Review Question - QID 108733

This patient is presenting with nausea, vomiting, headache, blurry vision, diarrhea, and pruritus in the setting of eccentric supplement use suggestive of vitamin A toxicity.

This patient presents with new onset headache, blurry vision, nausea, and vomiting in the setting of starting "an array of supplements and herbal preparations" which should raise concern for vitamin A toxicity. Vitamin A toxicity is rare but can occur in individuals who use supplements or practice eccentric dietary habits. The case also mentions diarrhea as well as diffuse pruritus which further suggests the diagnosis of vitamin A toxicity over other causes. Though this patient presents with other possible causes of her symptoms, there is specific information in the history that rules out each of these diagnoses.

Incorrect Answers:
Answer 1: Head trauma suggests a diagnosis of concussion. Though this patient does present with head trauma during cheerleading practice, the symptoms preceded this episode. In addition, the patient denies any mental slowing or trouble participating in school, other than when her current symptoms are poorly managed. Given the chronology of this presentation and the history of dietary habits, concussion is a less likely diagnosis.

Answer 3: Idiopathic intracranial hypertension (pseudotumor cerebri) typically occurs in overweight young women and can present with the symptoms mentioned in the above case (nausea, vomiting, and dizziness) and can also present with cranial nerve VI palsy. This patient has a low BMI and has a history that would suggest vitamin A toxicity to be the most likely cause.

Answer 4: Migraine headache with aura presents with unilateral throbbing or pulsating head pain. It is more common in women and can be triggered by many stimuli (caffeine, stress, noise, etc.). Visual aura can occur and may be described as the patient experiencing waves or blind spots in their vision.

Answer 5: Bulimia nervosa is possible given this patient's history of excessive exercise, vomiting, and dizziness (reflecting dehydration and electrolyte abnormalities). However, there are no other symptoms that point toward this diagnosis (parotitis and cuts on the dorsum of the hand) and the history of supplement use points more toward vitamin A toxicity.

Bullet Summary:
Vitamin A toxicity occurs in patients with eccentric dietary habits and supplement use and presents with symptoms of nausea, vomiting, headache and blurry vision.