Diagnosis: Scurvy (Vitamin C Deficiency)
This 2-year-old female presenting with gum bleeding, nasal ulcerative patches, and preceding fever is most consistent with scurvy (vitamin C deficiency), requiring immediate oral vitamin C supplementation.
Clinical Assessment
The constellation of findings strongly suggests scurvy:
- Mucosal bleeding (gingival hemorrhage) is a classic early manifestation of vitamin C deficiency 1, 2
- Nasal patches that ulcerated represent perifollicular purpura and mucocutaneous bleeding characteristic of impaired collagen synthesis 1, 2
- Preceding fever may indicate concurrent infection or systemic inflammation often seen with scurvy 2
- The 2-week timeline aligns with progressive vitamin C depletion affecting connective tissue integrity 1
While scurvy is rare in developed countries, it remains underrecognized in at-risk populations including children with restricted diets, low socioeconomic status, or behavioral feeding issues 2, 3.
Differential Considerations
Rule out other causes requiring biopsy if lesions persist >2 weeks despite treatment:
- Systemic vasculitis (Wegener granulomatosis) - typically presents with nasal ulceration before systemic symptoms 4
- Infectious causes (tuberculosis, deep fungal infections) - endemic considerations 4
- Hematologic disorders - though platelet count and coagulation studies would be abnormal 2
- Malignancy - less likely given age and bilateral presentation 4
However, given the clinical picture with mucocutaneous bleeding, gingival involvement, and nasal lesions, scurvy is the most likely diagnosis and should be treated empirically without waiting for laboratory confirmation 2, 5.
Treatment Plan
Immediate Management
Vitamin C (Ascorbic Acid) 100-300 mg orally once daily for 1-3 months 2, 5
- For a 2-year-old: Start with 100 mg once daily
- Dispense: 30 tablets (100 mg each) for 1 month initial treatment
- Expected improvement within 1-2 weeks with complete resolution of skin lesions and bleeding 2, 5
- Continue for minimum 1 month, then reassess 3
Cost consideration: Vitamin C 100 mg tablets are typically <50 pesos for 30 tablets, well within the 300 peso budget.
Supportive Care
- Ensure adequate dietary vitamin C intake (citrus fruits, vegetables) - one medium orange provides ~60 mg daily requirement 2
- Monitor for clinical improvement (cessation of bleeding, healing of nasal lesions, improved mobility)
- Do not discontinue treatment prematurely - relapse symptoms can occur if stopped too early 3
Critical Pitfalls to Avoid
- Never assume benign etiology without treatment trial - untreated scurvy progresses to severe complications including subperiosteal hemorrhage and joint contractures 1, 2
- Do not delay vitamin C supplementation while awaiting laboratory confirmation - clinical diagnosis is sufficient and rapid improvement confirms diagnosis 2, 5
- Inadequate treatment duration - continue for at least 1 month even after symptom resolution to replenish body stores 3
- If no improvement within 2 weeks or worsening, perform tissue biopsy to exclude malignancy, vasculitis, or infection 4
Follow-up Recommendations
- Reassess in 1-2 weeks - expect cessation of bleeding and healing of nasal lesions
- Continue vitamin C for minimum 1 month total duration
- If symptoms recur after stopping treatment, restart supplementation 3
- Evaluate dietary intake and address any nutritional restrictions
Medical Certificate
DIAGNOSIS: Scurvy (Vitamin C Deficiency) with mucosal bleeding and nasal ulceration
RECOMMENDATION:
- Vitamin C 100 mg orally once daily for 1 month
- Ensure adequate dietary vitamin C intake
- Follow-up in 1-2 weeks for reassessment
- May return to school/daycare once bleeding has stopped (typically within 1-2 weeks of treatment)
- Fit to return to school once gingival bleeding resolves (expected within 7-14 days)
DISPENSED: Vitamin C 100 mg tablets #30 (one month supply)