Scurvy can be mistaken for rheumatologic disorders

Dietary vitamin C deficiency was identified in 10 patients previously suspected to have juvenile idiopathic arthritis, vasculitis, or chronic nonbacterial osteomyelitis.

Scurvy is seldom suspected in children presenting with arthritis or extremity problems. A case series describes 10 children in Seattle (ages 3–20 years, 9 males) over 4 years who were found to have scurvy after referral to a rheumatology service for evaluation of lower extremity pain, limp, or refusal to bear weight. Among the findings:

• Other symptoms included ecchymoses (5 patients), petechiae, myalgias, polyarthralgia, gingivitis, epistaxis, sores in the mouth, anaemia, and corkscrew hairs. One patient had arthritis.

• Reasons for referral were suspected juvenile idiopathic arthritis, vasculitis (Henoch-Schönlein purpura), and diffuse nonbacterial osteomyelitis.

• Eight patients had autism, developmental delay, or both. Most patients had limited diets that lacked fruits and vegetables.

• Erythrocyte sedimentation rate and C-reactive protein levels were elevated in 9 patients. Haematocrit values were low in all 10 patients; platelet counts were normal.

• In none of the diagnostic radiographs was scurvy offered as a potential diagnosis.

• Magnetic resonance imaging showed diffuse sub-periosteal fluid oedema. Scurvy was mentioned as a possibility in three of eight studies.

• Ascorbic acid levels were below normal in all in whom it was measured.

• Symptoms responded to supplemental vitamin C in all patients.

• Time to diagnosis ranged from 1 to 47 months.

These cases demonstrate that subpopulations of patients may have nutritional deficiencies and that scurvy can mimic inflammatory conditions. Taking dietary histories is important in all our patients; had that been done sooner, the patients in this report could have received a diagnosis sooner.