Scurvy and food selectivity in childhood: a case report

ABSTRACT Despite its rarity, symptomatic micronutrient deficiency remains a public health problem. Scurvy is the differential diagnosis for bleeding disorders and hematological and rheumatological diseases, especially in patients with eating disorders. However, it is unrelated to autism spectrum disorders or other neurodevelopmental disorders. A previously healthy 10-year-old boy living in São Paulo, Brazil, had a history of significant food selectivity unrelated to autism spectrum disorder, resulting in symptomatic ascorbic acid deficiency (scurvy). This resulted in pain and purpuric lesions on the lower limbs, gingival edema, bleeding during tooth brushing, asthenia, weakness, malaise, and sadness. Therefore, dietary anamnesis is important for routine monitoring of child growth and development. This process helps prevent nutritional deficiencies, facilitates early diagnosis of eating disorders, and enables multidisciplinary follow-up for these patients.

Investigação de surto de doença compatível com escorbuto em uma penitenciária masculina do Ceará, 2019-2020: um estudo de caso-controle / Investigation of an outbreak of disease compatible with scurvy in a male penitentiary in the state of Ceará, Brazil, 2019-2020: a case-control study / Investigación de un brote de enfermedad compatible con escorbuto en una penitenciaría masculina en el estado de Ceará, Brasil, 2019-2020: un estudio de casos y controlesInvestigação de surto

Objetivo: identificar ocorrência de surto compatível com escorbuto e fatores de exposição associados aos sinais/sintomas típicos de hipovitaminose, em penitenciária masculina, Ceará, Brasil, 2019-2020. Métodos: estudo de caso-controle populacional; foram utilizados registros clínicos e entrevistas com casos compatíveis - sinais/sintomas iniciados no período - e com controles; realizou-se análise multivariável. Resultados: 62 casos; idade média de 40,6 anos (DP = 10,8); principais sinais/sintomas foram edema e dor em membros inferiores (100,0%), dificuldade para deambular (91,9%), hematoma/equimose em membros inferiores (90,3%), febre (88,7%); identificou-se, como fator de exposição, média de idade > 40 anos (ORa = 1,10; IC95% 1,05;1,17; p-valor = 0,001); e como fatores protetores, trabalho (ORa = 0,11; IC95% 0,03;0,36; p-valor < 0,001) e participação em aulas (ORa = 0,21; IC95% 0,08;0,59; p-valor = 0,003) dentro da penitenciária. Conclusão: surto da penitenciária compatível com escorbuto pelos sinais/sintomas característicos, associados aos fatores identificados; recomendou-se oferta regular de dieta rica em vitamina C para todos os internos e acompanhamento clínico dos casos.

Objective: to identify the occurrence of an outbreak compatible with scurvy and exposure factors associated with typical signs/symptoms of hypovitaminosis that occurred in a male penitentiary in Ceará, Brazil between 2019-2020. Methods: this was a population-based case-control study; we used clinical records and interviews with compatible cases - based on sign/symptom onset during the study period - and with controls; we carried out multivariate analysis. Results: out of 62 cases, mean age was 40.6 years (SD = 10.8); main signs/symptoms were edema and pain in the lower limbs (100.0%), difficulty in walking (91.9%), hematoma/ecchymosis in the lower limbs (90.3%) and fever (88.7%); we identified being over 40 years old as an associated factor (aOR = 1.10; 95%CI 1.05;1.17; p-value = 0.001); and as protective factors: working (aOR = 0.11; 95%CI 0.03;0.36; p-value < 0.001) and taking part in classes (aOR = 0.21; 95%CI 0.08;0.59; p-value = 0.003) in the prison. Conclusion: we considered the penitentiary outbreak to be compatible with scurvy due to characteristic signs/symptoms, associated with the identified factors; we recommended regular provision of a diet rich in vitamin C to all male inmates and clinical follow-up of cases.

Objetivo: identificar la ocurrencia del brote compatible con escorbuto y los factores de exposición asociados con signos/síntomas típicos de hipovitaminosis que ocurrieron en una penitenciaría masculina en Ceará, Brasil entre 2019-2020. Métodos: estudio poblacional de casos y controles; se utilizaron historias clínicas y entrevistas con casos compatibles, con inicio de signos/síntomas durante el período de estudio, y controles; se realizó análisis multivariable. Resultados: de los 62 casos, edad media fue 40,6 años (DE = 10,8); principales signos/síntomas fueron edema y dolor en miembros inferiores (100,0%), dificultad para caminar (91,9%), hematoma/equimosis en miembros inferiores (90,3%) y fiebre (88,7%); la edad mayor de 40 años se identificó como factor asociado (ORa = 1,10; IC95% 1,05;1,17; p-valor = 0,001); y como factores protectores: trabajo (ORa = 0,11; IC95% 0,03;0,36; p-valor< 0,001) y participación en clases (ORa = 0,21; IC95% 0,08;0,59; p-valor = 0,003) dentro del centro penitenciario. Conclusión: el brote en centro penitenciario fue considerado compatible con escorbuto debido a los signos/síntomas característicos, asociados a los factores identificados; se recomendó oferta regular de dieta rica en vitamina C a todos los internos y seguimiento clínico de los casos.

