P0875 - Autism and Scurvy: A Case Series

Introduction:
Scurvy has been documented for centuries with the first pediatric case documented in 1889. Given the minimal amount of required daily Vitamin C, scurvy is preventable, and is often thought of as a historic diagnosis. However, this diagnosis still exists and may have dire consequences if not diagnosed in a timely manner. This series includes two patients with an underlying diagnosis of autism found to have serious consequences of scurvy.
Case 1 is a 17-year-old male autism who presented for inability to walk and easy bruising. He had a petechial rash on bilateral lower extremities with areas of ecchymosis, blood tinged gums, right knee swelling and calf tenderness. He demonstrated decreased motion of bilateral lower extremities. Comprehensive radiologic evaluation was negative. The patient was found to be anemic and Vitamin D deficient. A thorough history discovered his diet almost exclusively consisted of soy milk and meat patties. His Vitamin C level was found to be zero and after supplementation, the patient showed improvement.
Case 2 is a 16-year-old male with autism admitted due to difficulty with ambulation, bruising of the lower extremities, and abdominal pain. He had right knee tenderness, diffuse petechiae and scattered purpura throughout bilateral lower extremities, and mild periumbilical abdominal tenderness. CBC, CMP, coagulation studies, UA, EKG, and abdominal ultrasound were all normal. The patient was discharged with a diagnosis of Henoch-Schonlein Purpura.
He was readmitted for worsening symptoms including bruising, pain, leg swelling, complete inability to ambulate, gum bleeding and polyarthralgia. His diet was noted to consist almost exclusively of chips, a plant-based supplement, and almond milk. His physical exam revealed gum hypertrophy and erythema, abdominal tenderness, lower extremity edema, perifollicular petechiae, and decreased range of motion and tenderness at multiple joints. His CBC showed anemia that was not present the week prior. His hospital course was complicated by left lower extremity compartment syndrome which required a fasciotomy and hematoma evacuation. His Vitamin C level was found to be zero and he was started on supplementation resulting in resolution of symptoms.

Discussion:
The findings of vitamin C deficiency include musculoskeletal manifestations, bone pain, anemia, and blood vessel wall damage resulting in bleeding, petechiae/purpura, and edema. The effect on collagen results in poor wound healing and oral cavity abnormalities. There are also general findings including poor weight gain, irritability, anorexia, and depression.
Both patients have an underlying diagnosis of autism which can be associated with restrictive eating habits. Both patients had an extended hospital stay, multiple consults, laboratory studies, and radiologic studies despite presenting with classic scurvy symptoms. These two cases point out the importance of taking a detailed dietary history and considering nutritional deficiencies for patients with autism and known restrictive eating habits.