Giulio Ferrari, M.D., and Maurizia Viganó, M.D.
May 30, 2013
N Engl J Med 2013; 368:e29

Image from NEJM

A 10-year-old boy with no notable medical history presented with ocular burning. A lesion consisting of a dry, scaly patch with a foamy appearance was observed on the temporal conjunctiva of the left eye (Panel A). Corrected visual acuity was 10/20 in the left eye; the remainder of the ocular examination was normal. Bitot’s spot is highly suggestive of vitamin A deficiency and, sometimes, chronic conjunctival inflammation. The condition is characterized by metaplasia of the conjunctival epithelium and tangles of keratin admixed with gas-forming bacteria (e.g., Corynebacterium xerosis), giving the lesion its typical foamy appearance. The serum level of vitamin A in this patient was extremely low, at <2 μg per deciliter (0.07 μmol per liter; normal range, 30 to 70 μg per deciliter [1 to 2 μmol per liter]); he was given vitamin A supplementation. Vitamin A deficiency affects approximately 140 million children worldwide, making it the second most prevalent nutritional disorder after caloric malnutrition; in developed countries, it can be associated with fat malabsorption. At follow-up approximately 12 months after diagnosis, slit-lamp examination revealed complete healing of the lesion (Panel B), and symptoms were substantially improved. Giulio Ferrari, M.D. Maurizia Viganó, M.D. San Raffaele Scientific Institute, Milan, Italy ferrari.giulio@hsr.it Story Source