Intended for healthcare professionals

Practice Lesson of the Week

Unrecognised scurvy

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3580 (Published 17 September 2009) Cite this as: BMJ 2009;339:b3580

Neurodisability: An unrecognised risk factor for scurvy

We read with great interest the paper by Choh et al on unrecognised
scurvy.(1) We would like to highlight some aspects of the modern
epidemiology of scurvy which the authors have failed to mention.

Although sporadic cases have been described throughout history, the
evolution of scurvy in the developed world can be broadly described under
three distinct eras:

a. Scurvy in sailors due to extreme dietary depletion at sea which
was successfully prevented following pioneering studies by James Lind, b.
Scurvy in large populations affected by social upheaval (eg.wars and
famines) in subsequent years and c. Re-emergence of scurvy towards the end
of 19th century in infants from affluent families due to usage of heated
milk and proprietary foods.(2)

The understanding that scurvy is caused by a biochemical deficiency
followed by the landmark event of isolation of vitamin C led to changes in
dietary practices and widespread food supplementation. This led to the
near eradication of scurvy in the latter half of 20th century. The
authors suggest that in the current era, scurvy is confined to people with
poor social status, malnutrition and alcoholism. We would like to propose
neurodisability and neuropsychiatric illness as a previously undescribed
risk factor for developing scurvy.

Further to late diagnosis of scurvy in a child with cerebral palsy,
we conducted a literature review on cases of scurvy reported in the 21st
century.(3) A Medline search performed through Pubmed interface in April
2009 with the keyword “scurvy” revealed 237 articles in English published
in the previous 9 years. Further analysis of these articles revealed 68
reports about new clinical cases of scurvy. Of these case reports, where
the age of the patient could be verified, 25 were adults and 30 were
children. Most of the adults fell into the risk categories alluded to by
Choh et al. However half of the children had varying degrees of
neurodisability (cerebral palsy, seizures, developmental delay, autism
etc). This population group is not yet widely recognised as an at-risk
group for scurvy. Subtle signs of early scurvy are even more difficult to
pick up in this group due to learning and communication difficulties.
Feeding problems (neurological or behavioural) which are widely prevalent
in these children might be a contributing factor. Children with
neurodisability who are otherwise thriving and seem to have an adequate
caloric intake are still at risk for undetected vitamin C deficiency.(4)
The small number of cases identified by our review might represent the
proverbial “tip of the iceberg”.

The authors also suggest that scurvy is a diagnosis of exclusion
based on history and clinical features. However scurvy has classic
radiological features which can be recognised on x ray and Magnetic
Resonance Imaging (MRI) of the limbs.(5,6)

References

1. Choh CT, Rai S, Abdelhamid M, Lester W, Vohra RK. Unrecognised
scurvy. BMJ 2009; 339:b3580.

2. Rajakumar K. Infantile scurvy: a historical perspective.
Pediatrics 2001; 108(4):E76.

3. Anjay MA, Palanivel V, Chaudhary R, Stocks R. Paediatric Scurvy:
old wine in new bottles. Arch Dis Child 2009; 94: A65-A66

4. Noble JM, Mandel A, Patterson MC. Scurvy and rickets masked by
chronic neurologic illness: revisiting "psychologic malnutrition".
Pediatrics 2007; 119:e783-e790.

5. Park EA, Guild HG, Jackson D, Bond M. The recognition of scurvy
with especial reference to the early x-ray changes. Arch Dis Child 1935;
10: 265-294

6. Choi SW, Park SW, Kwon YS, Oh IS, Lim MK, Kim WH et al. MR imaging
in a child with scurvy: a case report. Korean J Radiol 2007; 8:443-447.

Competing interests:
None declared

Competing interests: No competing interests

08 February 2010
Vijay Palanivel
Specialist Registrar in Paediatric Neurodisability
Anjay MA
Great Ormond Street Hospital for Children, London WC1 3JH