Case contributed by Micheál Anthony Breen


One-month history of limp and progressive refusal to bear weight. On physical examination, he was found to have a petechial rash and gingival bleeding.

Patient Data

Age: 3 years
Gender: Male

There are metaphyseal abnormalities in the distal femur and the proximal and distal tibia characterized by sub-physeal horizontally oriented foci of lucency with inteveneing parallel bands of sclerosis. Although the overall mineralization appears within normal limits, there does appear to be periarticular demineralization.

MR of both lower extremities without and with contrast


There is bilateral diffuse abnormal marrow signal throughout the femoral and tibial metaphyses which is characterized by T2 hyperintensity and T1 hypointensity. Of note, these areas also demonstrate abnormal enhancement on the postcontrast images. There is no evidence of cortical disruption. However, abnormal signal and enhancement does extend along the sub-periosteum. Additional areas of abnormal soft tissue edema and post contrast enhancement surrounding the metaphyses are most notable surrounding the knees and ankles. Abnormal soft tissue signal involves the vastus medialis muscles bilaterally, and to a lesser extent the vastus lateralis and the short head of the biceps femoris muscle bilaterally. 

Case Discussion

The differential diagnosis for this appearance includes hematologic malignancies such as leukemia and nutritional disorders. Chronic recurrent multifocal osteomyelitis (CRMO) is considered less likely given the symmetry. Withheld history, in this case, is that this 3-year-old boy had a history of autism, sensory processing disorder and poor dietary intake consisting mainly of crackers, yoghurt and water. Blood tests showed no evidence of leukemia however his ascorbic acid (Vitamin C) level was undetectable. A presumptive diagnosis of scurvy was made and the patient was treated with 1g ascorbic acid for 2 days followed by 100mg ascorbic acid three times a day. Iron, vitamin D and other nutritional supplementation was also commenced. The patient made a rapid symptomatic improvement and no further imaging was obtained.

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