Escorbuto en la adolescencia: reporte de un caso / Scurvy in adolescence: case report

El escorbuto es una enfermedad producida por déficit de vitamina C. Si bien en la actualidad es poco frecuente, la bibliografía describe grupos de riesgo en la población pediátrica, dentro de los que se encuentran los pacientes con alteraciones alimentarias. Se reporta el caso de un adolescente varón, de 11 años de edad, que desarrolló la enfermedad por un hábito alimentario selectivo, sin ingesta de frutas ni verduras. El objetivo del reporte es resaltar la importancia de la anamnesis alimentaria completa en la consulta con el equipo de salud, que permita sospechar y detectar de manera temprana y oportuna trastornos por déficit de micronutrientes como el escorbuto.

Scurvy is a disease caused by vitamin C deficiency. Although it is currently rare, risk groups in the pediatric population are described in the bibliography, including patients with eating disorders. We report the case of an 11-year-old male adolescent who developed the disease due to a selective eating habit, without fruits or vegetables. The objective of this report is to highlight the importance of complete food anamnesis in consultation with the health team, which allows to suspect and detect early and timely micronutrient deficiency disorders such as scurvy.

Escorbuto en el siglo XXI / Scurvy in XXI century

El escorbuto es una enfermedad causada por la deficiencia de vitamina C o ácido ascórbico. Sus manifestaciones clínicas son variadas debido a que esa vitamina es un cofactor de enzimas que intervienen en numerosos procesos, como la síntesis de colágeno y la absorción de diferentes nutrientes. La expresión cutánea característica son las petequias foliculares con pelos en cuello de cisne y en tirabuzón. El compromiso mucoso se manifiesta como hipertrofia y hemorragia gingival, gingivitis y pérdida de piezas dentarias. El diagnóstico es clínico y puede confirmarse mediante la determinación de la vitamina C plasmática o leucocitaria. El tratamiento se basa en el aporte suplementario de esa vitamina. Se presenta el caso de un paciente de 32 años con escorbuto debido a una dieta casi exclusivamente a base de harinas y carente de frutas y verduras. (AU)

Scurvy is a disease caused by vitamin C deficiency (also called ascorbic acid). Its clinical manifestations are varied because this vitamin is a cofactor of enzymes that take part in numerous processes, such as the synthesis of collagen and the absorption of different nutrients. Cutaneous expression of scurvy is follicular petechiae with corkscrew hairs. Mucous involvement manifests as gingival hypertrophy and bleeding, gingivitis and loss of teeth. The diagnosis of this entity is clinical and can be confirmed by plasma or leukocyte vitamin C dosing. The treatment consists of vitamin C supplementation. We present a 32-year-old male patient with scurvy secondary to a diet based almost exclusively on flour and lacking in fruits and vegetables. (AU)

Escorbuto secundario a una dieta restrictiva en un niño con diagnóstico de trastorno del espectro autista: Reporte de un caso / Scurvy due to restrictive diet in a child with autism spectrum disorder: Case report

Actualmente, el escorbuto es una entidad infrecuente en pediatría. Se han publicado reportes de casos que describen la enfermedad en lactantes alimentados con leche hervida, en pacientes con sobrecarga de hierro por enfermedades hematológicas y en niños con restricciones alimentarias por trastornos del neurodesarrollo. Se reporta el caso de un paciente masculino de 4 años con diagnóstico de trastorno del espectro autista que desarrolló la enfermedad por un hábito alimentario selectivo de larga evolución, sin ingesta de frutas ni verduras. La importancia del reporte radica en informar al pediatra y a otros profesionales dedicados a la atención primaria de salud acerca del desarrollo de escorbuto como potencial consecuencia de las dietas restrictivas en niños con trastornos del neurodesarrollo y de la trascendencia de la anamnesis alimentaria en pacientes con patología para evitar enfermedades asociadas a micronutrientes.

Scurvy is a very uncommon entity in pediatric population. Some case reports have been published in infants fed with boiled milk, in patients with iron overload secondary to hematological diseases and in children with food restrictions secondary to neurodevelopmental disorders. We report a case of a 4-year-old male patient with a diagnosis of autism spectrum disorder, which developed scurvy secondary to a long-term selective eating habit without fruit or vegetable intake. The objective of this case report is to announce the pediatrician and other professionals dedicated to primary health care about scurvy as a potential consequence of restrictive diets in children with autism spectrum disorders as well as the importance of dietary history in sick patients to prevent associated micronutrient deficiencies.

