Leg pain in a 4 year-old child with selective diet, think about scurvy!

Introduction: Scurvy is the disease generated by the lack of vitamin C, although it is considered a rare and past disease, scurvy continues to be detected in children with neurodevelopmental disorders and with restricted and selective diet habits. Clinical features are hypertrophy, swelling and bleeding of the gums, follicular hyperkeratosis, lower limbs swelling and tenderness. Identifying scurvy could be demanding due to the perceived rarity of the condition, and it could become a tricky diagnostic question given to the variety of nonspecific symptoms, including gingival manifestations. Objectives: Here we present a case report of Scurvy in a 4 year-old child. Methods: A 4 year-old child presented to our Department with lower limbs pain and refusal to walk for about 4 months. The symptoms were partially managed with Non Steroidal antinfiammatory Drugs. Patient’s mother did not refer ferver, skin rash or weight loss. Patient psychomotor development was referred in the norm up to 7-8 months of age, then patient presented a delay of psychomotor and language development. Dietary history reveals highly selective eating since the second year, based exclusively on ham and white meat homogenized, with refusal of fruits and vegetables. Since about 1 year the mother reports difficulty in eating, and several episodes of gengivitis with antivirals and topical antifungals with partial benefit. When patient came to our department he was in fair general conditions, his weight was 17 kg (25-50 th), his height was 105 cm.(25-50 th). Physical examination althought difficult because of the patient’s developmental delay revealed :pale and dry skin, corkscrew hair, signs of follicular hyperkeratosis in the lower and upper limbs. Child refused to walk, with legs fixed in flexion at hips and knees (“Frog leg-position”). Both legs were diffusely tender to palpation. The child was uncooperative for oral examination but erythematous, hemorrhagic, and swollen gums in maxillary anterior region were noted. Blood examinations revealed low iron and vitamin D level, inflammatory parameters (C-reactive ptotein and erythrocyte sedimentation rate) were normal. Hips, knees and ankle ultrasound did not revealed joints effusion. X-ray of the lower limbs did not revealed fractures, but generalized osteopenia and typical features of malnutrition, including a ground glass appearance, Pelkan spur, which represents a healing metaphyseal pathologic fracture, and a Wimberger ring sign, which denotes a thin sclerotic cortex surrounding a lucent epiphysis. Periosteal new bone formation secondary to subperiosteal, hemorrhage, a dense provisional calcification immediately adjacent to the physis (Frankel line), and an adjacent lucent band more, diaphyseal in location (Trummerfeld line). Results: In consideration of personal history, result of blood examinations and of lower limbs X-ray, we hypothesized a state of vitamin C deficiency. This clinical suspicion was confirmed by the finding of low levels serum vitamin C <2.4 micromol / L (normal value 26.1-84.6). Supplementary treatment with oral vitamin C (300 mg daily) and D (800 UI daily) was started . Patient clinical condition improved with recovery of walking. One month after discharge, the boy had normal vitamins’ levels: 35,6 micromol/L (normal value 26.1-84.6). Conclusion: Scurvy is rare, but it still occurs among children with autism and developmental disorders, so this condition should be keep in mind in a clinical constellation of lower extremity pain, limp, recurrent gengivitis, fatigue, anemia, in particular in children with an history of selective diet. The adoption of a detailed dietary anamnesis is fundamental to the early recognition of nutritional deficiency diseases in order to avoid invasive procedures and/or their severe complications.