(33) Two Pediatric Cases of Scurvy Presenting as Suspected Rheumatologic Disease

Background: This case series highlights the resurgence of scurvy in children with autism, restrictive food intake disorder, or sensory processing disorders. Scurvy can mimic rheumatologic disease, and early consideration in children with highly selective diets may prevent unnecessary testing and costs.

Objectives: Case 1: ZC is a 9-year-old male referred from an outside hospital for further evaluation of painful shin nodules. He reported a three-week history of bilateral shin bruising, swelling, and tenderness, along with polyarthritis, difficulty ambulating, fevers, and gingival swelling. Initial evaluation revealed severe normocytic anemia (Hg 4.9 g/dL). The differential diagnosis included endocarditis and acute rheumatic fever, prompting a broad diagnostic workup and consultations (see Table 1).
A dietary history revealed an extremely restricted intake consisting solely of white bread and water. Subsequent evaluation identified an undetectable vitamin C level. The patient was initiated on supplementation and enrolled in feeding therapy.
His infectious/rheumatologic workup was negative at follow up. He continues to make progress in feeding therapy and is awaiting evaluation for autism spectrum disorder. Vitamin C levels normalized with supplementation.

Design/Methods: Case 2: MS is a 2-year-old male who presented with refusal to walk, fussiness and constipation. He was previously diagnosed with transient synovitis but showed no improvement after two weeks of ibuprofen. Extensive work up and consultations were pursued (see Table 1). Notable findings included MRI evidence of multifocal bone enhancement, edema and inflammation–findings concerning for chronic recurrent multifocal osteomyelitis.

Results: A dietary history revealed intake consisting mainly of Little Debbie Mini Muffins with limited intake of additional snacks and vegetables. A vitamin panel revealed undetectable levels of vitamin C, confirming scurvy. He was started on supplementation and referred to nutrition and feeding therapy.
At follow-up, all cultures were negative and he resumed ambulation with physical therapy, though vitamin C remained undetectable. He continues feeding therapy with pending autism evaluation.

Conclusions: In conclusion, scurvy can present with nonspecific symptoms such as bone pain, mucocutaneous findings, general fussiness and decreased ambulation, sometimes mimicking a rheumatologic disease. Early dietary history, prompt vitamin C testing, and awareness of related imaging findings can help avoid unnecessary tests and interventions.