Vitamin C Deficiency and Scurvy
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Direct answer
Vitamin C deficiency causes scurvy, a disorder of defective collagen synthesis, because vitamin C is needed to hydroxylate proline and lysine in procollagen. In infants it presents with irritability, pseudoparalysis of the legs, gum bleeding and subperiosteal haemorrhage of long bones. Diagnosis is clinical, the classic radiological signs lag behind, and oral vitamin C usually produces a prompt response.
What you must remember
- Mechanism: vitamin C is a cofactor for prolyl and lysyl hydroxylases, so deficiency yields unstable collagen in vessels, gums, bone and skin.
- Pseudoparalysis: the infant refuses to move a limb because of subperiosteal haemorrhage, commonly around the knee and lower limb bones.
- Gum signs: swollen, spongy, bleeding gums, sometimes with loose teeth in older children.
- Perifollicular haemorrhage: petechiae around hair follicles on the legs, with corkscrew-shaped hair.
- Sources: amla, guava, citrus fruits, tomato, green chillies and green leafy vegetables; heat and prolonged storage destroy vitamin C.
- Infant risk: bottle-fed infants given boiled milk without fruit or vegetables after about 6 months are the typical group.
- Differential: non-accidental injury, osteomyelitis, leukaemia, haemophilia and rickets mimic scurvy and must be excluded.
Radiology after the clinical picture
An 11-month-old bottle-fed infant has refused to move both legs for four days, and his gums are swollen and bleeding. The skeletal changes of scurvy appear on films later than the clinical signs, and the table lists the classic findings.
| Radiological sign | Site | Feature |
|---|---|---|
| Wimberger ring | Epiphysis of proximal tibia | Dense sclerotic ring around the ossific nucleus |
| Frankel line | Metaphysis | Dense white line of provisional calcification |
| Trümmerfeld zone | Metaphysis beneath Frankel line | Rarefaction with loss of trabeculae |
| Pelkan spur | Corner of the metaphysis | Spur of compact bone at the corner |
These changes appear after the clinical picture, so treatment starts on clinical suspicion rather than waiting for films. Their presence supports the diagnosis and helps separate scurvy from other causes of limb pain. Because scurvy is diagnosed by exclusion in an infant with a limb problem, the gums, skin and diet history carry as much weight as the films.
Where the exam tries to catch you
Stems test the refusal to move a limb, the timing of radiological change, and the mimics.
- Trap: attributing refusal to move a limb to neurological disease. Correct: pseudoparalysis from subperiosteal haemorrhage is a classic scurvy presentation, so examine the gums and limbs.
- Trap: waiting for radiographic changes before treating. Correct: X-ray signs lag behind the clinical picture, so treatment starts on the diagnosis.
- Trap: assuming bruising and limb swelling always mean non-accidental injury. Correct: scurvy must be excluded, though it also prompts a feeding history and welfare review.
- Trap: assuming milk supplies enough vitamin C. Correct: milk is a poor source and boiling destroys what remains, so infants need fruit or vegetable sources after six months.
Frequently asked questions
At what age does scurvy usually present in infants?
Scurvy in infants typically presents between about 6 and 18 months of age, when breast milk stores have fallen and complementary foods are inadequate. Bottle-fed infants given boiled milk without fruit or vegetables are the typical group.
Why does an infant with scurvy refuse to move the legs?
The legs are held still because of subperiosteal haemorrhage, which makes the limbs painful, a presentation called pseudoparalysis. Irritability and swollen, bleeding gums are other features that point to scurvy in the infant.
Which X-ray signs suggest scurvy?
The classic radiological signs of scurvy are the Wimberger ring, the Frankel line, the Trümmerfeld zone and the Pelkan spur. They appear at the lower ends of long bones, around the knee, and usually lag behind the clinical picture.
How is scurvy treated in children?
Scurvy is treated with oral vitamin C in divided daily doses, and limb pain usually improves within days. The child then needs a diet rich in vitamin C, such as amla, guava and citrus fruits, to prevent relapse.
What are the main mimics of scurvy in a child?
Non-accidental injury, osteomyelitis, leukaemia and haemophilia can mimic the bleeding and limb signs of scurvy. A careful diet history, examination of the gums and appropriate imaging help separate these conditions.