A 15-Year-Old Girl With Steatorrhea Who Can’t See at Night

Jaime Shalkow, MD; Mayela E. García

Disclosures

November 13, 2019

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 15-year-old, pale-appearing patient presents with an inability to digest food properly. Her symptoms started 3 months ago, with intermittent abdominal cramps. She then noticed bloating, flatulence, and greasy stools that were floating on the toilet water and were difficult to flush. Despite an adequate diet, she feels tired and looks pale. High fat ingestion worsens the amount of bulky malodorous stools, with oily droplets. She states having lost night vision acuity over the last 6 weeks.

Her medical history is significant for acute lymphoblastic leukemia (ALL) at age 6 years. During her second round of induction chemotherapy that included L-asparaginase and steroids, she became exceedingly sick and was transferred to the intensive care unit (ICU). She developed sudden-onset severe epigastric pain, radiating to her back, with nausea, vomiting, and abdominal distension. At some point, she had a bruise around her umbilicus. She developed a low blood pressure and became lethargic. She overcame that episode after several days in the ICU with antibiotics, gastric decompression, transfusions, and parenteral nutrition.

She eventually entered remission and was cured of her leukemia after 52 cycles of treatment. She has been in regular follow-up for the last 9 years.

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