P3D327: Hypovitaminosis C: A Topsy-turvy Case of Scurvy

Introduction: Vitamin C deficiency, also known as scurvy, is historically documented as one of the greatest threats at sea, affecting more than two million sailors in the 18th century. More recently, outbreaks of scurvy have been seen among refugees living in areas prone to micronutrient deficiencies. While thought to be rare in resource-rich environments, a thorough review of recent literature provides multiple pediatric case reports of scurvy in well-resourced, developed countries, most often in the setting of severely restrictive dietary habits secondary to developmental or behavioral disorders.

Case Description: A five-year-old female, living in Germany, with history of a chronic restrictive diet and speech delay presented with 6 months of progressive lower extremity pain, gingival hyperplasia with bleeding, and pinpoint perifollicular rash. She was first evaluated at a civilian hospital in Germany and underwent extensive and invasive workup under the primary care of pediatric hematology/oncology. She received chemotherapy for suspected Langerhans Cell Histiocytosis, but treatment was discontinued following negative confirmatory studies.
Due to multiple inpatient admissions for severe pain, significant language barrier with the German medical team, and a diagnosis yet to be identified, patient was medically evacuated to Unites States of America for further investigation. Initial evaluation revealed clinical and laboratory findings highly suspicious for scurvy. Treatment with daily ascorbic acid led to prompt resolution of pain and clinical symptoms.

Discussion: Despite history and presentation strongly suggestive of scurvy in our case, there was significant delay in recognition likely due the rarity of the condition. This was further exacerbated by the substantial language barrier between the family and the civilian German medical team. This case highlights the critical need for military pediatricians in overseas locations to mitigate these barriers and the high index of suspicion all clinicians must have for vitamin C deficiency presenting as unexplained pain in the setting of restrictive diets and developmental delay.

Conclusion: Vitamin C deficiency is a rare, easily preventable, and curable condition if diagnosed promptly and accurately.