Is vitamin C enough? A case report of scurvy in a five-year-old girl and review of the literature

A comprehensive review on the co-occurrence of scurvy and anorexia nervosa

Scurvy, a rare disease resulting from vitamin C deficiency, can occur in individuals with restrictive eating disorders like anorexia nervosa (AN), leading to severe health complications. This review explores the complex relationship between scurvy and AN, highlighting the overlapping symptoms and challenges in diagnosis and treatment. Vitamin C is essential for collagen synthesis, immune function, and neurotransmitter production, and its deficiency manifests as fatigue, gingival bleeding, joint pain, and perifollicular hemorrhages. AN exacerbates these symptoms through extreme food restriction, causing severe nutritional deficiencies. Analyzing nine case reports, this review reveals that patients with co-occurring AN and scurvy often present with gastrointestinal, psychiatric, and dermatological symptoms. Treatment with vitamin C supplementation typically results in rapid symptom improvement. However, the malnutrition inherent in AN complicates the clinical picture, making timely diagnosis and intervention crucial. This review underscores the importance of a comprehensive, multidisciplinary approach to managing these conditions, emphasizing the need for early recognition and treatment to prevent severe complications. Future research should include a more diverse patient population to enhance understanding of the interplay between AN and scurvy, aiming to improve patient outcomes through tailored treatment strategies.

A 7-year-old boy with scurvy owing to coeliac disease

ABBREVIATIONS

ESR: erythrocyte sedimentation rate; Hb: haemoglobin; HSP: Henoch-Schönlein purpura; WCC: white-cell count.

The Impact of Vitamin Deficiencies on Oral Manifestations in Children

Vitamins play a vital role in human health, particularly in the development and maintenance of oral health in children. These nutrients are broadly categorized into fat-soluble and water-soluble types, crucial for children's well-being. The objective of this study is to investigate the impact of vitamin deficiencies on the oral health of children, focusing on how these deficiencies contribute to various oral health issues and determining the relationship between specific vitamin shortages and oral diseases. Findings indicate that shortages in vitamins A and D lead to enamel issues and a higher susceptibility to dental diseases, vitamin E assists in treating oral mucositis, and vitamin K is essential for blood clotting in dental surgeries. Deficits in B-complex and vitamin C result in enamel hypomineralization and soft tissue ailments, including aphthous stomatitis and gingival petechiae. Additionally, a lack of vitamin B7 compromises the immune response, increasing oral candidiasis risk. Therefore, vitamin deficiencies markedly affect children's oral health, highlighting the need for joint efforts between dental professionals and caregivers for effective pediatric care. Addressing vitamin deficiencies through supplementation and tailored dental care emphasizes the significance of nutritional health in children's overall and dental well-being, advocating for a collaborative approach to achieve optimal health outcomes.

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.

Selenium deficiency and scurvy due to an imbalanced diet of snacks and lacto-fermenting drinks: a case report of a 7-year-old boy with autism spectrum disorder

BACKGROUND

There have been reports of isolated trace elements or vitamin deficiencies due to imbalanced diets, but no cases of selenium deficiency combined with scurvy have been reported.

CASE PRESENTATION

A 7 year-old boy diagnosed with autistic spectrum disorder and mild psychomotor retardation, started an imbalanced diet including specific snacks and lacto-fermenting drinks from 5 years of age. Gingival hemorrhage and perioral erosions occurred at 6 years and 8 months of age, and he was referred to our hospital at 7 years of age. Slight tachycardia was found. Serum vitamin C level was 1.1 µg/dL (reference range (rr): 5-17.5 µg/dL), and selenium level was 2.8 µg/dL (rr: 7.7-14.8 µg/dL). He was diagnosed with both selenium deficiency and scurvy. Multivitamins and sodium selenate were administered for 12 days during admission, and symptoms of selenium deficiency and scurvy improved. After discharge, symptoms abated following the administration of multivitamins and regular administration of sodium selenate every 3 months.

CONCLUSIONS

We report a complicated case of both selenium deficiency and scurvy due to an imbalanced diet of snacks and lacto-fermenting drinks in a 7-year-old boy with autism spectrum disorder. In patients with imbalanced diet, regular blood tests including trace elements and vitamins are necessary.

