eMedicine Specialties > Pediatrics: General Medicine > Nutrition

Scurvy: Differential Diagnoses & Workup

Author: Bradley S Buckler, MD, Fellow in Neonatal-Perinatal Medicine, Medical College of Georgia
Coauthor(s): Anjali Parish, MD, Assistant Professor of Pediatrics, Department of Neonatology, Medical College of Georgia
Contributor Information and Disclosures

Updated: Jul 16, 2009

Differential Diagnoses

Acute Lymphoblastic Leukemia
Poliomyelitis
Arthritis, Septic
Retinoblastoma
Child Abuse & Neglect: Physical Abuse
Rheumatic Fever
Osteomyelitis
Syphilis

Other Problems to Be Considered

Acrodynia
Henoch-Schönlein purpura
Rheumatoid arthritis

Workup

Laboratory Studies

Laboratory tests are usually not helpful to ascertain a diagnosis of scurvy. Presentation of an infant with the typical clinical and radiologic picture of scurvy, along with a supportive history of dietary deficiency of vitamin C, is often sufficient to diagnose infantile scurvy.

  • Serum ascorbic acid levels
    • A fasting serum ascorbic acid level greater than 0.6 mg/dL rules out scurvy.
    • Serum ascorbic acid levels of 0.2 mg/dL or greater are considered nutritionally acceptable.
    • Levels of 0.10-0.19 mg/dL are considered low.
    • Levels less than 0.10 mg/dL are considered deficient.
  • WBC ascorbic acid concentration is a more accurate measure of a vitamin C nutritional state.
    • A level of zero indicates latent scurvy.
    • Levels greater than 15 mg/dL reflect a state of nutritional adequacy.
    • Levels of 8-15 mg/dL are considered low.
    • Levels of 0-7 mg/dL reflect a state of deficiency.

Imaging Studies

  • Radiologic findings in infantile scurvy are diagnostic.
  • The characteristic radiologic changes occur at the growth cartilage-shaft junction of bones with rapid growth. The knee joint, wrist, and sternal ends of the ribs are typical sites of involvement.
  • Radiologic diagnosis of scurvy is based on the following specific changes:
    • In the early phase of scurvy, the cortex becomes thin and the trabecular structure of the medulla atrophies and develops a ground-glass appearance. The zone of provisional calcification becomes dense and widened, and this zone is referred to as the white line of Frãnkel. The epiphysis also shows cortical thinning and the ground-glass appearance.
    • As scurvy becomes advanced, a zone of rarefaction occurs at the metaphysis under the white line. The zone of rarefaction typically involves the lateral aspects of the white line, resulting in triangular defects called the corner sign of Park. This area has multiple microscopic fractures and may collapse with impaction of the calcified cartilage onto the shaft. The lateral aspect of the calcified cartilage can project as a spur. Subperiosteal hemorrhages are not visualized in the active phase. With healing, they become calcified and are readily observed.

More on Scurvy

Overview: Scurvy
Differential Diagnoses & Workup: Scurvy
Treatment & Medication: Scurvy
Follow-up: Scurvy
Multimedia: Scurvy
References
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References

  1. [Guideline] Jenny C. Evaluating infants and young children with multiple fractures. Pediatrics. Sep 2006;118(3):1299-303. [Medline].

  2. Ratanachu-Ek S, Sukswai P, Jeerathanyasakun Y. Scurvy in pediatric patients: a review of 28 cases. J Med Assoc Thai. Aug 2003;86 Suppl 3:S734-40. [Medline].

  3. Tveden-Nyborg P, Lykkesfeldt J. Does vitamin C deficiency result in impaired brain development in infants?. Redox Rep. 2009;14:2-6. [Medline].

  4. Ragunatha S, Inamadar AC, Palit A, Sampagavi VV, Deshmukh NS. Diffuse nonscarring alopecia of scalp: an indicator of early infantile scurvy?. Pediatr Dermatol. Nov-Dec 2008;25(6):644-6. [Medline].

  5. Akikusa JD, Garrick D, Nash MC. Scurvy: forgotten but not gone. J Paediatr Child Health. Jan-Feb 2003;39(1):75-7. [Medline].

  6. Barlow T. On cases described as 'acute rickets' which are probably a combination of scurvy and rickets, the scurvy being essential, and rickets a variable element. Med Chir Trans (London). 1883;66:159-220.

