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Two-Year-Old With a Limp and Suspected Nonaccidental Injury

Manyapu, Mallika*; Warraich, Gohar J.; Kugathasan, Subra; Syed, Sana§

Journal of Pediatric Gastroenterology and Nutrition: July 2018 - Volume 67 - Issue 1 - p e11
doi: 10.1097/MPG.0000000000001161
Image of the Month

*Emory University School of Medicine, Atlanta, GA

Aga Khan University, Karachi, Pakistan

Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Atlanta, GA

§Center for Nutrition at Boston Children's Hospital, Harvard Medical School, MA.

Address correspondence and reprint requests to Subra Kugathasan, MD, Division of Pediatric Gastroenterology, Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive, Room 248, Atlanta, GA 30322 (e-mail:

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

The authors report no conflicts of interest.

A 2-year-old boy of Vietnamese origin with total intestinal aganglionosis and complete parenteral nutrition (PN) dependence presented with 2 weeks of leg pain, limping, and lightening of hair color from black to almost “dirty blond.” Physical examination was notable for severe leg tenderness. Nonaccidental trauma, which can mimic bone fragility, was ruled out (1–4). Skeletal survey showed periosteal reaction involving bilateral humerus, radii, and left femur along with distal right tibia and femur fractures (Figs. 1 and 2). Laboratory investigations were significant for mild anemia (Hb 11.3 g/dL, MCV 107 FL, MCHC 32.9%) and copper deficiency (serum copper 31 μg/dL [normal 75–153 μg/dL], serum ceruloplasmin 31 mg/dL [normal 18–37 mg/dL]). His PN was manufactured by an established home-care company with standard PN micronutrients (5). It was discovered that owing to a national shortage, there had been no copper in this patient's PN since 3 months before presentation. Subsequently, copper was added back to his PN at the recommended enteral dosage of 60 mcg · kg−1 · day−1 for 4 weeks (6). At his 6-month follow-up, the patient's serum copper level had normalized, skeletal pain had resolved and hair color had reverted back to its original black. The patient's serum copper levels remain normal on follow-up with standard 20 mcg/kg of copper in his daily PN.





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