Case Presentation:
BM is a 37 y.o. male with a past medical history significant for irritable bowel
syndrome. He presented to Maine Medical Center from a rheumatology office
with the chief complaint of left lower extremity swelling. Patient reported the
swelling developed 3 weeks after being struck by his dog in the leg and few
weeks after a plane ride to and from Chicago. He presented himself to his PCP
for initial evaluation. His PCP noted left lower extremity swelling and
discoloration. She also noted petechiae on both lower extremities bilaterally. She
was concerned for possible vasculitis with secondary cellulites of the left lower
extremity. She started the patient of keflex and prednisone then referred patient
to Rheumatology for further evaluation and management. Patient was follow
rheumatology who felt patient should be admitted for further evaluation for
possible focal myositis. Patient had an initial 3 day hospital course. He was
noted on presentation to have mildly leukopenia, and anemia. He was imperially
started on vancomycin and prednisone was discontinued. US was negative for
DVT. MRI was nonspecific but showed hyperintensity of the gastrocnemius
muscle. A muscle biopsy was preformed and results were pending at time of
discharge from first hospitalization. Patient was discharge on doxycyline with
follow up with Rheumatology. Patient returned to Maine Medical Center for non
improvement of left lower extremity 3 days after initial discharge. Patient was
started imperially on Vancomycin for concern for worsening cellulitis. Patient was
noted to be anemic, leukopenic, platelets were within normal limits. C
protein and ESR were mildly elevated. Rheumatology and Infectious disease
were consulted to aid in diagnosis and treatment.
Discussion:
Differential included focal myositis with superimposed cellulitis , infected
hematoma, vasculitis or lupus. Vasculitis panels and ANA were found to be
negative. Preliminary read on the pathology tissue showed non
inflammation with no indication of myositis. Cultures of blood and muscle biopsy
showed no growth. Orthopedics was consulted for suspicion of infected
hematoma of left leg. Repeat MRI showed slight worsening of inflammation with
finding consistent with post traumatic changes of large fascial hematoma vs
infected hematoma. Orthopedics did not feel there was role for surgical
intervention. Patient remained afebrile and showed little improvement or
worsening of symptoms on IV antibiotic. A review of social history showed that
the patient had an extremely strict diet of eggs and spinach secondary to irritable
bowel syndrome. Vitamin level were taken at previous hospitalization showed a
Vitamin C level 0.0. Patient was start on vitamin C supplements and showed
remarkable improvement of symptoms.
Conclusions:
Patient was diagnosed with Scurvy at second hospitalization. Testing for
Whipple patient vitamin C deficiency was due to restricted diet.