Clinician’s Corner
Case 2: An adolescent refugee
with lower-extremity pain and
weakness
A
12-year-old boy reported to a tertiary-care paediatric emergency department with gradual, intense pain and weakness in
the lower limbs. As an Iraqi refugee who had resided in Canada for
almost a year, he was living in a precarious social and economic
condition with his mother and three siblings. He had transfusiondependent β-thalassemia major with associated hemosiderosis,
splenectomy and hepatitis C. At presentation, he was taking an
iron chelator and was receiving blood transfusions every three
weeks. He had been recently hospitalized for cellulitis at the site of
catheterization for his chelation sessions and treated with intravenous antibiotics. Pain and weakness in both legs were the only
symptoms reported and were interfering with his school attendance. He denied experiencing other neurological symptoms. He
had neither voiding problems nor fecal incontinence. He reported
no fever, night sweats or weight loss. The physical examination
revealed a frail and small-for-age boy with normal vital signs. He
had extensive gingivitis and his neurological examination was
somewhat inconsistent, revealing symmetrical hyperesthesia and
moderate weakness of the lower limbs. His gait was laboured, but
his deep tendon reflexes were normal. There was no joint or soft
tissue swelling, and his skin showed no rash. Further investigations
revealed the diagnosis.
Correspondence (Case 2): Dr Richard E Bélanger, Centre mère-enfant Soleil du CHU de Québec, 2705, Laurier Boulevard – R1742, Quebec G1V 4G2.
Telephone 418-654-2282, fax 418-654-2137, e-mail [email protected]
Case 2 accepted December 17, 2013
Paediatr Child Health Vol 19 No 6 June/July 2014
©2014 Pulsus Group Inc. All rights reserved
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Clinician’s Corner
CASE 2 DIAGNOSIS: SCURVY
Because of the severity of the clinical presentation and the overall
complexity of the case, the patient was hospitalized. Blood samples
were drawn, showing moderate anemia (hemoglobin 81 g/L), with a
hemoglobin level similar to his baseline level. His white blood cell
(18.4×109/L) and platelet (856×109/L) counts were high but also
unchanged. C-reactive protein and creatine kinase levels were normal. In the following days, he underwent electromyography and
magnetic resonance imaging (cerebral and spinal), which showed no
neurological cause for his symptoms. Extended radiographs revealed
low bone mineralization. Otherwise, psychosocial assessments pointed
toward intimidation and rejection at school, mainly from cultural barriers, as important factors to consider in the understanding of his
symptomatology. However, a few weeks after discharge, the nutritional work-up revealed a very low vitamin C level (6 µmol/L; normal
40 µmol/L to 90 µmol/L) and the diagnosis of scurvy was reached.
Although historically an important issue among mariners,
scurvy is currently rare, especially in industrialized countries. It
results from a deficiency in vitamin C (ascorbic acid), which is
derived exclusively from the diet. After absorption in the distal
small bowel, a one- to three-month supply of ascorbic acid can be
stored in the body, while some is used immediately as a cofactor for
many biological processes. The first symptoms to arise are nonspecific: malaise, lethargy, low-grade fever and poor weight gain.
Once the body pool of ascorbic acid is depleted, patients may
complain of bruises/petechiae, bleeding gums, arthralgia and poor
wound healing. Scurvy may also cause generalized tenderness and
weakness (especially in the lower limbs), neuropathy and multifactorial anemia. Severe deficiency may even result in skeletal
muscle degeneration, growth delay, cardiac hypertrophy and
adrenal atrophy. In the present case, scurvy explained the neurological symptoms reported as well as the poor oral condition, and
may have contributed to previous cellulitis.
Thus, when faced with vague symptoms, nutritional deficiency
should be considered as an underlying cause whenever risk factors
are present. Regarding scurvy, the latter include exclusive cow’s
milk feeding during the first year of life, poverty, refugee life conditions, anorexia, type 1 diabetes, small intestinal diseases and
restricted diets due to developmental or behavioural factors such
as autism. In the present case, the cause was most likely multifactorial including low vitamin C intake associated with life as a
poor and chronically ill refugee. Moreover, iron overload promotes
irreversible ascorbic acid oxidation into oxalic acid, which then
becomes largely excreted in the urine (1).
The patient’s condition improved after oral ascorbic acid supplementation was initiated. He left with nutritional advice and
social interventions were undertaken to alleviate the psychosocial
difficulties, including at school. Since then, he has not experienced any cellulitis or limb pain, and his oral condition has completely resolved. Throughout follow-up, his plasma vitamin C
concentration normalized.
Acknowledgements: The authors thank Richard Poulin PhD
for his help in the preparation of the manuscript.
Sébastien Bergeron MD
Valérie Larouche MD
Department of Paediatrics
Centre mère-enfant Soleil du CHU de Québec
Laval University
Richard E Bélanger MD
Department of Paediatrics
Centre mère-enfant Soleil du CHU de Québec
Population Health and Optimal Health Practices Research Unit
CHU de Québec Research Center
Laval University, Laval, Quebec
References
1. Cohen A, Cohen IJ, Schwartz E. Scurvy and altered iron stores in
thalassemia major. New Engl J Med 1981;304:158-60.
2. Islam B, Ali S. Demographic characteristics and needs of families at
an urban, low-income, multicultural paediatric clinic.
Paediatr Child Health 2012;17:181-4.
Clinical Pearls
• Health care providers should remember that scurvy still occurs
and must be considered as a diagnosis, especially in high-risk
groups with restricted diets.
• Nutritional deficiencies should be considered to explain
atypical symptoms, even in the presence of strong
psychosocial stressors.
• In providing culturally adapted care, paediatricians should
consider that poverty, social stigmatization and language
barriers are only some of the hurdles new immigrants and
refugees face after their arrival (2).
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