A 15-MONTH-OLD boy had a history of unexplained bleeding from his gums for several weeks and fever for 2 days. He had been fed only cow's milk and oatmeal since age 4 months. On physical examination he had almost no spontaneous movement. His legs were held in a "frog leg" position (Figure 1), were swollen along the long bones, and were tender to palpation. His skin was dry and pale. Hemorrhages of the gingiva were obvious as were 2 blood-filled cysts of the lower canine teeth (Figure 2). The tympanic membranes were hyperemic, and evidence of middle-ear fluid was present. Palpable prominence of the costochondral junctions of the chest wall was noted.
The results of laboratory examinations revealed a normal white blood cell count, a hemoglobin level of 76 g/L, and a platelet count of 334 × 109/L. The serum calcium, phosphorous, copper, and alkaline phosphatase levels were normal. Thyroid stimulating hormone, triiodothyronine, and thyroxine levels were also normal. The serum level of vitamin D was normal, but vitamin C levels were low, 28 µmol/L (reference range, 45-108 µmol/L). Chest x-ray film showed a scorbutic rosary at the costochondral junctions with a "corner" sign noted in the proximal metaphysis of the humerus. Lower extremity radiographs demonstrated abnormalities (Figure 3).
Riepe FG, Eichmann D, Oppermann HC, Schmitt HJ, Tunnessen WW. Picture of the Month. Arch Pediatr Adolesc Med. 2001;155(5):607-608. doi:10.1001/archpedi.155.5.607