Scurvy in a 29-Month-Old Patient Presenting With a Gower Sign

Scurvy is a preventable condition caused by a severe vitamin C deficiency for prolonged periods. Most literature cases describe children with neurobehavioral disorders or extreme dietary restrictions. Vitamin C deficiency may be a rare clinical presentation in the developed world; hence, it is often overlooked and can lead to extensive workups when the history alone could have raised suspicion for the diagnosis. We report a previously healthy 29-month-old boy initially admitted to the hospital due to loss of ambulation over a three-week course. The patient had no history of fever, and the inflammatory parameters were normal. Blood workup, plain radiographs, and magnetic resonance imaging (MRI) of the right lower extremity were unremarkable. The patient was discharged home with antibiotics and anti-inflammatory medication but arrived a week later with worsening lower extremity weakness leading to complete loss of ambulation. Vitamin C deficiency was confirmed to be below normal levels (<0.4mg/dL), and a diagnosis of scurvy was confirmed and treated with oral ascorbic acid. Subsequently, his mother brought him to the orthopedic clinic with a positive Gower sign. CPK levels were normal. Within a month of ascorbic acid replacement, all symptoms disappeared. Our patient was a picky eater, which emphasizes the importance of early dietary screening to discover the underlying cause of symptoms. Vitamin C deficiency should be part of the differential diagnosis in patients with unremarkable laboratory workup for infection and other diseases presenting with a Gower sign.

Carbon Nanotube and Its Derived Nanomaterials Based High Performance Biosensing Platform

After the COVID-19 pandemic, the development of an accurate diagnosis and monitoring of diseases became a more important issue. In order to fabricate high-performance and sensitive biosensors, many researchers and scientists have used many kinds of nanomaterials such as metal nanoparticles (NPs), metal oxide NPs, quantum dots (QDs), and carbon nanomaterials including graphene and carbon nanotubes (CNTs). Among them, CNTs have been considered important biosensing channel candidates due to their excellent physical properties such as high electrical conductivity, strong mechanical properties, plasmonic properties, and so on. Thus, in this review, CNT-based biosensing systems are introduced and various sensing approaches such as electrochemical, optical, and electrical methods are reported. Moreover, such biosensing platforms showed excellent sensitivity and high selectivity against not only viruses but also virus DNA structures. So, based on the amazing potential of CNTs-based biosensing systems, healthcare and public health can be significantly improved.

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.

Scurvy in children - A neglected disease?

BACKGROUND

The incidences of pediatric scurvy has decreased substantially, particularly in developed countries, but there are still reports of it from developing countries. Unusual manifestations have led to delays in diagnosis and treatment. Nevertheless, there are few publications regarding misdiagnosis of scurvy. The objective is to determine dietary factors, clinical manifestations, laboratory and radiologic findings, treatment, and outcomes of scurvy cases. The occurrence of misdiagnosis and its associated factors are also explored.

METHOD

The medical records of 0-18 year-old children from 2003 to 2016, diagnosed with scurvy, were included and reviewed. Clinical data, and data regarding feeding history, nutritional status, laboratory and radiologic findings, and misdiagnosis were collected. Univariate and logistic regression analysis were used for identification of the independent associated factors.

RESULTS

The study consisted of 106 children. The boys-to-girls ratio was 2.2:1, and their mean age was 44.65 months ± 30.50 months. The common manifestations were refusal to walk, tenderness, and swelling at the lower extremities. Four participants had unusual manifestations including proptosis and scalp hematoma. Low serum vitamin C level and abnormal radiologic findings were detected in most patients. All of them fully recovered after receiving vitamin C supplementation. Misdiagnosis was identified in 74 cases (69%). Logistic regression analysis revealed that temperature higher than or equal to 38 °C, participants aged 3 years or below, and swelling at lower extremities were independently associated with misdiagnosis (adjusted OR 5.91, 3.78, and 3.56 respectively).

CONCLUSIONS

Scurvy still exists, and misdiagnosis often occurs. Taking a careful medical history and conducting a physical examination are still the best way to diagnose scurvy.

Paediatric scurvy: frequently misdiagnosed

Paediatric scurvy is uncommon in the modern age but cases have been reported in children with neurodevelopmental issues and restricted dietary habits. The broad clinical picture is frequently overlooked as primarily other systemic diseases are considered first leading to extensive investigations and delay in diagnosis. A 4-year-old boy with autism and bilateral lower limb pain and refusal to walk is reported. His restricted diet and radiographic findings were highly suggestive of scurvy which was confirmed by the extremely low levels of ascorbic acid. Treatment with ascorbic acid replenishment and maintenance resulted in remarkable improvement. This case highlights the importance of a high index of suspicion in at-risk children so as to avoid unnecessary invasive investigations and procedures.

Vitamin C deficiency and impact of vitamin C administration among pediatric patients with advanced chronic kidney disease

BACKGROUND

Vitamin C deficiency is common in chronic kidney disease (CKD) due to losses through dialysis and dietary intake below requirement. We investigated prevalence of vitamin C deficiency and impact of vitamin C treatment in deficient/insufficient patients.

METHODS

A prospective cohort study in patients aged 1-18 years with CKD stages 4 and 5D collected demographic data including underlying disease, treatment, and anthropometric assessment. Vitamin C intake was assessed using 24-h dietary recall. Hemoglobin, iron status, serum vitamin C, and serum oxalate were measured at baseline and after treatment. Vitamin C (250 mg/day) was given orally for 3 months to deficient/insufficient patients.

