So far, little attention has been paid to the increase in acute phase reactants (APRs) in patients with scurvy. We report that elevated levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and serum amyloid A were shown in a pediatric patient with scurvy despite the absence of inflammation. These peculiar findings are important to discriminate scurvy from other rheumatic diseases.
An increase in acute phase reactants (APRs) has not been observed in patients with scurvy. In fact, there are few cases of scurvy with descriptive comments on APRs . Pediatric rheumatologists usually measure APRs to evaluate the level of inflammation in patients with leg pain or a limp. Because patients with scurvy complain of leg pain or a limp, it is necessary to discriminate it from other rheumatological diseases. Thus, we aim to discuss why elevated APRs, including C-reactive protein (CRP), in scurvy is an important clinical problem.
A 4-year-old male with autism was referred to our hospital because of severe leg pain and gingival bleeding. His laboratory results showed a CRP level of 2.21 mg/dL (reference range <0.05 mg/dL), a serum amyloid A protein level of 544 μg/ml (reference range <8 μg/ml), and an erythrocyte sedimentation rate (ESR) of 94 mm/hour (reference range 5-15 mm/hour). His leg pain did not subside with acetaminophen. His physical symptoms and APRs improved quickly on the administration of vitamin C after a diagnosis of scurvy.
Although several reports have described the levels of elevated CRP, ESR, and serum amyloid A, they have not garnered enough attention (Table 1) [1-7]. The peculiar findings could be misleading as an inflammatory reaction. But, an increase in acute phase reactants (APRs) in scurvy should be recognized as a common phenomenon.
It is difficult to interpret elevations in APRs that are caused by local bone lesions in scurvy, which, by radiology, are reflected by increases in zones of provisional calcification in the margins of the growth plate. Conversely, CRP does not increase in vitamin D deficiency rickets, which appears in radiological findings as a failure of mineralization in such zones. The levels of APRs fall after the administration of vitamin C, but anti-inflammatory drugs do not have the same effect. Therefore, it is difficult to conclude that inflammation due to scurvy induces a rise in APRs.
It is well-known that plasma vitamin C is inversely related to CRP . Both, the low levels of serum vitamin C and the levels of elevated CRP, may participate in atherothrombosis and ischemic heart disease. However, the levels of CRP in scurvy are higher than those in atherosclerosis. Only CRP, apart from the other APRs, increases in atherosclerosis. The source of CRP in scurvy might be different from the vascular endothelial site in atherosclerosis. Vitamin C deficient rats without inflammatory stimuli experience an increase in APRs, which are produced in the liver [9-10]. Although the mechanism by which APRs are elevated in scurvy remains unknown, these rats can provide vital clues for elucidating it.
We believe that a deficiency of serum vitamin C itself can generate APRs, to resemble an aspect of inflammatory biomarkers. The specific findings are important to discriminate scurvy from any other rheumatic diseases with an inflammatory reaction.
We conclude that the depletion of vitamin C (i.e., scurvy) leads to the production of APRs in the liver, the laboratory results for which resemble acute inflammation despite a lack of inflammation.
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Increases in Acute Phase Reactants in a Patient with Scurvy Despite No Inflammation: Review of Literature
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Cite this article as:
Kimura K, Inamo Y (September 09, 2019) Increases in Acute Phase Reactants in a Patient with Scurvy Despite No Inflammation: Review of Literature. Cureus 11(9): e5608. doi:10.7759/cureus.5608
Received by Cureus: January 25, 2019
Peer review began: January 29, 2019
Peer review concluded: September 03, 2019
Published: September 09, 2019
© Copyright 2019
Kimura et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.