini A, Putignani L. Autism, Gastrointestinal Symptoms and Modulation of Gut Microbiota by Nutritional Interventions. Nutrients 2019; 11:nu11112812. [PMID: 31752095 PMCID: PMC6893818 DOI: 10.3390/nu11112812] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/07/2019] [Accepted: 11/13/2019] [Indexed: 02/07/2023] Open
Abstract
Autism spectrum disorder (ASD) is a complex behavioral syndrome that is characterized by speech and language disorders, intellectual impairment, learning and motor dysfunctions. Several genetic and environmental factors are suspected to affect the ASD phenotype including air pollution, exposure to pesticides, maternal infections, inflammatory conditions, dietary factors or consumption of antibiotics during pregnancy. Many children with ASD shows abnormalities in gastrointestinal (GI) physiology, including increased intestinal permeability, overall microbiota alterations, and gut infection. Moreover, they are "picky eaters" and the existence of specific sensory patterns in ASD patients could represent one of the main aspects in hampering feeding. GI disorders are associated with an altered composition of the gut microbiota. Gut microbiome is able to communicate with brain activities through microbiota-derived signaling molecules, immune mediators, gut hormones as well as vagal and spinal afferent neurons. Since the diet induces changes in the intestinal microbiota and in the production of molecules, such as the SCFA, we wanted to investigate the role that nutritional intervention can have on GI microbiota composition and thus on its influence on behavior, GI symptoms and microbiota composition and report which are the beneficial effect on ASD conditions.
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Affiliation(s)
- Maria Vittoria Ristori
- Unit of Human Microbiome, Children’s Hospital and Research Institute “Bambino Gesù”, IRCCS, Piazza Sant’Onofrio 4, 00165 Rome, Italy; (M.V.R.); (A.Q.); (S.R.)
| | - Andrea Quagliariello
- Unit of Human Microbiome, Children’s Hospital and Research Institute “Bambino Gesù”, IRCCS, Piazza Sant’Onofrio 4, 00165 Rome, Italy; (M.V.R.); (A.Q.); (S.R.)
| | - Sofia Reddel
- Unit of Human Microbiome, Children’s Hospital and Research Institute “Bambino Gesù”, IRCCS, Piazza Sant’Onofrio 4, 00165 Rome, Italy; (M.V.R.); (A.Q.); (S.R.)
| | - Gianluca Ianiro
- Dipartimento di Gastroenterologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy;
| | - Stefano Vicari
- Neuropsichiatria dell’infanzia e dell’adolescenza, Children’s Hospital and Research Institute “Bambino Gesù”, IRCCS, Piazza Sant’Onofrio 4, 00165 Rome, Italy;
| | - Antonio Gasbarrini
- Istituto di Patologia Speciale Medica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- UOC Medicina Interna e Gastroenterologia, Area Gastroenterologia ed Oncologia Medica, Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Correspondence: (A.G.); (L.P.); Tel.: +39-0668-59-4127 (L.P.)
| | - Lorenza Putignani
- Units of Parasitology and Human Microbiome, Children’s Hospital and Research Institute “Bambino Gesù”, IRCCS, Piazza Sant’Onofrio 4, 00165 Rome, Italy
- Correspondence: (A.G.); (L.P.); Tel.: +39-0668-59-4127 (L.P.)
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Lund RM, Becker ML, Shapiro S, Allison T, Harris JG. Scurvy presenting with limp and weakness: a case report. BMC Pediatr 2019; 19:228. [PMID: 31279337 PMCID: PMC6612164 DOI: 10.1186/s12887-019-1605-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 06/30/2019] [Indexed: 11/10/2022] Open
Abstract
Background Scurvy is one of the oldest diseases known to mankind. Although presently rare in the developed world, scurvy was a common potentially fatal disease. In recent times, the most common risk factors for scurvy include alcoholism, low socioeconomic status, and severely poor nutrition or dietary restriction secondary to psychiatric illness or developmental disorders. Our case demonstrates the importance of having a high index of clinical suspicion of an uncommon disease in developed countries and emphasizes the necessity of a dietary screening that could potentially reduce extensive work-up in patients with nonspecific complaints. Case presentation We report a case of a 3-year-old previously healthy female originally seen in the rheumatology clinic for limp. She developed weakness and was admitted to the hospital for further evaluation. She underwent extensive diagnostic testing including blood work, magnetic resonance imaging, lumbar puncture, electromyogram, and nerve conduction studies. Ultimately, her vitamin C level returned undetectable. She had immediate and complete improvement upon starting vitamin C supplementation. Conclusions Despite being developmentally appropriate, our patient’s refusal to eat fruits or vegetables had limited her diet, emphasizing the importance of obtaining a diet history in a child presenting with an unknown diagnosis. In addition, our patient had no other characteristic features of scurvy, which further supports the need to consider this diagnosis in a child presenting with lower extremity weakness or abnormal gait.
