Case report: Pulmonary hypertensive crisis leading to cardiac arrest during endoscopic evaluation in a 6-year-old boy with autism, severe malnutrition, and undiagnosed scurvy

Physical health complications in children and young people with avoidant restrictive food intake disorder (ARFID): a systematic review and meta-analysis

BACKGROUND

Avoidant restrictive food intake disorder (ARFID) is a feeding and eating disorder with known acute and longstanding physical health complications in children and young people (CYP) and commonly presents to paediatricians.

OBJECTIVE

To systematically review the published literature on physical health complications in CYP with ARFID using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

A systematic search of PubMed, Embase, Web of Science, PsycINFO and Cochrane Library was performed on 14 February 2024. Studies reporting physical health complications in CYP ≤25 years with ARFID were included. We pooled studies for meta-analysis comparing ARFID with healthy controls or anorexia nervosa (AN).

RESULTS

Of 9058 studies found in searches, we included 132 studies. We found evidence for low weight, nutritional deficiencies and low bone mineral density. CYP with ARFID can present across the weight spectrum; however, the majority of CYP with ARFID were within the healthy weight to underweight range. Most studies reported normal range heart rates and blood pressures in ARFID, but some CYP with ARFID do experience bradycardia and hypotension. CYP with ARFID had higher heart rates than AN (weighted mean difference: 12.93 bpm; 95% CI: 8.65 to 17.21; n=685); heterogeneity was high (I2: 81.33%).

CONCLUSION

There is a broad range of physical health complications associated with ARFID requiring clinical consideration. Many CYP with ARFID are not underweight yet still have complications. Less cardiovascular complications found in ARFID compared with AN may be related to chronicity.

PROSPERO REGISTRATION NUMBER

CRD42022376866.

Vitamin C deficiency can lead to pulmonary hypertension: a systematic review of case reports

BACKGROUND

In the early literature, unintentional vitamin C deficiency in humans was associated with heart failure. Experimental vitamin C deficiency in guinea pigs caused enlargement of the heart. The purpose of this study was to collect and analyze case reports on vitamin C and pulmonary hypertension.

METHODS

We searched Pubmed and Scopus for case studies in which vitamin C deficiency was considered to be the cause of pulmonary hypertension. We selected reports in which pulmonary hypertension was diagnosed by echocardiography or catheterization, for any age, sex, or dosage of vitamin C. We extracted quantitative data for our analysis. We used the mean pulmonary artery pressure (mPAP) as the outcome of primary interest.

RESULTS

We identified 32 case reports, 21 of which were published in the last 5 years. Dyspnea was reported in 69%, edema in 53% and fatigue in 28% of the patients. Vitamin C plasma levels, measured in 27 cases, were undetectable in 24 and very low in 3 cases. Diet was poor in 30 cases and 17 cases had neuropsychiatric disorders. Right ventricular enlargement was reported in 24 cases. During periods of vitamin C deficiency, the median mPAP was 48 mmHg (range 29-77 mmHg; N = 28). After the start of vitamin C administration, the median mPAP was 20 mmHg (range 12-33 mmHg; N = 18). For the latter 18 cases, mPAP was 2.4-fold (median) higher during vitamin C deficiency. Pulmonary vascular resistance (PVR) during vitamin C deficiency was reported for 9 cases, ranging from 4.1 to 41 Wood units. PVR was 9-fold (median; N = 5) higher during vitamin C deficiency than during vitamin C administration. In 8 cases, there was direct evidence that the cases were pulmonary artery hypertension (PAH). Probably the majority of the remaining cases were also PAH.

CONCLUSIONS

The cases analyzed in our study indicate that pulmonary hypertension can be one explanation for the reported heart failure of scurvy patients in the early literature. It would seem sensible to measure plasma vitamin C levels of patients with PH and examine the effects of vitamin C administration.

What Do We C in Children With Scurvy? A Case Series Focused on Musculoskeletal Symptoms

OBJECTIVES

Vitamin C deficiency in children commonly presents with musculoskeletal symptoms such as gait disturbance, refusal to bear weight, and bone or joint pain. We aimed to identify features that could facilitate early diagnosis of scurvy and estimate the cost of care for patients with musculoskeletal symptoms related to scurvy.

METHODS

We conducted a retrospective chart review of patients at a single site with diagnostic codes for vitamin C deficiency, ascorbic acid deficiency, or scurvy. Medical records were reviewed to identify characteristics including presenting symptoms, medical history, and diagnostic workup. The Pediatric Health Information System was used to estimate diagnostic and hospitalization costs for each patient.

RESULTS

We identified 47 patients with a diagnosis of scurvy, 49% of whom had a neurodevelopmental disorder. Sixteen of the 47 had musculoskeletal symptoms and were the focus of the cost analysis. Three of the 16 had moderate or severe malnutrition, and 3 had overweight or obesity. Six patients presented to an emergency department for care, 11 were managed inpatient, and 3 required critical care. Diagnostic workups included MRI, computed tomography, echocardiogram, endoscopy, lumbar puncture, and/or EEG. Across all patients evaluated, the cost of emergency department utilization, imaging studies, diagnostic procedures, and hospitalization totaled $470 144 (median $14 137 per patient).

CONCLUSIONS

Children across the BMI spectrum, particularly those with neurodevelopmental disorders, can develop vitamin C deficiency. Increased awareness of scurvy and its signs and symptoms, particularly musculoskeletal manifestations, may reduce severe disease, limit adverse effects related to unnecessary tests/treatments, and facilitate high-value care.

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.

Avoidant-restrictive food intake disorder and autism: epidemiology, etiology, complications, treatment, and outcome

PURPOSE OF REVIEW

There is considerable overlap between the features of avoidant-restrictive food intake disorder (ARFID) and autism. The purpose of this scoping review is to provide an overview of studies published on ARFID and autism in 2022 and the first half of 2023.

RECENT FINDINGS

ARFID and autism are highly heritable conditions that often co-occur. In a large autism cohort, 21% of participants and 17% of their parents presented with avoidant-restrictive features. Of children diagnosed with ARFID, 8.2-54.8% are autistic. More than half of individuals with ARFID also have other neurodevelopmental, psychiatric, or somatic diagnoses. Anxiety, depression, sleep disorders, and learning difficulties are particularly common co-occurring issues. Various strategies have been developed to support autistic children with feeding difficulties. It appears that their feeding difficulties, particularly sensory sensitivities, food preferences, and mealtime rituals and routines frequently persist into adolescence and adulthood, but research on optimal support for adults and adolescents is still scarce. Untreated ARFID in autistic individuals may lead to serious complications.

SUMMARY

Individuals seeking specialist care for autism, eating disorders, or gender dysphoria should be screened for ARFID. More research is needed on how to support autistic adolescents and adults with features of ARFID.