Pediatric Physiatrist Joe DiMaggio Children's Hospital Hollywood, Florida, United States
Case Diagnosis: Hypovitaminosis C (Scurvy)
Case Description: A 3-year-old unvaccinated boy, with no PMH and delivered at home at 37-weeks, presented with 1-2 months of refusal to walk. He had been developmentally appropriate but was breastfed until 30-months. Subsequent PO intake was reportedly minimal. Examination revealed diffuse muscle wasting, severe lower extremity allodynia, bilateral knee effusions, and a stage-1 sacral ulcer. MRI C/T/L-spine was unremarkable. X-ray/MRI of tibia/fibula showed diffuse cortical thinning with subperiosteal hemorrhages. Labs revealed an extremely low Vitamin C level at 0.1. TPN, fluids, and vitamin supplementation was started. He required transfusions for severe anemia. Neurology/GI workup did not suggest any organic disorder. He was transferred to inpatient rehabilitation at a total-assist level on nasoduodenal feeds. With ST/dietician assistance, his oral caloric intake was progressively increased. He participated in PT/OT. His allodynia/effusions/sacral ulcer improved significantly. In 4 weeks, he gained 10lbs and was discharged at a min-assist level for ambulation (using posterior walker).
Discussions: Hypovitaminosis C, or scurvy, classically presents with bone pain, myalgia (due to reduced carnitine production), joint effusions, poor wound healing, bleeding diathesis, and allodynia. It is associated with malnutrition, but can also be seen with prolonged diets devoid of green vegetables and citrus fruits. Refusal to walk secondary to pain has been observed in multiple cases of childhood scurvy. Severe anemia is characteristic, secondary to combined iron and folate deficiencies. Treatment of scurvy consists of aggressive vitamin C replenishment and nutritional/physical rehabilitation.
Conclusions: Scurvy, which is rare in developed countries except for cases involving caregiver neglect, can result in significant acute/subacute functional decline in pediatric patients. This case illustrates that a multidisciplinary inpatient rehabilitation program combined with nutritional intervention can lead to significant symptom resolution and functional restoration. It also subtly adds to the growing scientific discussion on the role of Vitamin C in acute and chronic pain.