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CASE IMAGE
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 65-66

Subgaleal and extradural hematoma in scurvy


Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Date of Submission02-Oct-2020
Date of Decision03-Nov-2020
Date of Acceptance23-Nov-2020
Date of Web Publication27-Feb-2021

Correspondence Address:
Dr. Mahesh Maheshwari
F-48, Dwarka Dham Campus, Karond Bypass in Front of Sanjeev Nagar, Bhopal - 462 038, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipcares.ipcares_27_21

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How to cite this article:
Rafeek N, Ikram S, Malik S, Maheshwari M. Subgaleal and extradural hematoma in scurvy. Indian Pediatr Case Rep 2021;1:65-6

How to cite this URL:
Rafeek N, Ikram S, Malik S, Maheshwari M. Subgaleal and extradural hematoma in scurvy. Indian Pediatr Case Rep [serial online] 2021 [cited 2021 Nov 29];1:65-6. Available from: http://www.ipcares.org/text.asp?2021/1/1/65/310225

A 10-year-old boy presented with swelling over the left side of his head for 8 days. It occurred spontaneously and was acute in onset, painful, and gradually progressive. There was no history of any preceding trauma. The child started walking by 15 months of age and could ride a tri-cycle. Medical help had been sought at the age of 3 years due to pain in both hip and knee joints, resulting in limitation of movement, recurrent oral ulcers, and gum bleeding. He was treated with multiple analgesics and multivitamins but continued to have difficulties in walking, due to which he was not enrolled in school. The child was an extremely picky eater, and the parents were unable to get him to eat vegetables, fruits, or meat. According to his parents, there were no other developmental or behavioral issues, but the child had never undergone formal assessment. Three younger sisters were going to school and had no similar complaints. Examination revealed pallor, oral ulcers, gingival hypertrophy with active bleeding, and tenderness at multiple large joints. A large (15 cm × 10 cm) boggy, fluctuant swelling was noted over the left temporal region. Weight and length for age were less than third centile, whereas body mass index was 11.8 kg/m2. Systemic examination was unremarkable. On the basis of this history and examination, a clinical diagnosis of scurvy with extracranial hematoma was kept.

This was confirmed by the classical radiological features of scurvy in X-rays of the long bones [Figure 1]. Contrast-enhanced computed tomography of the head showed a large subgaleal hematoma (12 cm × 10 cm) and a small extradural collection (25 mm × 7 mm) without any evidence of bone erosion [Figure 2]. The platelet count and coagulation profiles were normal. The child was started on therapeutic dose of Vitamin C at 300 mg/day in divided doses for 4 weeks followed by maintenance of 100 mg/day for 3 months. The parents were counseled regarding the need for a well-balanced diet. After starting treatment, the joints pains resolved and the range of motion improved. By the 10th day, his gingival lesions resolved and the scalp swelling reduced in size and tenderness. After a month of good compliance to management, there was complete resolution of the swelling and the child had become ambulatory. He was referred for the evaluation by a clinical psychologist and child psychiatrist to rule out mental health issues.
Figure 1: Radiographs of bilateral knees, anteroposterior and lateral views showing (A) pencil outlining of diaphysis, (B) Pelkan spurs, (C) White line of Frankel, (D) Ring of Wimberger, and the (E) Trummerfeld zone suggestive of scurvy

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Figure 2: Contrast-enhanced computed tomography of the head – large (A) subgaleal collection of size 12 cm × 10 cm in the left temporoparietal region with area of blood attenuation - subgaleal hematoma and a small (B) extradural collection of 25 mm × 7 mm in the left temporal region without evidence of bone erosion

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Scurvy is caused by nutritional deficiency of ascorbic acid or Vitamin C. Human beings cannot synthesize Vitamin C due to lack of the L-gluconate enzyme.[1] Commonly seen more than a century ago, it has now become a rare entity in the pediatric population. It is usually seen in infants fed with boiled milk with absence of timely initiation of complementary feeding or children with iron overload (i.e., in thalassemia), on dialysis, having malignancies, or with neurodevelopmental or psychiatric disorders that are associated with restricted diets due to extreme food fussiness (like in our patient).[2] Scurvy is a clinicoradiological diagnosis. The typical radiographic findings occur at distal end of long bones and include pencil outlining of the diaphysis, Pelkan spurs, White line of Frankel, Ring of Wimberger, and the Trummerfeld zone.[3] As the number of cases of scurvy has decreased remarkably, so has its awareness among physicians and it is often overlooked in the list of differential diagnoses. There have been instances in which scurvy has been misdiagnosed as malignancy, infection, or rheumatological disorders. Other uncommon presentations of scurvy that have been reported in the past include muscle bleeds, hemarthrosis, proptosis,[4] extradural hematoma, and hemorrhagic pleural effusion.[1]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given consent for images and other clinical information to be reported in the journal. The guardian understands that the names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kumar V, Choudhury P. Scurvy - A forgotten disease with an unusual presentation. Trop Doct 2009;39:190-2.  Back to cited text no. 1
    
2.
Saavedra MJ, Aziz J, Cacchiarelli San Román N. Scurvy due to restrictive diet in a child with autism spectrum disorder: Case report. Arch Argent Pediatr 2018;116:e684-7.  Back to cited text no. 2
    
3.
Agarwal A, Shaharyar A, Kumar A, et al. Scurvy in pediatric age group - A disease often forgotten? J Clin Orthop Trauma 2015;6:101-7.  Back to cited text no. 3
    
4.
Verma S, Sivanandan S, Aneesh MK, et al. Unilateral proptosis and extradural hematoma in a child with scurvy. Pediatr Radiol 2007;37:937-9.  Back to cited text no. 4
    


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  [Figure 1], [Figure 2]



 

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