Case Report on Celiac Disease

Case Report on Celiac Disease

Sonali J Deore1, Dr Amirtha Tom*2, Nikita D Ugale1, Avanti H jadhav1

1 PharmD, Dr D Y Patil Institute of pharmaceutical science and research

2 PharmD, Msc Research ethics, Assistant professor, Dr D Y Patil Institute of pharmaceutical science and research

 

*Correspondence to: Dr Amirtha Tom, Assistant professor, Dr D Y Patil Institute of pharmaceutical science and research email: dramirthatom.in@gmail.com.

 

Copyright

© 2023 Dr Amirtha Tom. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 26 September 2023

Published: 05 October 2023

 

Abstract

Celiac disease is a prevalent autoimmune condition that affects gluten-sensitive people. We provide a case study of a 25-year-old female who reported with bloating, itching, weight loss, and exhaustion.  The patient began with antihistamine and anti-leukotriene medications. The patient was discovered to have gallbladder stones and underwent cholecystectomy; celiac disease was first misdiagnosed, and the woman lost her gallbladder.  The patient was put on a gluten-free diet, which resulted in a dramatic improvement in her symptoms as well as normalization of her test values. This case report emphasises the need of examining celiac disease in the differential diagnosis of persons experiencing weight loss and exhaustion.

Key Words: Celiac Disease, Diagnosis, Gluten free diet, bloating, antihistamine, gall bladder stone.


Case Report on Celiac Disease

Introduction

Celiac disease is an autoimmune disorder that affects the small intestine in response to the consumption of gluten -containing foods. Celiac disease is triggered by gluten, a protein found in wheat barley, and rye. When a person with celiac disease consume glutent, their immune system mistakenly attacks the lining of the small intestine. Damaged villi make it nearly impossible for the body to absorb nutrients leading to malnourishment and a host of other issues. (1)

 

CD is commom, affecting at least 1% of the population .upwards of 83% of people with CD are undiagnosed .The genes known to be associated with CD are HLA-DQ2 and HLA-DQ8. When a first degree family has CD, the probability of developing it increases significantly.CD can develop at any age .CD affects individuals of all ethnicities (2) CD is a unique autoimmune disease in that its key genetic elements (human leukocytes antigen HLA-DQ2 and HLA-DQ),the auto antigen involved (tissue transglutaminase(tTG) and the environmental trigger (gluten) are all well defined .(3) The syspmtoms of celiac disease can range from mild to severe . They can change over time ,and they vary from person toperson .Somepeople  have no symptoms or only experience them later in life.A persom may not know that they have celiac disease until they develop a nutrient deficiency or anemia.(4)

 

Symptoms of celiac disease that are digestive can include weight loss fatigue ,depression or anxiety,joint pain ,mouth sores,a rash called dermatitis, herpetiformis nerve damage in the extremities called  peripheral neuropathy which can cause tingling in the leg and feet (4) Diagnosis is supported by a positive tissue transglutaminase serologic test but ,in generL,should be confirme by a small bowel biopsy showing the characteristic histology associated with celiac disease.The presence of humal leukocyte antigen alleles DQ2 ,D8 or brothis essential for the development of celiac disease and can be useful  genetic test in select instances.(5).Intestinal cholecystokinin secretion and gall bladder emptying in response to a fatty meal are impaired before celiac patient start the glutent free diet (GFD) (11)

 

Approach  to  the Diagnosis of the Celiac  Disease:

Patient suspected celiac disease,then go for

A) IgA deficiency test if test comes negativethen patient can be or can not be suspecious for celiac disease,if not suspicious then celiac disease unlikely consider other diagnosis.If yes and/or IgA deficiency test is positive then refer for small bowel biopsy.

B)  IgA tTG posotive and total IgA normal then  refer for small bowel biopsy.

C)  IgA tTG and total IgA normal,patient is suspicious forceliac disease ,if  suspicios then refer for small bowel biopsy,if no t suspicious then celiac disease unlikely consider other diagnosis.

Once a diagnosis has been confirmed through a biopsy to be celiac disease, the patient is instructed to begin following the gluten-free diet. This can often be difficult at first because so many foods contain gluten. However, through support and guidance from experienced celiac patients and a skilled dietitian, many newly diagnosed patients learn that the gluten-free diet requires some creativity and planning, but that great-tasting food isn’t out of reach.(11)

 

Case:

A 25-year old female presented with a history of abdominal pain ,bloating and intermittent diarrhea for several months.She also reported a chronic rah that appearedafter consuming certain foods .The patient had cholecystectomy (removal of gall bladder ) performed due to episodes of cholecystitis.

On physical examination, the patient appeared pale and thin with a body mass index (BMI) of 19.2.She had rash on elbows knees and buttocks, scalp and face that appeared to be urticarial in nature .The abdomen was soft .non -tender, and non -distended.

