Pediatr Radiol (2007) 37:937–939
DOI 10.1007/s00247-007-0543-9

CASE REPORT

Unilateral proptosis and extradural hematoma in a child
with scurvy
Sumit Verma & Sindhu Sivanandan &
Mangalasseril K. Aneesh & Vaibhav Gupta &
Rachna Seth & Shushil Kabra

Received: 30 April 2007 / Accepted: 18 May 2007 / Published online: 7 July 2007
# Springer-Verlag 2007

Abstract We report a 3-year-old boy with unilateral
proptosis, painful swelling of the right thigh and aphasia.
He had radiographic evidence of scurvy in the limbs and
bilateral frontal extradural hematomas with a mass lesion in
the left orbit on MRI. He was treated with vitamin C and on
follow-up 8 weeks later had recovered with no evidence of
the orbital mass on clinical or radiological study. Scurvy
manifesting as proptosis and extradural hematoma is rare.
Keywords Proptosis . Extradural hematoma . Scurvy . Child

Introduction
In 1753, Sir James Lind gave the first clinical description of
vitamin C deficiency disease known as scurvy. In the last
50 years, the number of cases of scurvy has decreased
remarkably, and so has the awareness among physicians. It
is not surprising to find scurvy and its complications being
misdiagnosed as malignancy or infection. One such case
with extremely rare complications is presented.

S. Verma (*) : S. Sivanandan : R. Seth : S. Kabra
Department of Pediatrics,
All India Institute of Medical Sciences (AIIMS),
Ansari Nagar,
New Delhi, India 110029
e-mail: drsumitverma@yahoo.com
M. K. Aneesh : V. Gupta
Department of Radiodiagnosis,
All India Institute of Medical Sciences (AIIMS),
New Delhi, India

Case report
A 3-year-old boy presented with proptosis of the left eye
for 15 days. He had been unable to walk for the last
2 months and had a poor nutritional history. His diet had
consisted of diluted cow’s milk and rice since late infancy
and lacked fruit and vegetables. On examination he was
extremely irritable and was undernourished with weight,
height and head circumference well below the third
percentile. He had pallor, but no bleeding gums or
petechiae. The left eye was proptotic with ulceration and
displayed seropurulent discharge and no perception of light.
The right eye, including fundus evaluation, was normal.
Costochondral junctions were sharply angulationed. The
right thigh was swollen and tender to the touch. The boy
barely moved the affected limb and had motor aphasia.
Laboratory investigation revealed a hemoglobin level
of 4.8 g/dl (normal range 8–12 g/dl), a total leukocyte
count of 12,300/mm3 (neutrophils 70%, lymphocytes
30%), a platelet count of 4.3×105/mm3, and a prothrombin
time of 14 s (control 13 s). Peripheral smear showed
microcytic hypochromic anemia. His renal function test
and electrolytes were within normal limits. Liver function tests showed hypoproteinemia and raised alkaline
phosphatase. Radiographs of the right femur demonstrated a thin cortical outline of the epiphysis, splayed
metaphysis with evidence of a Pelkan spur, submetaphyseal lucencies in the distal femur and subperiosteal
hemorrhage (Figs. 1 and 2). MRI of the brain showed
bilateral extradural hematomas compressing the frontal
lobes. There was a subperiosteal hematoma in the left orbit
along with subretinal hemorrhage and retinal detachment. An
additional finding was an ill-defined soft-tissue mass lesion
in the superior aspect of the orbit, which was hypointense to
the extraocular muscles on T1-weighted images and slightly

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Pediatr Radiol (2007) 37:937–939

Fig. 1 Right femur with a thin
cortical outline of the epiphysis
with a splayed metaphysis

hyperintense on T2-weighted images and showed inhomogeneous enhancement on fat-suppressed images after gadolinium administration (Figs. 3 and 4).
Based on clinical findings and investigations, scurvy
was the initial clinical diagnosis and the child was started
on vitamin C, 300 mg daily. The extradural hematoma
was evacuated. On close follow-up 8 weeks later, the
child could stand, speak words and his general condition
had improved. The left eye swelling had regressed
clinically and radiologically with no evidence of a mass
lesion in the orbit.

Fig. 3 T1-weighted axial MR image shows bilateral extradural
hematoma compressing the frontal lobes

Discussion
Vitamin C is an essential micronutrient in the diet required
for synthesis of supporting tissue of mesenchymal origin
such as osteoid in bone, chondroid in cartilage, dentin in
teeth and collagen on capillary walls. It enhances iron
absorption from the gastrointestinal tract, acts as an
antioxidant and is required in the coagulation pathway.
Deficiency of vitamin C leads to scurvy. The common
presenting features are irritability, pain, tenderness and
pseudoparalysis of the limbs; bleeding gums; and sharplyFig. 2 Right femur with subperiosteal hemorrhage

Fig. 4 Coronal, T1-weighted fat-suppressed image after gadolinium
administration shows an ill-defined soft-tissue mass in the left orbit

Pediatr Radiol (2007) 37:937–939

angulated scorbutic rosary. Diagnosis of scurvy is mainly
based on clinical and radiological features with rapid
clinical improvement within 2 days to 1 week of starting
vitamin C therapy [1]. Unusual manifestations include
hematuria, melena, subdural hemorrhage, subarachnoid
hemorrhage and retroorbital hemorrhage causing proptosis.
Extraocular muscle palsy can occur due to intraocular
hemorrhage. Hence, it is not uncommon to find scurvy
being mistaken as a more common disease such as
malignancy or infection [2]. Scurvy manifesting as unilateral proptosis associated with frontal extradural hematoma
is an extremely rare complication [3].

939
Acknowledgement We thank Prof. Arun Gupta, Department of
Radiodiagnosis, for assistance and guidance during the preparation of
this paper.

References
1. Ahuja SR, Karande S (2002) An unusual presentation of scurvy
following head injury. Indian J Med Sci 56:440–442
2. Ratanchu-Ek S, Sukswai P, Jeerathanyasakun Y et al (2003) Scurvy
in pediatric patients: a review of 28 cases. J Med Assoc Thai 86:
S734–740
3. Suman RL, Dabi DR (1998) Scurvy – an unusual cause of
proptosis. Indian Pediatr 35:915–916