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).