P23 Scurvy presenting as an unusual petechial rash in a patient with anorexia nervosa.

Abstract

An 18-year-old girl with extreme anorexia nervosa (BMI 13 kg/m2, 37.9 kilograms) was admitted for nutritional stabilisation. She reported a two-week history of abdominal pain, reduced urine output and a widespread rash on her abdomen, arms and legs. She appeared cachectic, drowsy, dehydrated and unwell. She was empirically started on intravenous piperacillin-tazobactam for suspected intra-abdominal sepsis. She had cutaneous signs of anorexia nervosa including pale skin with lanugo hair and xerosis, angular stomatitis, dry, listless, thin hair and calluses over the knuckles from self-induced vomiting (Russell sign). A non-blanching petechial and purpuric rash covered the peri-umbilical area, forearms and shins. Corkscrew hairs and perifollicular haemorrhages were visible on her shins. Laboratory tests including clotting were normal apart from mild renal impairment and severe hypophosphataemia. Ultrasound scan of the urinary tract, non-contrast full body CT scan, throat swab, peripheral blood and urine cultures were unremarkable. A 5 mm punch biopsy from the rash on the abdomen showed extensive fresh, pan-dermal interstitial haemorrhage in keeping with purpura, with no evidence of vasculopathy or active inflammation. This led to a diagnosis of scurvy secondary to anorexia nervosa. She received nasogastric feeding and IV phosphate replacement for refeeding syndrome. Treatment with IV Pabrinex, which contains 500 milligrams of Vitamin C in each No. 2 ampoule, achieved a dramatic resolution of the rash within a week. Our case of atypical scurvy presenting without the classical gingival signs highlights the importance of clinical examination and dietary history in malnourished, unwell patients presenting with a petechial rash.