Scurvy: A rare cause for limp in a child with autism spectrum disorder

A 6-year-old boy presented to a metropolitan hospital Emergency Department (ED) with a 10 day history of left sided limp, against a background of severe Autism Spectrum Disorder.He was non-verbal and incontinent.He had poor oral hygiene due to an aversion to mouth care.He had a longstanding very restricted diet and would only eat bread, cheese and water.His mother had noticed a rash on his lower legs several weeks prior to the limp.He developed gum bleeding two weeks before presenting to hospital.There was no history of weight loss, fevers or lethargy. Examination:The mother brought the child to the ED as he was no longer weight-bearing.The child was distressed with examination due to his leg pain.He had a limp, pretibial rash and red swollen gums.There was no pallor, lymph node enlargement or hepatosplenomegaly.Despite no history of fevers at home, on presentation he had a temperature of 38.2 degrees. Investigations:The child was investigated with a full blood examination, electrolytes, coagulation profile, erythrocyte sedimentation rate and a C-Reactive protein.He had a raised ESR of 115, a CRP of 19, and a normal haemoglobin and white cell count.Left leg X-Rays demonstrated subtle soft tissue swelling displacing the fat pad from the femur with a faint metaphyseal lucency.