The Troubling Rise of Scurvy: A Review and National Analysis of Incidence, Associated Risk Factors, and Clinical Manifestations.

INTRODUCTION: In the era of modern medicine, scurvy has been thought of as a rare disease of ancient times because of improved emphasis on diet and nutrition; however, isolated case reports are plentiful. This investigation presents a comprehensive review of scurvy, including an analysis on its rising incidence, with specific focus on its orthopaedic manifestations and commonly associated diagnoses. METHODS: This comprehensive review includes a retrospective analysis of 19,413,465 pediatric patients in the National Inpatient Sample database from 2016 through 2020. Patients with scurvy were identified by the ICD-10 code, and an estimated incidence of scurvy in the inpatient pediatric population was calculated. Concurrent diagnoses, musculoskeletal reports, and demographic variables were collected from patient records. Comparisons were made using analysis of variance or chi-square with Kendall tau, where appropriate. RESULTS: The incidence of scurvy increased over the study period, from 8.2 per 100,000 in 2016 to 26.7 per 100,000 in 2020. Patients with scurvy were more likely to be younger (P < 0.001), male (P = 0.010), in the lowest income quartile (P = 0.013), and obese (P < 0.001). A majority (64.2%) had a concomitant diagnosis of autism spectrum disorder. Common presenting musculoskeletal reports included difficulty walking, knee pain, and lower limb deformity. Burden of disease of scurvy was markedly greater than that of the average inpatient population, with these patients experiencing greater total charges and longer hospital stays. CONCLUSION: Clinicians should be aware of the increasing incidence of scurvy in modern medicine. In cases of vague musculoskeletal reports without clear etiology, a diagnosis of scurvy should be considered, particularly if risk factors are present. TRIAL REGISTRATION NUMBER: NA.

A macroscopic assessment of porosity and new bone formation on the inferior pars basilaris: Normal growth or an indicator of scurvy?

OBJECTIVES: This research aims to determine the aetiology of porosity and subperiosteal new bone formation on the inferior surface of the pars basilaris. MATERIALS: A total of 199 non-adult individuals aged 36 weeks gestation to 3.5 years, from a total of 12 archaeological sites throughout the UK, including Iron Age (n=43), Roman (n=12), and post-medieval (n=145) sites, with a preserved pars basilaris. METHODS: The pars basilaris was divided into six segments, with porosity (micro and macro) and subperiosteal new bone formation recorded on the inferior surface in scorbutic and non-scorbutic individuals. Scurvy was diagnosed using criteria from the palaeopathological literature that was developed using a biological approach. RESULTS: There was no statistically significant difference in microporosity between scorbutic and non-scorbutic individuals in four out of the six segments analysed. There was a significant negative correlation between age and microporosity in non-scorbutic and scorbutic individuals. A significant difference in subperiosteal new bone formation was observed between scorbutic and non-scorbutic individuals. CONCLUSIONS: Microporosity on the inferior pars basilaris should not be considered among the suite of lesions included in the macroscopic assessment of scurvy in non-adult skeletal remains (less than 3.5 years). SIGNIFICANCE: This study highlights the risk of over diagnosing scurvy in past populations. LIMITATIONS: It is difficult to distinguish between physiological (normal) and pathological (abnormal) bone changes in the skeleton of individuals less than one year of age. SUGGESTIONS FOR FURTHER RESEARCH: Future research should focus on the analysis of individuals over 3.5 years of age.

A 3-Year-Old With Gingival Hemorrhage and Musculoskeletal Pain.

A 3-year-old had spontaneous gingival hemorrhage and bilateral limb weakness with inability to bear weight. He had no preceding oral trauma or recent infection, took no regular medications, and had no recent use of aspirin or nonsteroidal anti-inflammatory drugs; his diet was limited to primarily chicken nuggets and milk. What is the diagnosis and what would you do next?

Scurvy. A forgotten pseudovasculitis.

