Ecchymosis and Bilateral Leg Pain in an 11-Year-Old Girl With Developmental Delay

Jeffrey M. Kalczynski, DO; Bryan T. Luu, DO


May 24, 2023


Initially, the laboratory evaluation was focused on identifying a hematologic process. The patient in this case was clinically anemic, and laboratory studies revealed a hemoglobin level of 5.9 g/dL. In order to rule out intravascular hemolysis, LDH and haptoglobin levels, a direct Coombs test, and a reticulocyte count were ordered. The results of these tests were essentially in their normal ranges, which indicated the absence of hemolysis. The patient's reticulocyte count was elevated appropriately, suggesting the absence of any dysfunction in the production of blood cells. In addition, her normal platelet count pointed away from thrombocytopenic processes. However, the iron profiles revealed decreased iron levels, which pointed toward a process causing iron-deficiency anemia. This could be due to poor iron intake or absorption or occult bleeding.

During the admission process, discussion among the ED team, admitting team, and hematology service brought up scurvy as a potential diagnosis. A vitamin C level was ordered in the ED and was obtained after the patient was admitted. The level (< 0.1 mg/dL [reference range, 0.6-2 mg/dL]), in combination with findings of gingival hypertrophy, anemia, and nonhealing ecchymoses on the lower extremities, led to a diagnosis of scurvy.

The patient was hospitalized for a total of 8 days. After scurvy was diagnosed, treatment focused on repletion of vitamin C. Intravenous vitamin C supplementation was started. Shortly thereafter, she began to tolerate oral intake and was transitioned to oral vitamin C supplementation. By the time of discharge, the range of motion in her lower extremities was much improved. She received multimodal therapy, including physical therapy, occupational therapy, and osteopathic manipulative therapy. She was discharged to an acute rehabilitation facility with hematology-oncology and nutritionist follow-up.


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