Laboratory investigation s showed anemia with hemoglobin level of 10.8g/dl and a mean corpuscular volume (MCV) OF 74FT .Liver function test showed slight increase in D.bilurubin .The total serum IgE level was within normal limits.

Based on the patient’s symptoms and finding a diagnosis of celiac disease was suspected abdominal USG report showed absence of gall bladder (cholecystectomy) and excessive bowel gases noted all over abdomen .The patient complain for back pain and epigastruc pain and patient labeled as uriticaria.

The patient was started on gluten free diet and advised to maintain food diary to avaoid other food that triggered her rash.She was also started on antihistamine and lekotrines  receptors and anti allergy lotion to apply.The patient was adducted about the importance of strict adherence to the glutent free diet to prevent long term complications of celiac disease.The patient’s symptoms improves significantly within weeks of starting the gluten free diet. The patient’s rash also improved and she reported no further episodes of abdominal pain or diarrhea.

 

 

 

TABLE 1

SR. NO FOLLOW UP DRUG NAME FREQUENCY DURATION

1

1

TAB. BILASTINE 20mg

TAB. LEVOCET

ALL SUTH LOTION

(change all the capital lette

1-0-1

0-0-1

LOCAL APPLICATION

21 DAYS

2.

2.

TAB BILASTINE 20mg

TAB. ALBENDAZOLE

ATARAX LOTION

 

1-0-1

STAT

LOCAL APPLICATION

21 DAYS

3

3.

TAB.BILASTINE 20 Mg

TAB.MONTELUKAST 10mg

TAB.THYRONORM 25mg

ATARAX LOTION

2TAB-0-02TAB

0-0-1

1-0-0

LOCAL APPLICATION

21DAYS

4

4

TAB.BILASTINE 20 Mg

ADV:TO MAINTAIN FOOD DIARY

2TAB-0-2TAB

21DAYS

5

5

TAB.BILASTINE 20mg

TAB MONTELUKAST 10mg

ATARAX LOTION

1TAB-0-2TAB

0-0-1

21 DAYS

6

6

TAB.MONTELUKAST 10mg

0-0-1TAB

21DAYS

7

7

TAB BILASTINE 10mg

CALAMINE LOTION

0-0-1TAB

21DAYS

8

8

Tab. Levocetrizine 5mg

Tab.Montelukast 10mg

Tab.Bilastine 20mg

Kivical Lotionon

0-0-1tab

0-0-1tab

Sos

Sos

21 Days

9

9

TAB .BILASTINE 20 Mg

TAB.LEVOCET 5mg

CALAMINE LOTION

1TAB-0-0

0-0-1TAB

LOCAL APPLICATION

21DAYS

10

10

TAB BILASTINE 20mg

0-0-1TAB

0-0-1 TAB

30 DAYS

ALTERNATE NIGHT FOR 30DAYS

11

11

TAB.BILASTINE 20mg

0-0-1TAB

ALTERNATE NIGHT FOR ONE MONTH

 

Disscussion
Gluten intolerance disease is an autoimmune disorder in which gluten (a protein found in wheat, barley ,and rye) cause an immune response that damages the small intestine lining. This can result in symptoms like abdominal; pain, diarrhea.and weight loss ,as well as long term complications like malnutrition and an increase risk of certain cancers. This case presents celiac disease but initially which was diagnosed as a urtiucaria,which is seen in few cases. Patients with chronic urticaria have a greater incidence of antithyroid antibodies than the general population, according to research done in 1983 by Leznoff et al. (12). This finding offered the first concrete proof that people who suffer from chronic urticaria might also have an autoimmune condition. This theory is further strengthened by the finding that people with chronic urticaria also have a greater frequency of CD, another immunological illness. As patient as anemic with low HB.

 

