Introduction: Often thought of a disease of the past, scurvy remains a disease of the present. Recent cases have been described in an infant fed exclusively almond beverage, in a child receiving peritoneal dialysis and in the context of neurodevelopmental disability. Children with autism spectrum disorder (ASD) may be at higher risk of scurvy, and other micronutrient deficiencies, because of restricted diet and limited food repertoire. Nevertheless, because of the perceived rarity of these conditions, diagnosis may be delayed and may only come after unnecessary, invasive investigations. Case Report: A 10-year-old boy with ASD presented to the emergency department with a 2 to 3 week history of limp and a 1 week history of right ankle swelling/bruising. There was no fever, night sweats, weight loss, fatigue, respiratory or gastrointestinal symptoms. Findings on physical examination included (1) an inability to bear weight on the right leg, (2) swelling and warmth in the right knee and ankle, and (3) limited range of motion in the right knee and ankle. Parafollicular hyperkeratosis and purpura, ecchymosis and subtle gingival changes were identified. Blood work showed a mild normocytic anemia, non-specific changes in red cell morphology on blood smear and a mildly elevated C-reactive protein (normal erythrocyte sedimentation rate). Blood culture was negative. X-rays showed soft tissue edema within the right popliteal region extending into the upper calf, without fracture. Magnetic resonance imaging identified multiple areas of focal bone marrow abnormality, without periosteal reaction; extensive myositis/cellulitis/fasciitis was seen around the right knee. Parenteral cloxacillin was empirically started for presumed osteomyelitis. Given the unusual presentation, a bone biopsy was planned and the need for bone marrow aspirate was also discussed. Invasive and ultimately unnecessary investigations were avoided when scurvy was considered in the context of classic signs of vitamin C deficiency and a very restricted diet (with no fruits or vegetables). Serum ascorbic acid (vitamin C) level was ultimately very low, as suspected (<5 µmol/L; normal >24 µmol/L). With oral ascorbic acid treatment, the patient was able to ambulate almost independently within days. Discussion: The differential diagnosis for limp and abnormal bone imaging is broad and includes both infectious and non-infectious conditions. A thorough review of the history may provide diagnostic clues useful in arriving at the correct diagnosis. In the context of restricted diet, the possibility of scurvy should be considered in the child with difficulty ambulating and abnormal bone imaging. Recognition of scurvy as a diagnostic consideration ensures appropriate treatment and may avoid unnecessary investigations. Conclusion: Pediatricians should be aware of scurvy as a relatively rare but important cause of limp and abnormal imaging that may mimic osteoarticular infections. In the context of restricted diet, scurvy should be considered as a diagnostic possibility.

Figure 1

Pre-treatment images of the patient, with (A) parafollicular hyperkeratosis and parafollicular purpura, (B) ecchymosis over the medial aspect of the right ankle, and (C) subtle gingival changes. The white arrows indicate the relevant clinical findings.

Figure 1

Pre-treatment images of the patient, with (A) parafollicular hyperkeratosis and parafollicular purpura, (B) ecchymosis over the medial aspect of the right ankle, and (C) subtle gingival changes. The white arrows indicate the relevant clinical findings.

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