It was a typical morning in our clinic, with residents, medical students, and pediatricians overseeing the care of the patients coming in for sick visits. But among the usual colds, rashes, minor injuries, and ear infections was a 7-year-old with severe autism and a curious constellation of symptoms.
He came in with a rash of scattered, small red dots, was less active than usual, and appeared to have leg pain, which the parents initially thought was due to a growth spurt.
The child had no fever, no vomiting or diarrhea, and no other symptoms besides poor oral hygiene and sensitive gums.
When pressure was applied to the red dots, they did not momentarily fade. This indicated petechiae — small areas of bleeding underneath the skin.
Children can develop petechiae for reasons as benign as severe coughing or vomiting, which can rupture small blood vessels, or for more serious causes such as infections or autoimmune diseases that lead to dangerously low levels of platelets, which help the body clot.
Although he did not appear acutely ill, the presence of petechiae and mild difficulty walking prompted admission for further evaluation, including blood tests to assess clotting and X-rays of his lower extremities.
When the lab and imaging results returned, we were shocked by the ultimate diagnosis — one that harkened back to the past.
Solution
The most recent data on autism prevalence in children is staggering: approximately 1 in 31, or 3.2% of this population. The spectrum of severity ranges widely, but one symptom that affects many children with autism is selective food intake — very picky eating.
Our patient would eat only French fries, pizza, and rice. Notably absent from his diet for years were fruits and vegetables. This explained his petechial rash, gum swelling, and difficulty walking: He had developed scurvy due to vitamin C deficiency.
Scurvy dates back at least to the Viking era, when sailors spent months at sea without adequate vitamin C. It became known as the “scourge of the sea,” as sailors suffered from bleeding gums, rashes, and severe bone pain. In 1795, the British Navy implemented the use of lime and lemon juice after Dr. James Lind, aboard the HMS Salisbury, discovered that consuming two oranges and one lemon per day cured sailors suffering from scurvy.
Our patient had classic X-ray findings of scurvy, such as reduced bone density, along with undetectable vitamin C levels in his blood. After just five days of vitamin C treatment, his symptoms resolved. Close follow-up with a nutritionist and his primary care physician to monitor his eating patterns will, hopefully, keep him afloat on the seas of good health.
Daniel R. Taylor is an associate professor at Drexel University School of Medicine and pediatrician at St. Christopher’s Hospital for Children.