Anemia affects people with CD often, with an incidence of between 5% and 60% .The more prevalent type of anemia in CD patients is iron -deficiency anemia, which can be brought on by a number of different processes. The patient with unexplained anemia should be evaluated for CD (13).Other lab reports like stool examination ,urine examination was normal. Patient presented with chief complains of itching on body and scalp ,treatment started with antihistaminic tab bilastine 20 mg bd,Tab levocetrizine 5 mg od and allsuth lotion for LA .Patient came forseconf follow up after 21 days and continued with lab bilastine and atarax lotion for LA abd Albendazole 400 mg stat dose was given .Albendazole is an anti-plastic medication and is not a recognised treatment for celiac disease.on 3rd follow up lab reports showed increase in TSH ,so patient started with Tab. Thyronorm 25 mg od before breakfast and Tab. Bilastine dose increased for 21 days.On 4th  follow up patient was stable on Tab Bilastine 20 mg so continued only with Tab.Bilastine and ask patient to maintain food diary .On 5th follow up patient came with complains itching so Tab.Bilastine morning od dose step down to 1tab and added montelukast 10 mg and atarax lotion for local application .On 6th follow up Tab.montelukast od only continued and discontinued with other treatment for 21 days.On 7th follow up patient shifted to  Tab bilastine 1 tab od and calamine lotion,for 21 days and discontinued montelukast .On 8th  follow up patient continued with Tab .Levocetrizine 5 mg od ,Tab montelukatst 10 mg od and tab bilastine on soso and kivical sos for 21 days.On 9th follow up patient is comlplaining chest pain and back pain on deep breathing .Two symptoms of celiac disease that are less frequently detected are chest pain and backpain.A case of 62 -years old man with celiac disease who presented with excriciating back pain and chest pain was recently detailed in a research that was published in the Journal  of Medical Case Reports .The patient’s symptoms significantly subside after 4 month gluten free diet .The study stresses the significance of taking celiac disease into account as a potential cause of these symptoms in patients who do not respond to conventional therapy and claims that back pain and chest discomfort may be under recognized sign of celiac disease.Patient may experience success with gluten free diet as a kind of treatment.(14) .On 10th follow up patient continued with Tab bilastine 20 mg od dose for 21days and after that patient shifted to alternate od dose at night for 30 days .On 11 th follow up patient continued with alternate od dose at night for 30 days . There are no episodes of urticaria since 4-5 months, and patient is symptom free with gluten diet.

 

Conclusion:

Celiac disease can present with a wide range of symptoms ,including urticaria,anemia,and gastrointestinal symptoms .In this case, the patient was initially misdiagnosed with urticaria and had her gall bladder removed.however, careful evaluation and serological testing led to correct diagnosed of celiac disease, and the patient’s symptoms improve signifucantly with glutent -free diet .Early diagnosis and treatment of celiac disease can prevent long term complications and improve the patient’s quality of life .

 

References

1.Celiac Disease: Symptoms, Testing, Treatment & Research [Internet]. Beyond Celiac. Available from: https://www.beyondceliac.org/celiac-disease/?gclid=Cj0KCQiAi8KfBhCuARIsADp-A57de719P4QkkYy1ZdinwpjD5q5Tip2ZMonwuXK4VaNPohgpm_BI1ZkaAoNbEALw_wcB

2.What is celiac disease? [Internet]. National Celiac Association. [cited 2023 Apr 12]. Available from: https://nationalceliac.org/resources/what-is-celiac-disease-2/?gclid=Cj0KCQiAi8KfBhCuARIsADp-A566b8p85PwAjoyBt81zGbB4XuBxe_cGdICe2EsNMRmODg03BIpPnCoaAvILEALw

3. Caio G, Volta U, Sapone A, Leffler DA, De Giorgio R, Catassi C, Fasano A. Celiac disease: a comprehensive current review. BMC medicine. 2019 Dec;17:1-20.

4.Celiac disease: Symptoms, diagnosis, diet, and treatment [Internet]. www.medicalnewstoday.com. Available from: https://www.medicalnewstoday.com/articles/38085#symptoms

5. Tariq A. 6. Cøliaki og Dermatitis herpetiformis. Orale ulcerasjoner: En oversikt over de mest aktuelle ulcerasjoner i.:38.

6. National Institutes of Health. NIH Consensus Development Conference on Celiac Disease,‘‘National Institutes of Health Consensus Development Conference Statement,’’NIH, Bethesda, MD.

7. Kagnoff MF. AGA institute medical position statement on the diagnosis and management of celiac disease. Gastroenterology. 2006 Dec 1;131(6):1977-80.

8. Rostom A, Murray JA, Kagnoff MF. American Gastroenterological Association (AGA) Institute technical review on the diagnosis and management of celiac disease. Gastroenterology. 2006 Dec 1;131(6):1981-2002.

9. Leffler DA, Schuppan D. Update on serologic testing in celiac disease. Official journal of the American College of Gastroenterology| ACG. 2010 Dec 1;105(12):2520-4.

10. Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA. ACG clinical guidelines: diagnosis and management of celiac disease. Official journal of the American College of Gastroenterology| ACG. 2013 May 1;108(5):656-76.

11.Treatment of celiac disease | University of Chicago Celiac Disease Center [Internet]. Cureceliacdisease.org. 2020. Available from: https://www.cureceliacdisease.org/treatment/

12. Leznoff A, Josse RG, Denburg J, Dolovich J. Association of chronic urticaria and angioedema with thyroid autoimmunity. Arch Dermatol. 1983;119:636–40.

13. Rampertab SD, Pooran N, Brar P, Singh P, Green PH. Trends in the presentation of celiac disease. The American journal of medicine. 2006 Apr 1;119(4):355-e9.
14. Jayatilaka S, Bala A, Kamath M. Back pain and chest pain in celiac disease: a case report. J Med Case Rep. 2020;14(1):37. doi:10.1186/s13256-020-02369
                                                                                                            

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