Scurvy: An unusual presentation of cerebral palsy

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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Bilateral distal femoral epiphyseal detachment in a young adult: a case report

Epiphyseal dislocations and fractures frequently occur in children and adolescents. However, these injuries seldom involve the distal femur, and bilateral cases are even rarer. We present an unusual case of bilateral epiphyseal detachment of the femur in a 21-year-old man who was involved in a traffic accident. Open reduction and fixation surgery were performed 5 days after the incident. The patient experienced favorable progress, with consolidation occurring at 3 months. No lower limb length discrepancies were observed at the 20-month follow-up. In summary, bilateral distal femoral epiphyseal detachment is an uncommon condition that can be effectively treated through surgical intervention.

Pseudoparalysis Secondary to Vitamin C Deficiency: A Rare Presentation in a Toddler

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.

Scurvy in Children: The Silent Masquerader

In modern society, scurvy is well known in its historical perspective rather than clinical relevance. Scurvy is classically thought to manifest with signs of 'bleeding painful gums' in the undernourished. Little is known regarding its ability to mimic a wide range of rheumatological, orthopaedic, neurological and haematological illnesses. Due to the rarity of its occurrence, there is a poor understanding among present-day clinicians, and so scurvy can easily deceive the uninitiated. We report a school-aged boy with normal neurodevelopment who presented with lower limb pain and difficulty in walking. He was seen by multiple specialist doctors before the clinical diagnosis of scurvy was made by a general paediatrician. Investigations showed that this child had X-ray changes typical of scurvy with low serum ascorbic acid levels. On supplementation with vitamin C, he showed dramatic improvement in symptoms and gradually achieved complete recovery.

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.

Slipped Capital Femoral Epiphysis Associated With Vitamin C Deficiency in a 7-year-old Boy

Scurvy is rare in the present world and is mostly found in children with abnormal dietary habits and physical and mental disabilities. Scurvy can present in various forms, mimicking several common diseases, thus making the diagnosis difficult. Spontaneous epiphyseal separation is known to occur in scurvy, although rarely reported. The usual locations of these epiphyseal separations are distal femur and proximal humerus. Our case is unique in that scurvy in a seemingly normal child resulted in proximal femur epiphyseal separation which was not reported previously. We report a case of a 7-year-old boy presenting with pain and swelling in multiple joints for 6 months and later inability to walk. Pseudoparalytic frog-leg posture, dietary history of selective eating, and typical radiologic features made us consider a diagnosis of scurvy which was confirmed by a low serum vitamin C level. He developed epiphyseal separation of proximal femur and was treated with percutaneous screw fixation. Vitamin C supplementation resulted in prompt improvement clinically and radiologically.

Bilateral traumatic distal femoral transphyseal fracture in a 9-year-old male

A case of bilateral traumatic distal femoral Salter-Harris Type I fracture presented to our emergency department. History was of a 9-year-old male playing at a building site when a concrete block fell from height on to his knees, which were extended in a sitting position. Management was with analgesia and transfer to theatre followed by closed reduction and internal fixation—position was assessed under mobile X-ray. The patient made a full clinical recovery within 18 weeks and was followed-up over 5 years. There was no clinical effect on final adult length of femur and no deficit in range of movement. The foot-drop observed at presentation resolved over a period of 12 weeks. This case highlights the importance of performing a thorough neurovascular examination of the patient at presentation, followed by a careful closed reduction and internal fixation under anaesthesia, being careful not to damage the distal femoral growth plates.

The risk for scurvy in children with neurodevelopmental disorders

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.

Neurological Complications of Nutritional Disease

Vitamins and minerals have essential functions in the body, from signal transduction to acting as cofactors for numerous enzymatic processes. Nutritional deficiencies and excess of certain vitamins and minerals can have profound effects on the central and peripheral nervous systems from early development into adulthood. This article summarizes the role of various nutritional factors in the nervous system and the neurological symptoms that can arise from deficiency or excess.

Scurvy in pediatric age group - A disease often forgotten?

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.