Skeletal Manifestations of Scurvy: A Case Report from Dubai

Abstract

Introduction. Nutritional deficiencies are rarely reported in developed countries. We report a child of Pakistani origin brought up in Dubai who developed skeletal manifestations of scurvy due to peculiar dietary habits. Case Presentation. A 4.5 year old boy presented with pain and swelling of multiple joints for three months and inability to walk for two months. Dietary history was significant for exclusive meat intake for the preceding two years. On examination the child's height and weight were below the 5th percentile for his age. He was pale and tachycardic. There was significant swelling and tenderness over the wrist, knee and ankle joints, along with painful restriction of motion. Basic blood workup was unremarkable except for anemia. However, X-rays showed delayed bone age, severe osteopenia of the long bones, epiphyseal separation, cortical thinning and dense zone of provisional calcification, suggesting a radiological diagnosis of scurvy. The child was started on vitamin C replacement therapy. Over the following two months, the pain and swelling substantially reduced and the child became able to walk. Repeat X-rays showed improvement in the bony abnormalities. Conclusion. Although scurvy is not a very commonly encountered entity in the modern era, inappropriate dietary intake can lead to skeletal abnormalities which may be confused with rickets. A high index of suspicion is thus required for prompt diagnosis of scurvy in patients with bone and joint symptoms.

The risk for scurvy in children with neurodevelopmental disorders

“…Literature reviewed yielded 77 cases of scurvy described in 65 published papers (Table S1), in addition to the two cases described here 1,8,9,11‐73 …”

Late Radiographic Findings of Infantile Scurvy in Northern Mali, a Region Facing a Humanitarian and Security Crisis

“…This confirms that the best evidence of scurvy is resolution of the manifestations of the disease after treatment with ascorbic acid. 7,8,12,13…”

Evidence of probable subadult scurvy in the Early Medieval cemetery of Castel Tirolo, South Tyrol, Italy

“…In particular, the principal scorbutic symptoms in children, where bone growth is rapid, are related to bleeding in the skin (Aufderheide & Rodríguez‐Martín, ), orbits (Sloan, Kulwin, & Kersten, ), gums (Omori et al, ), gastrointestinal tract, subperiosteal surfaces, and muscles (Fain, ). Arthralgia, inflammation, osteopenia, and trauma are also documented (Clemetson, ; Duggan, Westra, & Rosenberg, ; Halcrow, Harris, Beavan, & Buckley, ; Khonsari, Grandière‐Perez, & Caumes, ; Noordin, Baloch, Salat, Rashid Memon, & Ahmad, ). The consequences of chronic bleeding that manifest when physiological muscles contract and lacerate the blood vessels (Lovász et al, ) are fundamental pathological indicators for scurvy not only in living patients but also in human skeletal remains.…”

“…Recently, the interest in the detection of infantile scurvy, in skeletal materials from various time periods and geographical regions, has significantly increased (e.g., Bourbou, ; Brickley & Ives, , ; Buckley et al, ; Castilla, Carretero, Gracia, & Arsuaga, ; Halcrow et al, ; Klaus, ; Lovász et al, ; Mays, ; Schattmann, Bertrand, Vatteoni, & Brickley, ; Snoddy, Halcrow, Buckley, Standen, & Arriaza, ; Wrobel, ). Moreover, different scientific methods such as histology (Schultz, ), radiology (Noordin et al, ; Popovich, McAlhany, Adewumi, & Barnes, ; Tamura et al, ), computed tomography (Zuckerman, Garofalo, Frohlich, & Ortner, ), and chromatography (Koon, , ; Pendery & Koon, ) were applied to support the macroscopic analyses, especially in the early stages of scurvy. Despite these increasing efforts, the limited success of detecting scurvy in immature skeletons did not change.…”