To the Editor
Bone pain and bleeding are among the most common symptoms of leukemia.
Vitamin deficiencies are more commonly seen in developing countries
where the access to healthy food is difficult. In resource-rich
countries severe vitamin deficiencies are rarely seen and not always
considered in the differential diagnosis1. In
developed countries, severe vitamin deficiencies are associated with
restricted diets secondary to developmental or psychiatric
problems1. Both deficiencies can cause significant
bone pain, which may mimic other diseases, including
leukemia.1,2,3 Here we report two cases that presented
with bone pain and/or bleeding and were found to have severe vitamin
deficiencies.
CASE 1: 3-year-old Caucasian female with a history of autistic
spectrum disorder (ASD) and developmental delay presented with a
four-week history of worsening bilateral lower extremity pain and
refusal to bear weight. X-rays of the pelvis and lower extremities
showed lumbosacral spinal dysraphism and no other abnormalities. MRI of
the spine was suggestive of an infiltrating marrow process. A dietary
history uncovered a very restrictive diet consisting of almond milk and
mashed potatoes. Complete blood cell count and bone marrow biopsy and
aspirate were normal. 1-25-dihydroxy vitamin D and vitamin C levels were
low. A follow up bone survey showed changes consistent with scurvy but
not rickets.
CASE 2: A 4-year-old African-American female with history of ASD
and severe developmental delay presented with an eight-week history of
worsening bilateral lower extremity pain and decreased mobility with
mild edema and bruising on her left ankle. On examination the patient
was smaller for her age and her weight was < 1%ile. She was
in severe pain and barely tolerated palpation. She had gum bleeding and
bruises in her legs. CBC informed hypochromic microcytic anemia.
Inflammatory markers, ESR and CRP were elevated. Bone marrow biopsy was
normal. 1-25-hydroxy vitamin D level was low at 18 ng/dL. A bone survey
showed metaphyseal radiolucencies to varying degrees, concerning for
scurvy. Dietary history informed of a restrictive diet of mashed
potatoes.
Both patients were started on vitamin C and D supplementation with
resolution of bone pain, bleeding and recovery of motor function and
overall wellbeing.
In children, vitamin D deficiency can lead to muscle pain, skeletal
defects, and osteopenia.4 Scurvy or vitamin C
deficiency is a rare and mostly a forgotten disorder in modern times.1,2Classical signs of scurvy include gingival lesions
with inflammation, hypertrophy and bleeding resulting in loosened teeth.
The deficiency worsens in stages. Mucocutaneous manifestations appear in
the second stage including dry skin, folliculitis, vascular purpura and
painful hematomas. Third stage symptoms are of musculoskeletal nature,
involving osteoporosis, bone growth abnormality, and subperiosteal or
intraosseous hemorrhagic lesions. In the final fourth stage the general
physical condition worsens with asthenia which perpetuates food
selectivity.
Radiographic findings suggestive of scurvy have been previously
described and were seen in both cases (Figure 1).5,6
These cases of advanced scurvy and vitamin D deficiency highlight the
importance of recognizing the clinical manifestations and radiographic
findings of the disorder to avoid extensive hospitalization and
expensive work-up, and provide prompt supplementation.