Undiagnosed Metachromatic Leukodystrophy Presenting as Severe Gastrointestinal Bleeding and Cholestasis from Hemobilia.

• Authors: Paul Parker, Emory University; Nitika Gupta, Emory University; Rene Romero, Emory University; Anne Gill, Emory University; Bess Schoen, Emory University; JP Stevens, From the Division of Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Atlanta, GA.; J Dakshinamoorthy, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.; D Geem, From the Division of Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Atlanta, GA.; J-P Berauer, From the Division of Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Atlanta, GA.
• Journal Title: JPGN Rep
• Volume: Volume 2, Number 4
• Publisher: (publisher) | 2021-11, Pages e122-e122
• Type of Work: Article
• Publisher DOI: http://doi.org/10.1097/PG9.0000000000000122
• Keywords: gallbladder polyposis; hemobilia; metachromatic leukodystrophy; upper gastrointestinal bleeding

Abstract

Metachromatic leukodystrophy (MLD) is a neurodegenerative disorder caused by the accumulation of lipids called sulfatides throughout the nervous system. Sulfatides can also collect in other organs throughout the body including the gallbladder where they form polyps. Gallbladder polyps rarely have been found to bleed in patients with known MLD, presumably due to polyp shearing. Here we present a case of a child with autism presenting with severe gastrointestinal bleeding and direct hyperbilirubinemia, requiring significant resuscitation and biliary drain placement to tamponade ongoing bleeding. Subsequent neurologic and genetic investigation led to the diagnosis of MLD, with laparoscopic cholecystectomy revealing extensive, elongated gallbladder polyps. Clinicians who care for patients with MLD, including gastroenterologists who manage their progressive oropharyngeal dysphagia, should be aware of the risk for this life-threatening complication. Moreover, pediatric gastroenterologists and hepatologists should maintain a high index of suspicion for MLD in new patients presenting with developmental regression and gastrointestinal bleeding.