A 2-year-old girl from a low-income family in Delhi is brought to the clinic with a 2-week history of bleeding gums, poor wound healing, and irritability. Her mother reports the child has been a picky eater and refuses fruits and vegetables. On examination, she has perifollicular hemorrhages on the lower limbs, swollen and bleeding gums, and poor dentition. Hemoglobin is 9.2 g/dL. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis: Vitamin C Deficiency (Scurvy) ### Key Clinical Features **Key Point:** Vitamin C deficiency in children presents with a classic triad: bleeding manifestations (gum bleeding, perifollicular hemorrhages), poor wound healing, and irritability. The dietary history of refusing fruits and vegetables is the epidemiological clue. ### Diagnostic Criteria for Scurvy | Clinical Feature | Pathophysiology | Significance | |------------------|-----------------|-------------| | **Perifollicular hemorrhages** | Defective collagen → fragile blood vessels | Pathognomonic sign of scurvy | | **Bleeding gums** | Impaired gum collagen synthesis | Often the first sign in children | | **Poor wound healing** | Collagen cross-linking requires vitamin C | Wounds fail to heal properly | | **Irritability** | Microhemorrhages in muscles and joints | Causes pain and behavioral changes | | **Mild anemia** | Chronic bleeding + malnutrition | Secondary finding | ### Vitamin C Biochemistry & Function 1. **Cofactor for prolyl and lysyl hydroxylase** → essential for collagen cross-linking 2. **Antioxidant** → protects cells from oxidative damage 3. **Iron absorption enhancer** → facilitates non-heme iron uptake 4. **Deficiency consequence:** Collagen becomes unstable → bleeding and poor wound healing **High-Yield:** Vitamin C deficiency is rare in developed countries but remains common in malnourished children in low-income settings, particularly those with restricted diets (picky eaters, exclusive processed food intake). ### Management Algorithm ```mermaid flowchart TD A[Suspected Vitamin C Deficiency]:::outcome --> B[Clinical diagnosis: perifollicular hemorrhages + bleeding gums + poor diet]:::decision B -->|Confirmed| C[Start ascorbic acid 100-200 mg daily]:::action C --> D[Increase dietary vitamin C: citrus, tomatoes, leafy greens]:::action D --> E[Monitor clinical response: gum bleeding resolves in 1-2 weeks]:::outcome E --> F[Hemorrhages fade over 2-3 weeks]:::outcome B -->|Uncertain| G[Serum ascorbic acid level <0.2 mg/dL confirms deficiency]:::decision G --> C ``` ### Recommended Dosing - **Treatment:** Ascorbic acid 100–200 mg daily (oral) for 2–3 weeks - **Maintenance:** 10–20 mg daily (from diet) - **Expected response:** Gum bleeding resolves in 1–2 weeks; hemorrhages fade in 2–3 weeks **Clinical Pearl:** The rapid clinical response to vitamin C supplementation (improvement in gum bleeding within 1–2 weeks) is both diagnostic and therapeutic. If no improvement occurs, reconsider the diagnosis. **Mnemonic:** **SCURVY** = **S**wollen gums, **C**ollagen defect, **U**nhealed wounds, **R**ed hemorrhages (perifollicular), **V**itamin C deficiency, **Y**early dietary insufficiency. [cite:Park 26e Ch 9]