Scurvy is a nutritional disease caused by ascorbic acid (vitamin C) deficiency. Althought currently it is a rare disease, we should considerer it in the differential diagnosis of purpura and arthritis in patients with restrictive diets. We present the case of a 49-year-old man with a history of a nutritional disorder presented to our hospital with generalized purpura and hemarthros. Following the anamnesis and laboratory findings, rheumatological, infectious and hematological etiologies were excluded. Finally, the diagnosis of scurvy was made upon demostration poor levels of vitamin C and a spectacular response to nutritional supplements. We compare this case with 19 similar cases reported in the medical literature.

Scurvy masquerading as IgA vasculitis.

BACKGROUND: Vitamin C deficiency, or scurvy, is rare but poses risks for children with poor diets, limited resources, or malabsorption issues. It may also be common in children with restrictive or selective dietary habits in children with global developmental delay, autism spectrum disorder, and physical disabilities. Symptoms include fatigue, irritability, joint and muscle pain, joint swellings, edema, swollen gums, easy bruising, and delayed wound healing. Early recognition and prompt intervention are essential to prevent the progression of symptomatic vitamin C deficiency in children. CASE PRESENTATION: We present a case of a 13-year-old boy with developmental delay secondary to Lennox Gastaut syndrome referred for suspected recurrent, severe, and atypical IgA vasculitis. He presented with irritability, loss of appetite, petechial and ecchymotic lower limb lesions, unilateral gum swelling, severe arthritis, peripheral oedema, severe weight loss, anaemia, and raised inflammatory markers. Multiple investigations were performed before the diagnosis of scurvy was made. A surgical finding of friable gingival tissue with multiple loose teeth, a skin biopsy with follicular hyperkeratosis and extravasated perifollicular red blood cells, and a typical X-ray finding led to the diagnosis of scurvy. CONCLUSION: Scurvy should be given careful consideration as a differential diagnosis in patients presenting with musculoskeletal issues, mucocutaneous complaints, and constitutional symptoms such as malaise, asthenia, irritability, and loss of appetite. A focused and detailed dietary history looking for a lack of good sources of vitamin C can be an easy indicator of this differential. Imaging studies revealing the typical features can also help make the diagnosis. Pathology of the skin revealing pathognomonic features can add to the certainty of the diagnosis. In the absence of all else, the rapid response to treatment with an appropriate dose of vitamin C has a diagnostic and therapeutic role.

Evidence of non-adult vitamin C deficiency in three early medieval sites in the Jaun/Podjuna Valley, Carinthia, Austria.

OBJECTIVE: This study aims to determine and discuss the prevalence of non-adult scurvy cases from the early medieval Jaun/Podjuna Valley in southern Austria. MATERIALS: 86 non-adult individuals were assessed from three early medieval sites. METHODS: Morphological characteristics associated with suggestive and probable scurvy were observed macroscopically and under 20-40x magnification. RESULTS: A significant relationship between the prevalence of scurvy and age group was observed. Perinates (46%, 6/13) and children (27.5%, 8/28) showed a high prevalence of skeletal features indicating a diagnosis of scurvy, while no cases of scurvy were observed in adolescents and adults. CONCLUSIONS: In this Alpine region, scurvy occurred frequently in infants and children. Seasonal fluctuations of diet are discussed as factors triggering scurvy. SIGNIFICANCE: This study sheds new light on the prevalence of scurvy in the Alpine region and how the region developed after the fall of the Roman Noricum. It also models ways in which multiple lines of evidence can contribute to the diagnostic process. LIMITATIONS: Poor preservation posed a challenge to identifying probable cases of scurvy. Likewise, non-adult remains are difficult to diagnose due to their developing nature and it is not always possible to distinguish between normal bone growth and pathological growth. SUGGESTIONS FOR FURTHER RESEARCH: Future applications of biomolecular studies will help illustrate changes in diet that may have contributed to vitamin deficiencies.

Pediatric scurvy case report: a novel presentation with deep vein thrombosis secondary to large bilateral spontaneous iliac subperiosteal hematomas.