RESULTS

Nineteen patients (mean age 12.00 ± 4.1 years) showed prevalence of 10.6% vitamin C insufficiency and 78.9% deficiency. There were no associations between vitamin C level and daily vitamin C intake (p = 0.64) or nutritional status (p = 0.87). Median serum vitamin C was 1.51 (0.30-1.90) mg/L. In 16 patients receiving treatment, median serum vitamin C increased from 1.30 (0.23-1.78) to 3.22 (1.77-5.96) mg/L (p = 0.008) without increasing serum oxalate (79.92 (56.6-106.84) vs. 80.47 (56.88-102.95) μmol/L, p = 0.82). However, 62.5% failed to achieve normal vitamin C levels. Ordinal regression analysis revealed patients with non-oligoanuric CKD were less likely to achieve normal vitamin C levels (β = - 3.41, p = 0.03).

CONCLUSION

We describe high prevalence of vitamin C insufficiency/deficiency among pediatric CKD patients. Vitamin C levels could not be solely predicted by nutritional status or daily intake. The treatment regimen raised serum vitamin C without increasing serum oxalate; however, it was largely insufficient to normalize levels, particularly in non-oligoanuric CKD. Graphical abstract .

Pediatric Scurvy: How an Old Disease Is Becoming a New Problem

Ascorbic acid (vitamin C) functions as a cofactor and antioxidant within the human body that enables tissue growth and repair, but vitamin C is not intrinsically produced. Scurvy, or ascorbic acid deficiency, has traditionally been viewed as a historical disease. With the incidence of autism spectrum disorder and food restriction on the rise, children's hospitals may see increasing cases of scurvy. This is a single-center, retrospective case series including patients aged 7 to 14 years who were admitted to the Kentucky Children's Hospital with scurvy in the 2018-2019 period. Although selective or restricted eating is not an uncommon behavior among children, especially toddlers, parents of autistic children frequently report their children to be exceedingly selective eaters. However, there currently are conflicting findings on whether this leads to nutritional inadequacy. Although no guidelines exist for the treatment of scurvy, the mainstay of therapy is reintroduction of vitamin C. Oral therapy is generally preferred, but vitamin C can be given parenterally when necessary. In conclusion, oral aversion is a symptom commonly seen in patients with autism spectrum disorder and other developmental delays, potentially leading to increased cases of scurvy. Treatment of scurvy includes reintroduction of vitamin C into the diet. However, oral supplementation may pose unique challenges in this patient population.

Scurvy: A New Old Cause of Skeletal Pain in Young Children

We report 3 cases of scurvy in children that occurred during a short period (2018) in a general pediatrics unit of a tertiary hospital for children in Paris. All children were around 3 years of age and were admitted for skeletal pain and altered general state, which mimicked infectious or malignant diseases. Their selective diet was not the prominent issue. The diagnosis of scurvy was delayed, after too many unnecessary examinations and medications. Bone imaging findings (X-ray and MRI) were a posteriori considered typical, but lesions were not easily identified as scurvy lesions because scurvy is not well-known by pediatricians and radiologists who should be mindful of this historical diagnosis.

Oral Manifestation of Systemic Diseases

The US Surgeon General's report Oral Health in America highlighted ways in which oral health and systemic conditions are associated with each other. An oral examination can reveal signs and symptoms associated with systemic diseases. In this article, multiple systemic diseases including but not limited to viral and immune modulated conditions and associated oral symptoms are discussed.

Treatment of avoidant/restrictive food intake disorder for a teenager with typical development within the home setting

INTRODUCTION

Avoidant/restrictive food intake disorder (ARFID) can occur in children with typical development and persist past childhood. This significantly impacts most areas of children's lives, but may become more evident in teenage years, especially socially. There is an empirically supported treatment for ARFID with 40 years of research backing, this being behaviour-analytic feeding interventions. However, application to individuals over age 12 is lacking, and needs to be investigated for effectiveness. This is important as the addition of ARFID (formerly called feeding disorders) to the DSM-V has seen an increase in new treatments for ARFID by attempting to apply eating disorder treatments to this population including children. More research is needed to identify if already established behavioural intervention procedures are effective for ARFID in individuals with selectivity, without disabilities, older ages, and in settings outside of intensive specialised feeding hospital admissions in the United States.

METHOD

A 13-year-old female with ARFID and years of failed treatment attempts participated in her home in Australia. We conducted multiple stimulus without replacement preference assessments and used a changing criterion design with multiple baseline probes. Treatment consisted of demand fading, choice, differential attention, and contingent access. We did not use cognitive or family based treatment.

RESULTS

Consumption increased to 100%. Variety reached 61 foods across all food groups. She met 100% of goals and ate at a restaurant. Caregivers reported high satisfaction and social acceptability. Gains were maintained at 9 months.

CONCLUSION

This brief, behaviour-analytic in-home treatment was effective in increasing food group variety consumption.