in india , malabsorption syndrome ( mas ) is a fairly common condition . tropical sprue and celiac disease are common causes of mas among indian adults .
we present one interesting case of mas , where the patient predominantly had neurological manifestations .
there was no history of difficulty in standing from sitting position , losing grip over foot wear , difficulty in holding objects , difficulty in combing hair , decreased tactile sensory perception , or hearing loss .
there were complaints of the intermittent abnormal posturing of hands and fingers and feet and toes for the last 10 days .
there was a history of tingling of the perioral area for 10 days before presentation .
her parent 's marriage was consanguineous . in the past , she was diagnosed with graves disease 6 years ago .
about 5 years ago , she was also diagnosed as having abdominal tuberculosis and received anti tuberculosis therapy .
she was evaluated at different institutes for recurrent left thigh spontaneous hematoma for 1 year before the current presentation .
general examination revealed that her height was 153 cm , weight was 34.5 kg , and arm span was 157.5 cm .
the height for age fell between the 3 and 10 percentile on the center for disease control growth charts , whereas her weight for age fell below the 3 percentile - consistent with malnutrition .
she had arachnodactyly , high arched palate , elongated facies , and pes cavus ; features suggestive of marfanoid habitus .
on examination of the fundus , the patient had a pale optic disc , peripapillary crescent , arterial attenuation , and retinal pigment disturbance .
deep tendon reflexes ( biceps , triceps , supinator , knee , and ankle ) were absent .
vibration sense was impaired at the level of toe , ankle , thigh , wrist , and elbow bilaterally .
peripheral smear showed microcytic hypochromic red blood cells ( hemoglobin - 11.2 g / dl , mean corpuscular volume - 70 fl , mean corpuscular hemoglobin - 23 pg ) tear drop cells , acanthocytes , and target cells .
her prothrombin time ( pt ) and activated partial thromboplastin time ( aptt ) was prolonged .
( pt - 21.7 s [ c : 12.2 s ] , aptt - 56 s [ c : 31.9 s ] ) .
the biochemical investigations revealed decreased serum albumin and vitamin d level [ table 1 ] .
list of investigations molecular genetics did not reveal any mutation suggestive of either friedreich 's ataxia .
deoxyribonucleic acid analysis for spinocerebellar ataxia ( type - 13 ) were negative . at this juncture ,
the histopathological examination of the duodenal biopsy showed marked villus changes in the form of shortening and flattening of villi .
there were marked lymphomononuclear cell infiltration in the lamina propria extending into the intestinal epithelium [ figures 1 and 2 ] .
duodenal biopsy showing shortening and flattening of villi ( h and e , 10 ) lymphomononuclear cell infiltration in the lamina propria and in the intestinal epithelium ( h and e , 20 ) later on , immunoglobulin a anti - tissue transglutaminase antibody test was reported as negative .
she received megadose oral vitamin e ( 400 iu bd ) , parenteral vitamin d ( 600,000 iu intramuscular single dose ) , parenteral vitamin k ( 10 mg for 3 days ) , and parenteral vitamin b12 as well as supplements of calcium , iron , and multivitamin capsules ( having vitamin a , zinc , and water soluble b vitamins ) .
she has advised a gluten free diet and received a course of tetracycline for tropical sprue , under the advice of a medical gastroenterologist . with this intensive nutrient replacement followed by maintenance nutrient supplementation
the etiology of mas often differs in tropical areas from that in temperate countries . in the past
, epidemics of tropical malabsorption ( tm ) have been described in the southern indian villages .
this improvement can be attributed to better socioeconomic status , sanitary conditions , and increased use of antibiotics .
the data on the spectrum of mas in indian adults are sparse . in a recent study
, it was observed that tm is the most common cause of mas followed by celiac disease , in india .
it was further observed that celiac disease is more common among younger patients with malabsorption .
malabsorption results from various abnormalities of the small bowel function and may complicate diverse illnesses including celiac disease , crohn 's disease , whipple 's disease , tropical sprue , intestinal diverticulosis , lymphangiectasia , and postgastrectomy states
malabsorption of fat - soluble vitamins such as vitamins a , d , e , and k may lead to various complications that may be prevented if the problem is recognized and managed appropriately .
vitamin e deficiency can occur with abetalipoproteinemia , cholestatic liver disease , or fat malabsorption .
the classic abnormalities in vitamin e deficiency progress from hyporeflexia , ataxia , limitations in upward gaze and strabismus to long - tract defects , profound muscle weakness , and visual field constriction .
this patient 's presenting symptoms were predominantly neurological in nature , which may be due to vitamin e deficiency .
in addition , she had a history of spontaneous hematoma along with prolonged pt , which responded to vitamin k replacement .
she also had features of tetany with documented hypocalcemia , which improved after vitamin d therapy .
we present this rather unusual case highlighting the striking neurological manifestations , which improved after supplementation of vitamins .
 malabsorption syndrome ( mas ) is a common condition in india . in indian adults , tropical sprue and celiac disease 
 are leading causes of mas . 
 sometimes , the diagnosis of mas may pose a challenge due to the varied signs and symptoms . 
 we present a case of mas in a young female , whose presenting symptoms were mainly neurological . 
 she was successfully treated under regular follow - up for the past 6 years without any symptoms . 
Introduction
Case Report
Discussion
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