BACKGROUND: Scurvy is an uncommon disease in developed countries caused by deficiency of vitamin C. We present a case of scurvy in a 14-year-old male with autism with both novel presentation and imaging findings. This case had the novel presentation of lower limb deep vein thrombosis (DVT) secondary to compression of the external iliac vein from large bilateral iliac wing subperiosteal hematomas. Subperiosteal hematoma is a well-recognised feature of scurvy but large and bilateral pelvic subperiosteal hematoma causing DVT has not previously been described. CASE PRESENTATION: A 14 year old Caucasian male with background of autism and severe dietary restriction presented with lower limb swelling and immobility. He was diagnosed with lower limb DVT. Further investigation revealed an iron deficiency anaemia, and he was found on MRI to have large bilateral subperiosteal iliac hematomata causing compression of the iliac vessels. He improved following treatment with vitamin C replacement and follow-up imaging demonstrated resolution of the DVT and hematoma. CONCLUSION: DVT is rare in children and when diagnosed should prompt investigation as to the underlying cause. This case demonstrates an unusual cause of DVT and as an unusual presentation of paediatric scurvy.

Orthopaedic Manifestations of Scurvy in an Otherwise Healthy Child from a Low Opportunity Index Neighborhood: A Case Report.

CASE: A 23-month-old otherwise healthy female child from a low opportunity index neighborhood presented with 1 month of lower extremity pain and refusal to bear weight. Radiographic evaluation of bilateral knees revealed lucent metaphyseal bands and a nondisplaced distal femoral metaphyseal corner fracture. A workup identified vitamin C deficiency (scurvy), and the child's symptoms and radiographic abnormalities resolved with vitamin C supplementation. CONCLUSIONS: Scurvy should be considered in children with unexplained musculoskeletal symptoms who may lack access to nutrient-dense foods.

Vitamin C Deficiency as a Mimicker of a Coagulation Disorder.

Scurvy is caused by vitamin C deficiency and is often thought of as an ancient malady. However, it still afflicts present-day patients with insufficient nutrition, excessive alcohol consumption and disorders of absorption. Scurvy is traditionally characterised by ecchymosis, petechiae, haemorrhages, poor wound healing, myalgias and arthralgias, but it can also present with non-specific symptoms, including mood changes, fatigue, malaise and dyspnoea. Although scurvy can present with signs of excess bleeding, it does not involve blood clotting. We present a case of concurrent scurvy and pulmonary embolism in which clinical presentation and laboratory findings mimicked a coagulation disorder, resulting in delayed diagnosis and excessive resource expenditure. This case underscores the importance of obtaining an early dietary and substance use history in patients with unexplained haematological symptoms. These crucial components of history-taking can significantly reduce invasive and costly tests, resulting in quicker diagnosis and enhanced patient outcomes.

Reversible severe pulmonary hypertension related to scurvy in children.

BACKGROUND: Severe pulmonary hypertension (PH) in childhood is rare and can manifest as a life-threatening episode. We present 2 children with restrictive dietary habits with severe pulmonary hypertension secondary to scurvy and iron deficiency anemia with treatment and outcome. CASE PRESENTATION: The first case is a 2-year-old boy who presented with vomiting, diarrhea, and fever. After rehydration, he had recurrent episodes of hypotension with intermittent abdominal pain. Fluid resuscitation and inotropic medication were given. Then he suddenly collapsed. After 4-min cardiopulmonary resuscitation, his hemodynamic was stabilized. Most of the medical workup was unremarkable except for PH from the echocardiogram with estimated systolic pulmonary artery pressure (PAP) at 67 mmHg. Transient PH was diagnosed, and milrinone was prescribed. Since he had restrictive dietary habits and sclerotic rim at epiphysis in chest films, his vitamin C level was tested and reported low-level result. The second case is a 6-year-old boy with acute dyspnea, a month of low-grade fever, mild cyanosis, and a swollen left knee. Echocardiogram indicated moderate TR with estimated systolic PAP at 56 mmHg (systolic blood pressure 90 mmHg). Milrinone was given. Right cardiac catheterization showed PAP 66/38 (mean 50) mmHg and PVRi 5.7 WU.m2. Other medical conditions causing PH were excluded. With a history of improper dietary intake and clinical suspicion of scurvy, vitamin C was tested and reported undetectable level. Administration of vitamin C in both cases rapidly reversed pulmonary hypertension. CONCLUSION: Pediatric PH related to vitamin C deficiency can manifest with a wide range of symptoms, varying from mild and nonspecific to severe life-threatening episodes characterized by pulmonary hypertensive crises. PH associated with scurvy is entirely reversible with appropriate investigation, diagnosis, and treatment. Our report highlights the importance of considering nutritional deficiencies as potential confounding factors in pediatric PH, emphasizing the need for comprehensive evaluation and management of these patients.

