Scurvy in the developed world.

E752 CMAJ, August 9, 2011, 183(11) © 2011 Canadian Medical Association or its licensors Apreviously well 54-year-old woman was admitted to hospital for investigation of bilateral pain in her legs that prevented her from walking. She had a threeweek history of pain, which started in the knees and progressed to involve the muscles of her lower limbs diffusely. This pain was associated with mild swelling and bruising. She also noted red dots on her legs. Review of systems was positive for a progressive history of fatigue and a 5-lb weight loss over two years. The patient’s medical history included os teoarthritis and osteoporosis. Her medications were alendronate, calcium, vitamin D and acetaminophen. The patient reported allergies to sulfa, penicillin, codeine and nuts. She was a nonsmoker, was employed in a full-time job and denied any social or financial stressors. On presentation, the patient was mildly tachycardic (heart rate 103 beats/min) with a blood pressure reading of 100/67 mm Hg, but she was otherwise stable. Positive findings included small knee effusions and mild bilateral pitting edema of the lower limbs. Muscles of the lower limbs were very tender to palpation. Nonpalpable petechiae were present on the legs (Figure 1), and extensive ecchymosis could be seen on the posterior thighs and calves (Figure 2). In hospital, progressive normocytic anemia was noted, with a drop in hemoglobin level from 96 g/L to 73 g/L (normal 115–155 g/L) over 72 hours. The reticulocyte count was elevated. The leukocyte count was 9.3 (normal 3.0–10.5) 10/L, with a normal differential. Platelets were slightly elevated at 498 (normal 125–400) 10/L. The erythrocyte sedimentation rate was mildly elevated, and the ferritin level was normal at 312 (normal 24–336) μg/L. Total bilirubin was 75 (normal 24–336) μmol/L, and all other liver enzymes were normal. Haptoglobin, international normalized ratio, creatinine, thyroid-stimulating hormone, creatine kinase, folate and vitamin B12 levels were normal, as was the partial thromboplastin time. Workup for infection, including serology for hepatitis B and C, was negative. A chest radiograph was normal, as was a computed tomographic scan of the abdomen and pelvis. Further investigations included a normal electromyogram. A skin biopsy of the petechiae showed noninflammatory dermal hemorrhages. Subcutaneous edema was seen on a plain film of the femur. Magnetic resonance imaging (MRI) of the lower extremities showed mild peripheral increase in T2-weighted muscle signal in the distal vastus medialis and lateralis with more prominent bilateral dermal thickening, subcutaneous edema Cases