case_images: PMC4327555_01
case_images: Phrynoderma before treatment (a) and subtle follicular scarring after treatment (b).
case_images: cop-0006-0024-g01.jpg
case_images: PMC4327555_01_cop-0006-0024-g01.jpg
case_images: F1
case_images: 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).
case_images: Bitot's spots on the temporal conjunctiva (patient 1).
case_images: cop-0006-0024-g02.jpg
case_images: PMC4327555_01_cop-0006-0024-g02.jpg
case_images: F2
case_images: 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).
case_images: Scotopic ERG pre- and post-vitamin A replacement therapy.
case_images: cop-0006-0024-g03.jpg
case_images: PMC4327555_01_cop-0006-0024-g03.jpg
case_images: F3
case_images: 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).
case_images: PMC4327555_02
case_images: Normal conjunctival epithelium (a) and conjunctival epithelium of patient 2 (b) with squamous metaplasia and keratinization of conjunctival epithelium.
case_images: cop-0006-0024-g04.jpg
case_images: PMC4327555_02_cop-0006-0024-g04.jpg
case_images: F4
case_images: A conjunctival biopsy was diffusely abnormal, with squamous metaplasia of the conjunctival epithelium, submucosal inflammation and marked keratinization (fig. 4).