Case Presentation:
A 3‐year‐old boy with PDD, keratosis pilaris, and gingivitis presented to a New York City ED with limping after a fall. Initial evaluation was negative for fracture, and he was discharged with follow‐up and prescribed amoxicillin for a “gum infection.” The limp continued for 3 weeks and later was associated with low‐grade fever. Physical exam on his second ED visit revealed an irritable boy who refused to bear weight and left knee and hip tender to passive movement without obvious inflammation. His anterior gum line showed swelling, erythema, and a few ulcers. Repeat X‐rays of his lower extremities were read as unremarkable. A further workup after admission did not reveal an infectious etiology: WBC was 7.4, ESR 16, and CRP 0.31. A bone scan did not identify osteomyelitis or occult fracture, and MRI with contrast was read as normal. His microcytic anemia was attributed to underlying thalassemia trait. Rheumatology was consulted, and his basic workup (ANA and rheumatoid factor) was normal. The presumptive diagnosis was toxic synovitis versu. traumatic hematoma from the fall. However, his symptoms did not improve with rest and NSAIDS. His gingivitis worsened, and his gums started to bleed around the incisors. His keratosis was treated with emollient ointment. On hospital day 4, a phlebotomist noted a rash at the tourniquet site, appearing as discrete hemorrhagic papular eruptions. After further discussion, the medical team explored the child's diet history more thoroughly. His mother reported a diet consisting of chocolate chip cookies with cow's milk, occasional chicken nuggets, and Lipton Iced Tea with Lemon© (which contains lactic acid, not ascorbic acid). Further workup included a vitamin C level of 0.1 (normal 0.4‐2 mg/dL) and long bone films showing nonspecific lucencies in the metaphyses of the radius, ulna, femur, and tibia bilaterally. With a classic constellation of pseudoparalysis, irritability, hyperkeratosis, and gingival bleeding, the child was treated with oral ascorbic acid for presumptive scurvy. Within 3 days, his gingival symptoms resolved, and he started to walk a week later. He was discharged home with Pediasure supplement, vitamin C treatment, and follow‐up appointments. Six weeks later, the child was back to baseline activities, showed good weight gain and healthy gums and teeth. Repeat long bone X‐rays showed resolution of the metaphyseal lucencies. His vitamin C level normalized.
Discussion:
Malnutrition in children with behaviorally restricted diet is often overlooked by pediatricians. Children with these conditions often undergo costly evaluations before a correct diagnosis is made. Although rare, conditions caused by nutritional deficiencies like scurvy should be considered when children with behavior and developmental problems are evaluated for common complaints.
Conclusions:
The purpose of this case is to promote broadened differential diagnoses and thorough history taking when approaching children with behavioral and developmental conditions.
Author Disclosure:
J. Price, none: T. Jirasevijinda, none; N. Osorio, none.