  7. Barness LA. Vitamin C (Ascorbic Acid) (Scurvy). In: Nelson Textbook of Pediatrics. 14th ed. Philadelphia, Pa: W B Saunders Company; 1992:139-41.

  8. Bingham AC, Kimura Y, Imundo L. A 16-year-old boy with purpura and leg pain. J Pediatr. May 2003;142(5):560-3. [Medline].

  9. Carpenter KJ. The History of Scurvy and Vitamin C. New York, NY: Cambridge University Press; 1986:1-288.

  10. Chaudhry SI, Newell EL, Lewis RR. Scurvy: a forgotten disease. Clin Exp Dermatol. Nov 2005;30(6):735-6. [Medline].

  11. Cheung E, Mutahar R, Assefa F. An epidemic of scurvy in Afghanistan: assessment and response. Food Nutr Bull. Sep 2003;24(3):247-55. [Medline].

  12. Greene HL. Disorders of the water-soluble vitamin B-complex and vitamin C. In: Textbook of Pediatric Nutrition. 2nd ed. New York, NY: Raven Press; 1993:86-88.

  13. Hess AF. Scurvy, Past and Present. Philadelphia, Pa: JB Lippincott Company; 1920:1-279.

  14. Jacob RA. Three eras of vitamin C discovery. Subcell Biochem. 1996;25:1-16. [Medline].

  15. Kocak M, Akbay G, Eksioglu M. Case 2: sudden ecchymosis of the legs with feelings of pain and weakness. Diagnosis: adult scurvy. Clin Exp Dermatol. May 2003;28(3):337-8. [Medline].

  16. Park EA, Guild HG, Jackson D. The recognition of scurvy with special reference to the early x-ray changes. Arch Dis Child. 1965;4:82-9.

  17. Rosati P, Boldrini R, Devito R. A child with painful legs. Lancet. Apr 16-22 2005;365(9468):1438. [Medline].

  18. Sauberlich HE. Human requirements. Vitamin C status: methods and findings. Ann NY Acad Sci. 1975;258:438-450. [Medline].

  19. Truswell AS. Vitamin C (Ascorbic acid). In: Davidson's Principles and Practice of Medicine. 13th ed. New York, NY: Churchill Livingstone; 1981:107-9.

  20. Wilson LG. The clinical definition of scurvy and the discovery of vitamin C. J Hist Med. 1975;30:40-60. [Medline].

  21. Woodruff CW. Ascorbic Acid-Scurvy. Prog Food Nutr Sci. 1975;1:493-506. [Medline].

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Further Reading

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Keywords

scurvy, vitamin C deficiency, infantile scurvy, Barlow disease, Barlow's disease, Cheadle disease, Cheadle's disease, osteopathia hemorrhagica infantum, scurvy rickets, deficiency of ascorbic acid, impaired collagen synthesis, defective collagen, defective dentine formation, hemorrhaging

hemorrhaging into the gums, subperiosteal hemorrhage, pseudoparalysis, costochondral beading, scorbutic rosary, hyperkeratosis, corkscrew hair, sicca syndrome, whiteline of Frãnkel, treatment, diagnosis

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Contributor Information and Disclosures

Author

Bradley S Buckler, MD, Fellow in Neonatal-Perinatal Medicine, Medical College of Georgia
Disclosure: Nothing to disclose.

Coauthor(s)

Anjali Parish, MD, Assistant Professor of Pediatrics, Department of Neonatology, Medical College of Georgia
Anjali Parish, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Jatinder Bhatia, MBBS, Professor of Pediatrics, Chief, Section of Neonatology, Department of Pediatrics, Medical College of Georgia
Jatinder Bhatia, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American Dietetic Association, American Federation for Clinical Research, American Pediatric Society, American Society for Clinical Nutrition, American Society for Parenteral and Enteral Nutrition, New York Academy of Sciences, Society for Pediatric Research, and Southern Society for Pediatric Research
Disclosure: Mead Johnson Consulting fee Consulting; Mead Johnson Honoraria Speaking and teaching; Dey LP Consulting fee Consulting; Dey LP Honoraria Speaking and teaching; Ovation Honoraria Speaking and teaching

 
 
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