The Pitfall in Differential Diagnosis of Musculoskeletal Symptoms in Children: A Case Series of Pediatric Scurvy

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

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A 3-Year-Old With Gingival Hemorrhage and Musculoskeletal Pain

A 3-year-old had spontaneous gingival hemorrhage and bilateral limb weakness with inability to bear weight. He had no preceding oral trauma or recent infection, took no regular medications, and had no recent use of aspirin or nonsteroidal anti-inflammatory drugs; his diet was limited to primarily chicken nuggets and milk. What is the diagnosis and what would you do next?

Scurvy in a Child Presenting With a Limp and Elevated Inflammatory Markers: A Case Report

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.

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.