Rheumatic Manifestations of Scurvy: A Report of Three Recent Cases in a Major Urban Center and a Review

Mertens, Marty; Gertner, Elie

doi:10.1016/j.semarthrit.2010.10.005

Cited by 36 publications

(36 citation statements)

References 11 publications

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“…adult patients have been described in case reports to have this association. 6,7 In an animal model of PH, supplemental vitamin C reduced PH and the associated muscularization of pulmonary arterioles that is caused by their exposure to cool environmental temperatures. 8 Nitric oxide (NO) is a potent mediator of vascular smooth muscle relaxation and is generated by the conversion of L-arginine to L-citrulline by the enzymatic action of NO synthetase.…”

Section: Figurementioning

confidence: 99%

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Pulmonary Hypertension Associated With Scurvy and Vitamin Deficiencies in an Autistic Child

Duvall¹,

Pikman

Kantor³

et al. 2013

Pediatrics

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Restricted dietary intake is common among children with behavioral issues. Here we report a case of a severely autistic child who presented initially with limp but who soon developed cough, tachypnea, hypoxia, and tachycardia. An echocardiogram revealed evidence of pulmonary hypertension (PH) with severely dilated right ventricle and elevated right-sided pressures. The etiology of his PH was unclear but further laboratory evaluation demonstrated severe nutritional deficiencies, in particular an undetectable ascorbic acid (vitamin C) level as well as deficient levels of thiamine (vitamin B 1 ), pyridoxine (vitamin B 6 ), cobalamin (vitamin B 12 ), and vitamin D. Repletion of these vitamins was associated with resolution of his PH and his musculoskeletal complaints. We report this case and a review of the relevant literature as a clinical lesson to expand the differential diagnosis of limp in children who may be difficult to assess as well as to report on an unusual association between severe vitamin deficiencies and PH.

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Section: Figurementioning

confidence: 99%

“…55 nmol/L 70-180 nmol/L Vitamin B 6 3.5 ng/mL 5-30 ng/mL Vitamin B 12 ,150 pg/mL 190-778 pg/mL 25-hydroxy vitamin D 8.2 ng/mL 30-80 ng/mL…”

Section: Figurementioning

confidence: 99%

Pulmonary Hypertension Associated With Scurvy and Vitamin Deficiencies in an Autistic Child

Duvall¹,

Pikman

Kantor³

et al. 2013

Pediatrics

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“…However, in scurvy, the petechiae are perifollicular and associated with hyperkeratosis, as opposed to the palpable purpura often described in vasculitis. Further, marked elevations in ESR and CRP have also been reported in scurvy . The initial concern for vasculitis and clinician discomfort with a diagnosis based solely on a rash delayed the diagnosis.…”

Section: Discussionmentioning

confidence: 99%

“…Further, marked elevations in ESR and CRP have also been reported in scurvy. 10 The initial concern for vasculitis and clinician discomfort with a diagnosis based solely on a rash delayed the diagnosis. The complaint of polyneuropathy also seemed inconsistent with scurvy.…”

Section: Discussionmentioning

confidence: 99%

The missing element

Anderson

DeNiro

Harte

et al. 2016

Journal of Hospital Medicine

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A 57-year-old man presented to an emergency department with 1 month of progressive, bilateral lower extremity pain and weakness.The first step in evaluating "weakness" is to determine whether it is objective (ie, decreased muscle strength due to pathology along the neuromuscular axis) or subjective. The sensation of weakness without loss of muscle strength may result from a debilitating chronic disease (eg, congestive heart failure, anemia, or chronic obstructive pulmonary disease). In patients with true lower extremity weakness it is prudent to assess for a myelopathy with a focused history and exam that includes assessment of bowel or bladder impairment and anal reflex. The presence of pain along with weakness might suggest disease of the muscle itself. A myopathy may arise from an infectious (eg, influenza), inflammatory (eg, polymyositis), endocrine (eg, hypothyroidism), or drug-related (eg, statin) process.The patient described 1 month of generalized weakness and pain in his lower extremities, which had worsened progressively to the point where ambulation was difficult. He was able to rise from a seated position using his arms for assistance, but had difficulty balancing in a standing position without assistance. The pain also involved both of his knees and increased with weight bearing. He also complained of bilateral lower extremity numbness and paresthesias, which had been migrating proximally from his toes over several months. He denied any recent trauma to his legs or back.These symmetrical, distal sensory deficits favor a peripheral neuropathy over a myopathy, with neuropathic pain and arthralgia causing his impaired ability to ambulate or remain standing. In polyneuropathy, the type of nerve involvement (sensory vs motor) and pathology (axonal vs demyelinating) helps prioritize the differential. In developed countries, the most common causes of polyneuropathy are diabetes mellitus and alcohol. However, the tempo of his disease broadens the possibilities to include acute inflammatory demyelinating polyneuropathy, paraneoplastic syndrome (eg, monoclonal gammopathy), an autoimmune process (eg, rheumatoid arthritis, vasculitis), and heavy metal toxicity such as lead poisoning.He had no history of chronic medical illness or hospitalizations and took no medications. His social history was notable for a history of alcohol abuse. For the past several years, he had only been drinking 1 to 2 beers daily due to cost, but had a history of more significant alcohol abuse in the distant past. He smoked 1 pack of tobacco per day, and denied illicit drug use. He denied any sexual activity or recent travel. He lived in a van, and had been homeless for over 10 years.His socioeconomic status adds a layer of complexity to the case. Human immunodeficiency virus and hepatitis C virus (HCV) are more prevalent in the homeless and are associated with polyneuropathy. His lack of funds may drive him to drink illegally distilled alcohol, which can cause polyneuropathy through lead or arsenic toxicity. Excessive smoking could be ...

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“…In industrialized countries, nutritional deficiencies are rarely seen, but can occur in alcoholics, institutionalized elderly, or those with restrictive dietary intake related to eating disorders, psychiatric conditions, food allergies, or organic gastrointestinal disorders 1– 5 . This case highlights three specific vitamin deficiencies: scurvy, pellagra, and hypovitaminosis A.…”

Section: Discussionmentioning

confidence: 99%