Clinical Images: Scurvy in the modern era

Abstract

involved in posterior cerebral artery infarction but it is normally spared in PRES (3,4). Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) mapping can help to differentiate an ischemic lesion, which appears hyperintense on DWI and hypointense on ADC maps, from a lesion due to PRES, which does not appear hypointense on ADC maps (5). The distinction between PRES and central nervous system vasculitis can easily be made, since vasculitis lacks the typical MRI findings of PRES, and the diagnosis relies on corroborative data from cerebrospinal fluid analysis, angiography, and perfusion studies, with brain biopsy being the gold standard.When we initially presented our case, we decided against showing the subsequent MRI, since PRES MRI at presentation is characteristic and particularly useful in guiding diagnosis and treatment. We concur that reversibility is essential to the diagnosis of PRES and that was convincingly demonstrated in our patient during the followup MRI series, performed 1 year after the initial diagnosis. We observed a dramatic resolution of the characteristic lesions, aside from a small area of watershed infarction ( Figures 1A and B Clinical Images: Scurvy in the modern eraThe patient, a 42-year-old woman with chronic knee arthralgias attributed to early osteoarthritis, presented with a 2-week history of bilateral calf and ankle discomfort, along with lower extremity edema, which resulted in walking difficulty. She also noted scattered areas of bruising on her legs. Physical examination revealed multiple petechial lesions and ecchymoses on her lower extremities (left). Closer inspection of her skin showed perifollicular hemorrhages and corkscrew hairs (right). Results of blood tests for erythrocyte sedimentation rate, rheumatoid factor, antinuclear antibodies, antineutrophil cytoplasmic antibodies, hepatitis, cryoglobulins, antiphospholipid antibodies, and complement levels were unremarkable, but mild anemia, hypoalbuminemia, and a marginally depressed vitamin B 12 level were detected. She described her diet as severely limited, due to various food intolerances, and essentially devoid of fruits and vegetables. Serum vitamin C was undetectable (Ͻ0.12 mg/dl [normal 0.2-1.9]), and she was diagnosed as having scurvy. The patient was treated with daily oral supplements of ascorbic acid and within 2-3 weeks noted improvement in her symptoms, including the rash.