Malnutrition in a child with T‐cell ALL leading to superior mesenteric artery syndrome and Wernicke's encephalopathy

Editor: T-cell acute lymphoblastic leukemia (ALL) is a clonal malignancy arising from early lymphoid progenitors with T-cell differentiation. 1 Neurological complications are well described and include relapse, treatment-related complications, and infections. 2–4 Other complications not directly related to T-cell ALL may also arise, such as those related to malnutrition. 5 Wernicke’s encephalopathy (WE) is a complication arising from thiamine (vitamin B1) deficiency, characterized by the triad of encephalopathy, oculomotor dysfunction, and gait ataxia. 6 Superior mesenteric artery (SMA) syndrome is characterized by obstruction of the third part of the duodenum (D3) between the aorta and the SMA, 7 and is a well described complication of rapid weight loss. 8,9 We report a 13-year-old female who was diagnosed with T-cell ALL following a 3-week history of fever and weight loss. Her base-line weight was 51.9 kg (70th percentile) 10 and height was 164 cm (88th percentile). 10 She was treated based on Children’s Oncology Group (COG) AALL0434. 11 Her end of induction minimal residual dis-ease (MRD) was positive at 1.7%, with negative MRD following consol-idation chemotherapy. She presented to a satellite hospital on day 10 of interim maintenance therapy, with a 2-day history of vomiting and dehydration. A nasogastric tube was inserted and formula feeding was commenced.However,shecontinuedtohavebiliousvomiting.Shealso developed progressive weakness of her limbs along with tremors, and was referred