PMC4327555_01
Phrynoderma before treatment (a) and subtle follicular scarring after treatment (b).
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F1
The child was noted to have an increased BMI, and a follicular, erythematous rash was present, affecting predominantly the extensor surface of the upper limbs (fig. 1a). One month later, the phrynoderma had resolved, leaving pale, follicular scarring (fig. 1b).
Bitot's spots on the temporal conjunctiva (patient 1).
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F2
Two days after admission, the patient was seen by the ophthalmology team and was found to have a left relative afferent pupillary defect, bilaterally swollen optic discs and a featureless, dry conjunctiva with Bitot's spots (fig. 2).
Scotopic ERG pre- and post-vitamin A replacement therapy.
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F3
A level was undetectable (<0.1 ng/ml), the vitamin B12 level was borderline (150 pg/ml), and the vitamin D level was found to be insufficient (32 ng/ml). An electroretinogram (ERG) showed a marked attenuation of A and B waves in rod-isolated sequences (fig. 3), even though the patient did not describe nyctalopia and the parents denied observing any behavior suggestive of night blindness. A diagnosis of hypovitaminosis A was made with the presence of xerophthalmia, retinopathy and phrynoderma, a characteristic rash (fig. 3).
PMC4327555_02
Normal conjunctival epithelium (a) and conjunctival epithelium of patient 2 (b) with squamous metaplasia and keratinization of conjunctival epithelium.
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F4
A conjunctival biopsy was diffusely abnormal, with squamous metaplasia of the conjunctival epithelium, submucosal inflammation and marked keratinization (fig. 4).