A case report of a childhood scurvy musculoskeletal manifestation: Radiologic findings and diagnostic implications

Abstract

Scurvy is an infrequent pathological condition resulting from a sustained dietary vitamin C deficiency. Radiology becomes pivotal because the diagnostic process for scurvy can be intricate, given its resemblance to bone neoplasms. A 6-year-old boy, reported persistent pain and swelling in the right thigh for 2 months prior to hospitalization. Clinical examination revealed a mass localized in the right thigh and anemia. A radiograph of the right femur demonstrated extensive osteopenic changes, "Trümmerfeld zone", "Frankel line", "Pelkin fracture", "Wimberger ring sign", and para-epiphyseal subperiosteal hematoma. The absence of any such cases in our institution over the preceding decade emphasizes the uniqueness of this presentation. Histopathological evaluation yielded atypical results, prompting further radiographic assessment of the left femur and thorax. The subsequent findings corroborated the classic "scorbutic rosary" presentation, indicative of scurvy. The patient's symptoms gradually resolved with high-dose supplementation of vitamin C. Scurvy predominantly presents with musculoskeletal manifestations. Plasma vitamin C level assessment is the gold standard for the diagnosis, but it is currently inaccessible in our nation. Consequently, radiographic evaluation reveals pathognomonic features of the disorder. In thoracic radiographs, the "scorbutic rosary" presentation is evident. In contrast, long bones exhibit hallmarks of scurvy: diffuse osteopenia, "Frankel line", "Trümmerfeld zone", "Pelkin fracture", "Wimberger ring sign", and para-epiphyseal subperiosteal hematoma. Prompt intervention with vitamin C thwarts the progression to severe complications. Radiology is an indispensable tool in diagnosing pediatric scurvy, especially in developmental countries where the assessment of vitamin C serum levels is inaccessible.

Keywords: Musculoskeletal; Pediatric; Radiology; Scurvy; Vitamin C.

Fig. 1

Swelling of the right thigh. The patient is more comfortable in a semi-flexed hip and knee position.

Fig. 2

The imaging appearance of both femurs of the patient. Note the scorbutic features of both femurs, elaborated in Figure 3.

Fig. 3

The right femur x-ray with its scorbutic features. The findings were consistent with the left femur. (A) Diffuse osteopenia; (B) Pencil-thin cortex; (C) Para epiphyseal subperiosteal haemorrhage; (D) “Pelkin fracture”; (E) “Wimberger ring sign”; (F) “Trümmerfeld zone”; (G) “White line of Frankel”.

Fig. 4

The histopathologic evaluation showed an atypical osteoblastic reaction with chronic inflammation.

Fig. 5

Costochondral junction expansion, or “scorbutic rosary”, was seen on the patient's chest X-ray (white arrow).