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Affiliation(s)
- Robin M Lund
- University of Louisville School of Medicine, 571 S. Floyd Street, Suite 412, Louisville, KY, 40202, USA
| | - Mara L Becker
- Duke Clinical Research Institute, 200 Morris Street, Durham, North Carolina, 27701, USA
| | - Steven Shapiro
- Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Tyler Allison
- Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Julia G Harris
- Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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22
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Swed-Tobia R, Haj A, Militianu D, Eshach O, Ravid S, Weiss R, Aviel YB. Highly Selective Eating in Autism Spectrum Disorder Leading to Scurvy: A Series of Three Patients. Pediatr Neurol 2019; 94:61-63. [PMID: 30795887 DOI: 10.1016/j.pediatrneurol.2018.12.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 12/15/2018] [Accepted: 12/24/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Some children with autism spectrum disorder (ASD) have highly specific food selectivity and therefore are prone to nutritional deficiencies of different kinds. PATIENTS We document three children with ASD who presented with refusal to walk and gingivitis who underwent comprehensive evaluations before establishing the diagnosis of vitamin C deficiency (scurvy). The symptoms resolved after treatment with vitamin C. CONCLUSIONS Prevention of nutritional deficiencies in children with ASD is essential, and providing multivitamin supplementation whenever high food selectivity is noted may prevent significant morbidity.
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Affiliation(s)
- Rana Swed-Tobia
- Department of Pediatrics, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel.
| | - Ahmad Haj
- Department of Pediatrics, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Daniella Militianu
- Department of Radiology, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Orly Eshach
- Pediatric Gastroenterology Unit, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Sarit Ravid
- Pediatric Neurology Unit, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Ram Weiss
- Department of Pediatrics, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Yonatan Butbul Aviel
- Department of Pediatrics, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel; Pediatric Rheumatology Service, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
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Ceglie G, Macchiarulo G, Marchili MR, Marchesi A, Rotondi Aufiero L, Di Camillo C, Villani A. Scurvy: still a threat in the well-fed first world? Arch Dis Child 2019; 104:381-383. [PMID: 30087152 DOI: 10.1136/archdischild-2018-315496] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 11/04/2022]
Abstract
We report three cases of scurvy in previously healthy children referred to us for leg pain and refusal to walk. All children had no significant medical history, symptoms had started months before and subtly advanced. Two of them presented with gingival hyperplasia and petechiae, another one reported night sweats and gingival bleeding in the past few weeks. Two had vitamin D deficiency, and all had microcytic anaemia (in one case requiring transfusional support). A nutritional screening revealed low or undetectable levels of ascorbic acid. This, along with the clinical and radiological findings, led to a diagnosis of scurvy. Vitamin C supplementation was started with rapid improvement of the children's clinical condition. Scurvy is a rare disease in the 'first world', but there are anecdotal reports of scurvy in children without any of the known risk factors for this condition. In our cases, a selective diet was the only risk factor.
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Affiliation(s)
- Giulia Ceglie
- University Department of Pediatrics, Bambino Gesù Children's Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Giulia Macchiarulo
- University Department of Pediatrics, Bambino Gesù Children's Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Maria Rosaria Marchili
- General Pediatric and Infectious Disease Unit, University Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessandra Marchesi
- General Pediatric and Infectious Disease Unit, University Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Lelia Rotondi Aufiero
- General Pediatric and Infectious Disease Unit, University Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Chiara Di Camillo
- General Pediatric and Infectious Disease Unit, University Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Alberto Villani
- General Pediatric and Infectious Disease Unit, University Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
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24
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Rafee Y, Burrell K, Cederna-Meko C. Lessons in early identification and treatment from a case of disabling vitamin C deficiency in a child with autism spectrum disorder. Int J Psychiatry Med 2019; 54:64-73. [PMID: 30079810 DOI: 10.1177/0091217418791443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Yaseen Rafee
- 1 Hurley Medical Center, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Katherine Burrell
- 1 Hurley Medical Center, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Crystal Cederna-Meko
- 1 Hurley Medical Center, College of Human Medicine, Michigan State University, East Lansing, MI, USA
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25
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Brambilla A, Pizza C, Lasagni D, Lachina L, Resti M, Trapani S. Pediatric Scurvy: When Contemporary Eating Habits Bring Back the Past. Front Pediatr 2018; 6:126. [PMID: 29780794 PMCID: PMC5946015 DOI: 10.3389/fped.2018.00126] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/16/2018] [Indexed: 11/17/2022] Open
Abstract
Vitamin C deficiency is anecdotal in developed countries, mainly associated with underling clinical morbidities as autism or neurological impairment. Chronic insufficient dietary supply is responsible for vascular fragility and impaired bone formation, resulting in gingival bleeding, petechial lesions, articular and bone pain or limb swelling. Children may present anorexia, irritability, failure to thrive, limping or refusal to walk. Accordingly, pediatric scurvy is frequently misdiagnosed with osteomyelitis, septic arthritis, bone and soft tissue tumor, leukemia, bleeding disorders, and rheumatologic conditions. We report the case of a 3-years old child developing scurvy as consequence of strict selective diet; extensive and invasive investigations were undertaken before the correct diagnosis was considered. Despite being considered a rare condition, scurvy still exists nowadays, even in children with no apparent risk factors living in wealthy families. The increasing popularity of dietary restriction for children, especially those with allergies, may potentially enhance the occurrence of scurvy in apparently healthy children. Appropriate dietary anamnesis is fundamental in order to highlight potential nutritional deficit and to avoid unnecessary invasive diagnostic procedures. Patients without considerable risk factors may benefit from psychological support in order to investigate possible eating disorders.