Probable Cases of Scurvy in Subadults Crania from Archaeological Sites, South Korea / 체질인류학회지

In this study, the skeletal abnormalities associated with scurvy in subadults crania from three archaeological skeletal collections (Nukdo, Imdang, Yeanri), South Korea was analyzed to examine the prevalence and distribution of childhood scurvy of ancient Korea. For this, 30 subadults crania from the Nukdo, Imdang, Yeanri site were examined. Using criteria described by Ortner and Ericksen (1997) for identifying scurvy in skeletal material we evaluated the cranial skeleton of the subadults for evidence of abnormal porosity. All skeletal materials were macroscopically evaluated for pathological changes associated with scurvy. In results, lesions indicative of probable scurvy were observed in 22 individuals of 30 individuals. Based on the results, childhood disease relating to nutrition and metabolism in ancient Korea might have been widespread, along with scurvy. The results of the present study will be useful for understanding the health condition of the ancient Korean populations. Future work will add significantly to the larger picture of diet and disease within populations of ancient Korea.

Plasma Vitamin C Status of Adolescent Girls in a Slum of Delhi.

A cross-sectional study was conducted among 775 adolescent girls (11-18 years) residing in a slum of Delhi to assess plasma vitamin C levels. The mean (SD) plasma levels of vitamin C were 0.76 (0.45) mg/dL. Overall, 6.3% and 27.6% girls had deficient (<0.2 mg/dL) and suboptimal levels (0.2-0.49 mg/dL) of plasma vitamin C, respectively.

Jean-Baptiste Charcot, the French Antarctic expedition and scurvy / Jean-Baptiste Charcot, expedição Antártica e escorbuto

During the second expedition to the South Pole, Commander Jean-Baptiste Charcot and some members of the crew of “Pourquoi Pas?” developed symptoms suggestive of scurvy. The clinical picture was totally reversed after dietary changes.

Durante a segunda expedição polar do sul, o comandante Charcot e alguns membros da tripulação do “Porquoi Pas?” desenvolveram sintomas sugestivos de escorbuto. O quadro clínico foi totalmente reversível após modificações da dieta.

Rare Case of Scorbutic Gingivitis.

Scorbutic Gingivitis was a condition of great prevalence among sailors of the yesteryears. With added advancement and diet consciousness the condition is a rarity now. Although scurvy is prevalent in population below poverty line, in this patient having scorbutic gingivitis, it was ironic that the patient starved due to religious belief and not due to circumstances. Vitamin C is the vitamin with the second largest daily requirement and plays a vital role in a host of metabolic reactions. Its lack produces a panorama of signs and symptoms, many of which present primarily or originally in the mouth. This case report of a rare case of Scorbutic gingivitis was diagnosed and treated in Department of Periodontology and reviews the case itself and the recent literature on this potentially fatal condition.

Escorbuto na criança / Scurvy in child

O objetivo deste relato é alertar a comunidade médica sobre o escorbuto que, apesar de ser doença rara nos dias atuais, deve ser lembrado quando o paciente manifesta distúrbios hemorrágicos e história de erro alimentar. Reporta-se o caso de uma criança que foi hospitalizada por dor progressiva nos membros inferiores, edema e manifestaçõeshemorrágicas. O diagnóstico de escorbuto foi baseado nos achados clínicos, no relato histórico alimentar de ingestão somente de bolo e leite e na remissão dos sinais e sintomas após a administração de vitamina C.

The purpose of this report is to alert the medical community about scurvy. Although it is nowadays a rare disease, it must be taken into consideration when the patient presents bleeding disorders and bad eating habits. A case is presented of a child hospitalized with progressive pain in his lower limbs, edema and hemorrhages. The diagnosis of scurvy was based on clinical findings, on the alimentary history of only cake and milk intake and, on the remission of symptoms and signs after the administration of vitamin C.

Scurvy in a patient with AIDS: case report / Escorbuto em paciente com AIDS: relato de caso

We report the case of a 35-year-old homeless alcoholic and illicit drug user, with AIDS, who was admitted to the emergency unit complaining of asthenia and a weight loss of 30kg over the preceding three months. Clinical and laboratory data confirmed a diagnosis of marasmus, bacterial pneumonia, chorioretinitis caused by Toxoplasma gondii and oral Candida infection. The patient also presented loss of tongue papillae, gingival hypertrophy, perifollicular hyperkeratosis and hemorrhage, coiled, corkscrew-like hair, anemia, hypoalbuminemia, increased C-reactive protein levels and low serum vitamin C levels. The patient developed severe gastric hemorrhage, with hemodynamic instability and terminal disseminated intravascular coagulopathy.