What Do We C in Children With Scurvy? A Case Series Focused on Musculoskeletal Symptoms.

OBJECTIVES: Vitamin C deficiency in children commonly presents with musculoskeletal symptoms such as gait disturbance, refusal to bear weight, and bone or joint pain. We aimed to identify features that could facilitate early diagnosis of scurvy and estimate the cost of care for patients with musculoskeletal symptoms related to scurvy. METHODS: We conducted a retrospective chart review of patients at a single site with diagnostic codes for vitamin C deficiency, ascorbic acid deficiency, or scurvy. Medical records were reviewed to identify characteristics including presenting symptoms, medical history, and diagnostic workup. The Pediatric Health Information System was used to estimate diagnostic and hospitalization costs for each patient. RESULTS: We identified 47 patients with a diagnosis of scurvy, 49% of whom had a neurodevelopmental disorder. Sixteen of the 47 had musculoskeletal symptoms and were the focus of the cost analysis. Three of the 16 had moderate or severe malnutrition, and 3 had overweight or obesity. Six patients presented to an emergency department for care, 11 were managed inpatient, and 3 required critical care. Diagnostic workups included MRI, computed tomography, echocardiogram, endoscopy, lumbar puncture, and/or EEG. Across all patients evaluated, the cost of emergency department utilization, imaging studies, diagnostic procedures, and hospitalization totaled $470 144 (median $14 137 per patient). CONCLUSIONS: Children across the BMI spectrum, particularly those with neurodevelopmental disorders, can develop vitamin C deficiency. Increased awareness of scurvy and its signs and symptoms, particularly musculoskeletal manifestations, may reduce severe disease, limit adverse effects related to unnecessary tests/treatments, and facilitate high-value care.

Unusual case of 'scorbutic proptosis'.

Proptosis is a frequent presenting symptom/sign of many paediatric malignancies. Acute-onset proptosis is an ophthalmic emergency that can endanger vision if not treated promptly. Appropriate treatment must be instituted only after investigating for the underlying aetiology. Here, we report a developmentally delayed boy in middle childhood who presented with recent onset bilateral proptosis. Clinical examination followed by radiological evaluation suggested scurvy to be the underlying cause and vitamin C supplementation led to prompt reversal of proptosis. The relevant literature has been reviewed and presented here to apprise the paediatric oncologists about this rare but easily treatable cause of proptosis.

Infantile scurvy as a consequence of agricultural intensification in the 1st millennium BCE Etruria Campana.

The 1st millennium BCE in Italy was a time of agricultural intensification of staple cereal production which shaped sociocultural, political, and economic spheres of pre-Roman groups. The lifeways and foodways of the Etruscans, the greatest civilization in western Europe before Roman hegemony, are traditionally inferred from secondary written sources, funerary archaeology, archaeobotany, and zooarchaeology. However, no direct data extrapolated from the study of human skeletal remains are available to evaluate the extent to which agricultural intensification and decreased dietary diversity impacted health and the expression of skeletal indicators of metabolic disease. Macroscopic and radiological analyses were conducted on an archaeological skeletal sample of non-adults (n = 29) recovered from Pontecagnano (southern Italy) dating to the Orientalizing period (730-580 BCE). This allowed us to identify five cases of scorbutic non-adults and to assign diagnostic values to skeletal lesions of scurvy that have not been previously described in the literature. The onset of scurvy in the examined sample is related to the increased reliance of Etruscans on crops lacking vitamin C in this period of agricultural intensification. The skeletal expression of scurvy varied among the non-adults, with differences in location and disease severity; these were interpreted considering the age-at-death of the individuals coupled with feeding behaviors and interindividual variability.