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Affiliation(s)
- Alice Brambilla
- Pediatric Department, University of Florence, Anna Meyer Children Hospital, Florence, Italy
| | - Cristina Pizza
- Pediatric Department, University of Florence, Anna Meyer Children Hospital, Florence, Italy
| | - Donatella Lasagni
- Clinical Pediatric Department, Anna Meyer Children Hospital, Florence, Italy
| | - Lucia Lachina
- Clinical Pediatric Department, Anna Meyer Children Hospital, Florence, Italy
| | - Massimo Resti
- Clinical Pediatric Department, Anna Meyer Children Hospital, Florence, Italy
| | - Sandra Trapani
- Pediatric Department, University of Florence, Anna Meyer Children Hospital, Florence, Italy.,Clinical Pediatric Department, Anna Meyer Children Hospital, Florence, Italy
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26
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Lux-Battistelli C, Battistelli D. Latent scurvy with tiredness and leg pain in alcoholics: An underestimated disease three case reports. Medicine (Baltimore) 2017; 96:e8861. [PMID: 29382002 PMCID: PMC5709001 DOI: 10.1097/md.0000000000008861] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Scurvy is often diagnosed at the state of well-established signs as, for example, skin and visceral purpura, gums involvement, loss of healthy teeth, which derive mostly from disturbance of collagen metabolism. Little is known about the state of latent scurvy, which symptoms are nonspecific and may mimic more common conditions such as weakness, leg pain, and muscle aching. PATIENT CONCERNS We report 3 cases of extreme lassitude and leg pain in alcoholics. In 2 of the 3 cases, discreet classic symptoms such as petechiae or hyperkeratosis of the legs involving collagen metabolism were also present. DIAGNOSES Latent scurvy has been diagnosed thanks to historical experimental data reporting and undetectable ascorbic acid levels. INTERVENTIONS In addition to the treatments recommended by the French Alcohol Society, patients were given oral vitamin C 500 mg to 1000 mg per day for at least three months. OUTCOMES Vitamin C supplementation allowed the regression of the symptoms, greatly improved the quality of life, and gave the possibility to return to work. Cartinine, requiring vitamin C for its hydroxylation, is an essential cofactor in the transport of long-chain fatty acid into mitochondrial matrix. Therefore, it plays an important role in energy production via beta-oxidation. It is thought that carnitine metabolism impairment is responsible for weakness or muscle aching. LESSONS We recommend being aware of the possibility of latent scurvy in chronic alcohol abusers. The vitamin C supplementation and dietetic recommendation eating fresh fruit and vegetables may help to cure tiredness and to return more easily to socialization and to work.
