Sunday 3 October 2021

Vitamin C deficiency mimicking inflammatory bone disease MRI hip

A 15 years old school goer presented with on and off bilateral hip pain, restricted hip joint movement, associated backache. 
MRI bilateral hip joint shows abnormal bone marrow edema involving bilateral acetabulum and subchondral portion of right sacral ala. Associated mild left hip joint effusion.
Imaging finding were suggestive of either inflammatory bone disease or multifocal osteitis. However the possibility of nutritional cause like Vit C or D deficiency was kept during discussion with the referring physician. Accordingly, getting the lab investigation done, was assured by refereeing doctor.

Patient's CBC, ESR, C-reactive protein was normal, RA factor was negative. Vitamin and mineral status showed normal zinc, folate and vitamin B6 levels. The vitamin C turned out strikingly low at 5 μmol/L (normal range 23–114 μmol/L) and vitamin D 25-OH at 12.2 ng/mL (normal > 30 ng/mL).
Treatment was already initiated by refereeing doctor with ascorbic acid, cholecalciferol, and liquid meal supplements keeping the diagnosis of scurvy on the basis of severely low vitamin C levels. 

The crucial message from this case is considering the nutritional cause for nonspecific bone marrow edema in MSK imaging is mandatory rather than confining our diagnosis between infective, inflammatory and neoplastic etiology all the time as in our case the treatable cause like Vitamin C deficiency was mimicking the inflammatory bone disease. 

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