Scurvy presenting as difficulty in walking in a child.

Scurvy, a disease caused by ascorbic acid (vitamin C) deficiency, is a rare disease in the modern world. We report a case of a boy in middle childhood, with a background of autism, presenting bed-bound due to progressive bilateral lower limb pain, with concomitant rashes, bleeding gums and worsening lethargy. Detailed dietary history revealed a severely restricted diet. Physical examination showed bilateral lower limb ecchymoses, perifollicular hemorrhages, perifollicular hyperkeratosis and cockscrew hairs which are pathognomonic features of scurvy. A low serum ascorbic acid level confirmed the diagnosis. Therapy with oral vitamin C supplement and rehabilitation with multidisciplinary care was successful, with complete resolution of symptoms. This case emphasises the importance of thorough dietary evaluation in children with autism and food selectivity presenting with non-specific symptoms. Physician awareness of nutritional deficiencies avoids unnecessary extensive investigations and sub-specialty referrals and translates to savings in medical expenses.

Scurvy complicated with Capnocytophaga sputigena sepsis as a possible cause of death of king Saint-Louis of France (1270 AD).

The cause of death of Saint-Louis is not known, but recent findings indicated that he presented scurvy and inflammatory jaw disease, which has been associated with infection by oral commensals. Here, we have the exceptional opportunity to analyze the relics of the viscera of King Saint-Louis. A 4.3 g sample from the viscera relics of King Saint-Louis conserved in Versailles' cathedral was subjected to radiocarbon dating, electronic and optic microscopy, and elementary, palynological, molecular, proteomics and microbiological analyses including specific PCR and v3v4 16 S rRNA gene amplification prior to large-scale sequencing using an Illumina MiSeq instrument. The measured radiocarbon age was Cal 1290 CE-1400, which was compatible with that of the viscera of St Louis viscera, considering the addition of lime, incense and vegetables within the human organs. Elemental and palynological analyses confirmed a medieval embalming process. Proteomics analysis identified mainly human muscle and blood proteins. Specific PCR for plague, amoebiasis, shigellosis and typhoid fever was negative. C. sputigena was identified as the main pathogenic species representing 10.8 % of all microbial sequences. In contrast, C. sputigena was found in only 0.001 % of samples sequenced in our center, and the 23 positive human samples showed a dramatically lower abundance (0.02-2.6 %). In the literature, human infections with C. sputigena included odontitis, dental abscess, sinusitis, thoracic infections and bacteremia, particularly in immunocompromised patients with oral and dental diseases consistent with recent analysis of King Saint-Louis' jaw. C. sputigena, a commensal of the mouth that is potentially pathogenic and responsible for fatal bacteremia, may have been the cause of the king's death.

Scurvy: old disease, new lessons.

Scurvy, the condition associated with severe vitamin C deficiency, is believed to be one of the oldest diseases in human history. It was particularly prevalent during the Age of Sail, when long sea voyages without access to fresh food resulted in an epidemic which claimed millions of lives; however, scurvy has existed across time and geography, occurring whenever and wherever diets are devoid of vitamin C. Young children, specifically, were affected by the emergence of 'infantile scurvy' in the 19th century owing to the use of heated milk and manufactured infant foods of poor nutritional quality. Scurvy continues to occur in at-risk groups. In children and youths, it is primarily observed in the context of autism spectrum disorder and feeding problems such as a limited food repertoire and high-frequency single food intake. Diagnosis may be delayed and invasive testing undertaken owing to clinicians' lack of familiarity with the disease, or the mistaken assumption that it is exclusively a disease of the past. The aetiology, clinical manifestations and treatment of scurvy are described. Its long history and current epidemiology are also reviewed, demonstrating that scurvy is very much a disease of the present. It is suggested that future efforts should focus on (i) anticipatory guidance and early nutritional intervention, informed by an understanding of scurvy's epidemiology, with the aim of preventing the disease in those at risk, and (ii) prompt recognition and treatment to minimise morbidity and healthcare costs.Abbreviations: ASD: autism spectrum disorder.