title: Modern American scurvy - experience with vitamin C deficiency at a large children's hospital.
abstract: BACKGROUND
  Until recently scurvy has been viewed in developed countries as a disease of the past. More recently there have been reports of case series of children with scurvy who have had a delayed diagnosis after an extensive diagnostic workup that included imaging. Most of these children have had underlying neurologic conditions such as autism.
  
  
  OBJECTIVE
  To review the medical records of children diagnosed with vitamin C (ascorbic acid) deficiency based on serum ascorbic acid levels at a large pediatric health care system, to determine imaging findings and utility of imaging in management, and to identify at-risk pediatric populations.
  
  
  METHODS
  We retrospectively identified cases of vitamin C deficiency in children tested for serum ascorbic acid levels during the last 5 years. We used the criteria of normal ascorbic acid >23 μmol/L and included children with ascorbic acid levels <23 μmol/L. We evaluated their clinical history, underlying medical condition, imaging studies obtained and imaging findings.
  
  
  RESULTS
  We identified 32 children with vitamin C deficiency. All of these children had underlying medical conditions, most commonly iron overload from multiple transfusions related to sickle cell anemia or thalassemia (20), neurologic disorders (4) and bone marrow transplant/chemotherapy (3). No cases of scurvy from dietary deficiency in otherwise normal children were identified. All except two children had multiple imaging studies, primarily related to their underlying conditions. Three of these children had extensive imaging workups related to diffuse musculoskeletal pain. Imaging findings included ill-defined sclerotic and lucent metaphyseal bands (mainly at the knee) on radiography and MRI studies that showed diffuse increased T2-weighted signal in the bilateral lower-extremity long-bone metaphyses, periosteal reaction and adjacent soft-tissue edema.
  
  
  CONCLUSIONS
  Vitamin C deficiency is not uncommon in large pediatric health care facilities, and it is frequently missed on clinical evaluation and diagnostic imaging. At-risk populations include those with iron overload, neurologic conditions and history of chemotherapy. Scurvy related to dietary deficiency in otherwise normal children was not encountered. When characteristic MRI findings are seen, particularly in children with a predisposing condition for vitamin C deficiency, scurvy should be considered and a serum ascorbic acid level checked to potentially confirm a diagnosis prior to further invasive tests.
authors: Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.
authors: Farahnaz
authors: F
authors: Golriz
authors: Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA. lfdonnel@texaschildrens.org.
authors: Lane F
authors: LF
authors: Donnelly
authors: Department of Pathology and Laboratory Medicine, Texas Children's Hospital, Houston, TX, USA.
authors: Sridevi
authors: S
authors: Devaraj
authors: Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.
authors: Raj
authors: R
authors: Krishnamurthy
mesh_terms: D000293:Adolescent; D001205:Ascorbic Acid / Q000097:blood; D002648:Child; D002675:Child, Preschool; D002851:Chromatography, High Pressure Liquid; D003937:Diagnosis, Differential; D003952:Diagnostic Imaging; D006801:Humans; D035002:Lower Extremity / Q000000981:diagnostic imaging*; D008297:Male; D012189:Retrospective Studies; D012614:Scurvy / Q000097:blood / Q000000981:diagnostic imaging* / Q000453:epidemiology; D014481:United States / Q000453:epidemiology; D055815:Young Adult
chemical_list: D001205:Ascorbic Acid
keywords: Children; Magnetic resonance imaging; Malnutrition; Radiography; Scurvy; Vitamin C deficiency