Relatamos o caso de um paciente alcoólatra e usuário de drogas ilícitas com 35 anos de idade, morador de rua com AIDS, admitido na Unidade de Emergência referindo astenia e perda ponderal de trinta quilos nos últimos três meses. Dados clínicos e laboratoriais confirmaram o diagnóstico de marasmo, pneumonia, corioretinite por Toxoplasma gondii e candidíase oral. Apresentava ainda: língua despapilada com hipertrofia gengival, hiperqueratose e hemorragia folicular associada a pêlos tipo saca-rolhas, anemia, hipoalbuminemia, aumento dos níveis de proteína C reativa com baixos níveis séricos de vitamina C. O paciente desenvolveu hemorragia gástrica grave, com instabilidade hemodinâmica e coagulação intravascular disseminada terminal.

Escorbuto / Scurvy

Apesar de considerado raro, o escorbuto, doença clínica causada pela deficiência de vitamina C, ainda ocorre nos dias de hoje, inclusive em países desenvolvidos. É caracterizada por acometer pacientes com história de alcoolismo, baixo nível socioeconômico, alergia alimentar e doenças psiquiátricas. A causa principal é a insuficiente ingestão de frutas e vegetais frescos. A apresentação clínica consiste de sinais e sintomas inespecíficos. Essas manifestações podem estar associadas ao acometimento de diversos órgãos, como a pele e os sistemas hematológico, articular e ósseo, pois o ácido ascórbico constitui elemento fundamental na formação do componente essencial desses tecidos: o colágeno. O diagnóstico é essencialmente clínico, baseando-se na sintomatologia e história dietética do paciente. O tratamento é feito com reposição de vitamina C em doses que variam de 500mg a 1g por dia, com resultados satisfatórios em curto espaço de tempo. Descrevemos o caso de uma paciente com 24 anos, com manifestações típicas de deficiência de vitamina C, retratando uma apresentação clássica de escorbuto nos dias atuais

Although considered rare, scurvy, a clinical disease caused by deficiency of vitamin C, still occurs today, even in developed countries. It usually affects patients with a history of alcohol abuse, low socio-economic status, food allergy and psychiatric disorders. The main cause is insufficient intake of fresh fruit and vegetables. The clinical presentation consists of nonspecific signs and symptoms. These symptoms may be associated with the involvement of various organs such as the skin and the hematological, joint and bone systems, because ascorbic acid is a crucial element in the formation of collagen, the essential component of these tissues. The diagnosis is essentially clinical, based on symptoms and dietary history of the patient. Treatment is with supplements of vitamin C in doses ranging from 500mg to 1g per day, with satisfactory results in a short time. We report the case of a 24-year female patient with typical manifestations of vitamin C deficiency, featuring a typical presentation of scurvy today

Complex regional pain syndrome type 1 and scurvy.

A 5 year old female developed features of complex regional pain syndrome (CRPS) i.e excessive pain to touch, decreased sweating and edema of left ankle 2 years after fracture of left tibia. Gum bleeding, petechiae and pseudoparalysis and suggestive radiograph characterized scurvy. Hyperesthesia improved and child walked with support following administration of vitamin C.

MR Imaging in a Child with Scurvy: a Case Report

Scurvy is very rare disease in industrialized societies. Nevertheless, it still exists in higher risk groups including economically disadvantaged populations with poor nutrition, such as the elderly and chronic alcoholics. The incidence of scurvy in the pediatric population is very low. This study reports a case of scurvy in a 5-year-old girl with cerebral palsy and developmental delay based on MRI findings.

A Case of Scurvy Mimics Cutaneous Vasculitis / 대한내과학회지

The human body is unable to synthesize vitamin C and a diet deficient in vitamin C leads to scurvy. Scurvy has become a rare clinical entity in most developed country. However it may still be encountered in selected situation, such as old people live along, young children, food faddists, and alcoholics. Scurvy may mimic other medical conditions such as vasculitis, systemic bleeding disorders, and deep vein thrombosis. For this reason, scorbutic patient are often misdiagnosed or evaluated for other disorder, thus delaying the correct diagnosis. We describe a 63-year-old man who had petechiae and ecchymoses of lower extremity, follicular hyperkeratosis, gingival hemorrhage and corkscrew hairs after consuming a restricted diet for 3 year. The diagnosis was confirmed by low concentration of vitamin C in serum, and treatment with vitamin C leads to a rapid reversal of scorbutc changs. We emphasize the importance of taking into consideration scurvy in the diagnosis of patient presenting with a skin rash resembling vasculitis or systemic bleeding disorder in high risk group.