Case history
Case history #1
During a winter following a severe drought, four members of a family of subsistence farmers living in an area of conflict present to a medical outpost with varying degrees of fatigue, joint pains, bleeding gums, and thinning hair. One family member, a 3-year-old girl, cannot walk due to leg pains. Although there was fighting nearby, they have not been to refugee camps or received assistance from any public outreach programmes. Examination reveals varying clinical findings including gingival friability with loose teeth, ecchymoses on the limbs and torso, and friable corkscrew hairs. One of the adults has a painful knee effusion; another has peripheral oedema without cardiac murmur. Other community members experienced similar illness and fatalities 10 years prior, during a similarly poor year of farming.
Case history #2
A slender 6-year-old boy with autism presents with gait disturbance. Although he does not complain of pain, his parents had initially noted limping and an eventual unusual gait with wincing. He has been doing well since enrolling in an early intervention programme at age 4, but his family is concerned about regression in behavioural and social milestones over the last few weeks. He maintains a stable height and weight trajectory on growth charts (25th percentile height, 5th percentile weight), without any recent weight loss. On examination, the child is afebrile, is non-verbal, and avoids eye contact. His hips are tender to palpation with a bruise over the left forearm. His family is unaware of any recent trauma. Upon further review of the history, he is a picky eater, tending to favour salty foods such as savoury biscuits, crisps, crackers and sweets. He has refused to take his chewable vitamins for the past 4 months. No fruits, vegetables, or other sources of vitamin C were identified in the diet during that period.
Other presentations
Infantile scurvy presents with signs and symptoms in any order without a single predominant symptom, but can differ compared with presentation in adults or older children. Findings include irritability, brittle bones with microscopical fractures of the spicules between the shaft and calcified cartilage, intra-articular haemorrhage, and leg tenderness with pseudo-paralysis of the legs. A frog-leg or pithed frog body position (full knee flexion and partial hip flexion) reportedly affects half of infants with scurvy, but can be seen in older children as well.[3] Costochondral beading is found in 80%. Gingival haemorrhage around erupting teeth is very common. Petechial haemorrhages in the skin, a common hallmark in adults, may be uncommon in infants (10% to 15%). Laboratory abnormalities include very low levels of ascorbate in the blood and radiographic bone lesions (corner fraction sign, a ground-glass appearance, and trabecular atrophy).[1]
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