(111) Scurvy as a Manifestation of Avoidant-Restrictive Food Intake Disorder during the COVID-19 Pandemic: A Case Report

Abstract: Background

Scurvy is a rare deficiency of vitamin C characterized by hematologic, musculoskeletal, and neuropsychiatric symptoms [1-2]. Children with autism spectrum disorder (ASD) are particularly vulnerable to this nutritional deficiency due to selective eating [2]. While there are reports of scurvy in patients with ASD, these are limited to a pediatrics population [3]. We present the case of an adult patient with presumptive diagnosis of ASD who presented with severe symptoms of scurvy secondary to highly restrictive eating habits that were exacerbated during the coronavirus disease 2019 (COVID-19) pandemic.

Case Presentation

Patient is a 26-year-old male with unspecified depressive disorder and attention-deficit/hyperactivity disorder (ADHD) admitted with lower extremity weakness, perifollicular petechiae, and anemia concerning for scurvy. Psychiatry was consulted to evaluate for a contributing psychiatric condition after he reported eating exclusively “pizza bagels” for the preceding eight months. There were no signs or symptoms of acute depression, psychosis, or mania and no prior history of psychosis, intellectual impairment, or substance use. However, he met DSM-5 criteria for avoidant-restrictive food intake disorder (ARFID), and there was high suspicion of ASD. His presentation was not consistent with other eating disorders such as anorexia nervosa. Low blood ascorbic acid level was confirmed, and vitamin C was repleted, resulting in significant symptomatic improvement. He was discharged to a skilled nursing facility with recommendations for outpatient neuropsychiatric follow up.

Discussion

The adult psychiatric literature on scurvy is focused on patients with psychotic disorders, classic eating disorders, or substance use disorders - known risk factors for vitamin C deficiency [1,4]. There is minimal literature on scurvy in adults with ARFID. However, pediatric cases have described scurvy as an initial presentation of ASD co-occurring with ARFID [3], the suspected diagnoses in this patient. Social isolation during the COVID-19 pandemic likely exacerbated this patient’s restrictive eating, making him more prone to severe malnutrition [2].

Conclusion

This report highlights the importance of keeping a broad differential that includes neurodevelopmental disorders when evaluating adults with avoidant or restrictive eating patterns. Though uncommon, scurvy may present in vulnerable populations such as those with psychiatric illness, particularly under the strains of the COVID-19 pandemic.

References

1. Wright AD, Stevens E, Ali M, Carroll DW, Brown TM. The neuropsychiatry of scurvy. Psychosomatics. 2014;55(2):179-185.


2. Seifer CM, Glaser A, Gesiotto Q, Waknin R, Oller KL. Petechiae, Purpura, and a Pandemic: A Recipe for Scurvy. Cureus. 2020;12(10):e10960.


3. Sharp WG, Berry RC, Burrell L, Scahill L, McElhanon BO. Scurvy as a Sequela of Avoidant-Restrictive Food Intake Disorder in Autism: A Systematic Review. J Dev Behav Pediatr. 2020;41(5):397-405.


4. Nousari Y, Wu BC, Tausk F. From the Caravels to the Wards: Scurvy and Schizophrenia. J Acad Consult Liaison Psychiatry. 2021;62(6):665-666.