Tag Archives: Scurvy

Why a Diet History Can Be Helpful

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A recent clinical problem-solving case report (D Hafez, et al. NEJM 2016; 374: 1369-74) highlights why a dietary history is important.  The initial paragraph indicated that a 2 year old with delayed speech and a picky eater presented with a 6 week history of progressive inability to bear weight.

The authors of this report explained the entire sequence of diagnosis which included extensive studies like bloodwork, radiographs, MRI, and bone marrow biopsy.  The last paragraph indicates that finally someone asked about the child’s diet: “approximately 1.4 liters of chocolate milk and ate two to four graham crackers per day. His mother acknowledged that these items were the mainstay of his diet.”

It turns out that the patient had vitamin C deficiency causing scurvy.  “Unfortunately, a comprehensive dietary review was performed only after an exhaustive and costly workup had been pursued.”  Personally, if I were involved in such a case, I would be embarrassed if it were published.

My take: While scurvy is interesting and rare in this country, the broader lesson of this report is to get a better dietary history before pursuing a huge workup.

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Gibbs Gardens

Gibbs Gardens

Missing ingredients in TPN -Case Report

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Recently one of my radiology colleagues, Dr. Laura Hayes, put together (lead author) a presentation (poster) for an upcoming meeting.  The main focus of the presentation is a TPN-dependent toddler who presented with refusal to walk due to copper deficiency.

Attached is a link to the presentation: TPN Copper.  This link is a power point presentation with numerous radiographs and even bone scan images.

Key points:

  • All TPN components except dextrose have been in periods of shortage over the last few years.
  • TPN-dependent patients may not be receiving all the needed components and their physicians may not have been notified of the specific shortage(s).
  • Copper deficiency leads to reduced activity of numerous enzymes important for function of bone, blood, skin, nervous system and hair.
  • Subperiosteal hemorrhage leads to the periosteal thickening seen in this case and is associated with the bone pain our patient experienced.
  • Increased losses of bilious fluid can increase the risk of copper deficiency due to the excretion of copper in bile.
  • Other TPN-related deficiencies reviewed include thiamine deficiency (Wernicke’s encephalopathy), Vitamin D deficiency (Rickets), and Vitamin C deficiency (Scurvy).

Another recent case report:

Oestreich AE, Cole CR. Vigorous periosteal reaction secondary to copper deficiency in an infant on total parenteral nutrition. (2013) Pediatr Radiol 43:1411-1413.

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