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27
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Aziz A, Matonti F, Bautrant V, Foletti JM, Denis D. Infantile scurvy revealed by spontaneous orbital hematoma. Orbit 2017; 36:170-172. [PMID: 28362181 DOI: 10.1080/01676830.2017.1279665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Aurore Aziz
- a Service D'Ophtalmologie CHU Nord , Marseille , France
| | - Fréderic Matonti
- a Service D'Ophtalmologie CHU Nord , Marseille , France.,b Institut de Neurosciences de la Timone (UMR7289) , Aix-Marseille Université and CNRS , Marseille , France
| | | | - Jean-Marc Foletti
- c Service de Chirurgie Maxillo-faciale, CHU Nord , Marseille , France
| | - Danièle Denis
- a Service D'Ophtalmologie CHU Nord , Marseille , France
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28
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Golriz F, Donnelly LF, Devaraj S, Krishnamurthy R. Modern American scurvy - experience with vitamin C deficiency at a large children's hospital. Pediatr Radiol 2017; 47:214-220. [PMID: 27778040 DOI: 10.1007/s00247-016-3726-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 09/08/2016] [Accepted: 10/04/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Until recently scurvy has been viewed in developed countries as a disease of the past. More recently there have been reports of case series of children with scurvy who have had a delayed diagnosis after an extensive diagnostic workup that included imaging. Most of these children have had underlying neurologic conditions such as autism. OBJECTIVE To review the medical records of children diagnosed with vitamin C (ascorbic acid) deficiency based on serum ascorbic acid levels at a large pediatric health care system, to determine imaging findings and utility of imaging in management, and to identify at-risk pediatric populations. MATERIALS AND METHODS We retrospectively identified cases of vitamin C deficiency in children tested for serum ascorbic acid levels during the last 5 years. We used the criteria of normal ascorbic acid >23 μmol/L and included children with ascorbic acid levels <23 μmol/L. We evaluated their clinical history, underlying medical condition, imaging studies obtained and imaging findings. RESULTS We identified 32 children with vitamin C deficiency. All of these children had underlying medical conditions, most commonly iron overload from multiple transfusions related to sickle cell anemia or thalassemia (20), neurologic disorders (4) and bone marrow transplant/chemotherapy (3). No cases of scurvy from dietary deficiency in otherwise normal children were identified. All except two children had multiple imaging studies, primarily related to their underlying conditions. Three of these children had extensive imaging workups related to diffuse musculoskeletal pain. Imaging findings included ill-defined sclerotic and lucent metaphyseal bands (mainly at the knee) on radiography and MRI studies that showed diffuse increased T2-weighted signal in the bilateral lower-extremity long-bone metaphyses, periosteal reaction and adjacent soft-tissue edema. CONCLUSION Vitamin C deficiency is not uncommon in large pediatric health care facilities, and it is frequently missed on clinical evaluation and diagnostic imaging. At-risk populations include those with iron overload, neurologic conditions and history of chemotherapy. Scurvy related to dietary deficiency in otherwise normal children was not encountered. When characteristic MRI findings are seen, particularly in children with a predisposing condition for vitamin C deficiency, scurvy should be considered and a serum ascorbic acid level checked to potentially confirm a diagnosis prior to further invasive tests.
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Affiliation(s)
- Farahnaz Golriz
- Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA
| | - Lane F Donnelly
- Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.
| | - Sridevi Devaraj
- Department of Pathology and Laboratory Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Raj Krishnamurthy
- Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA
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Ma NS, Thompson C, Weston S. Brief Report: Scurvy as a Manifestation of Food Selectivity in Children with Autism. J Autism Dev Disord 2016; 46:1464-70. [PMID: 26590972 DOI: 10.1007/s10803-015-2660-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Nina S Ma
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | - Cynthia Thompson
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Sharon Weston
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
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30
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Agarwal A, Shaharyar A, Kumar A, Bhat MS, Mishra M. Scurvy in pediatric age group - A disease often forgotten? J Clin Orthop Trauma 2015; 6:101-7. [PMID: 25983516 PMCID: PMC4411344 DOI: 10.1016/j.jcot.2014.12.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 12/16/2014] [Indexed: 10/24/2022] Open
Abstract
Scurvy is caused by prolonged severe dietary deficiency of vitamin C. Being rare as compared to other nutritional deficiencies, it is seldom suspected and this frequently leads to delayed recognition of this disorder. Children with abnormal dietary habits, mental illness or physical disabilities are prone to develop this disease. The disease spectrum of scurvy is quite varied and includes dermatological, dental, bone and systemic manifestations. Subperiosteal hematoma, ring epiphysis, metaphyseal white line and rarefaction zone along with epiphyseal slips are common radiological findings. High index of suspicion, detailed history and bilateral limb radiographs aids physician in diagnosing this eternal masquerader. We searched Pubmed for recent literature (2009-2014) with search terms "scurvy" "vitamin C deficiency" "ascorbic acid deficiency" "scurvy and children" "scurvy and pediatric age group". There were a total of 36 articles relevant to pediatric scurvy in children (7 reviews and 29 case reports) which were retrieved. The review briefly recapitulates the role of vitamin C, the various disease manifestations and the treatment of scurvy to create awareness of the disease which still is reported from our country, although sporadically. The recent advances related to scurvy and its management in pediatric age group are also incorporated.
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Affiliation(s)
- Anil Agarwal
- Specialist and Head, Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi 31, India
| | - Abbas Shaharyar
- Senior Resident, Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi 31, India
| | - Anubrat Kumar
- Senior Resident, Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi 31, India
| | - Mohd Shafi Bhat
- Senior Resident, Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi 31, India
| | - Madhusudan Mishra
- Senior Resident, Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalya, Geeta Colony, Delhi 110031, India
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