Page 23 - Delaware Medical Journal - November/December 2020

CASE REPORT
TABLE 2
LABORATORY INVESTIGATION
LABORATORY VALUE
INSTITUTIONAL REFERENCE RANGE
Tissue Transglutaminase Ab IgA
31.3 U/nl Interpretation: Positive
< 4 U/nl
Tissue Transglutaminase Ab IgG
17.4 U/nl Interpretation: Positive
<6 U/nl
D deficiency. Final confirmation of celiac disease was obtained when she underwent an outpatient colonoscopy. Histopathological biopsy showed duodenal mucosa with moderately increased intraepithelial lymphocytes and moderate villous abnormalities, consistent with diagnosis of celiac disease. (Figures 5 and 6 compare histological findings of normal small intestine mucosa versus what is usually seen with celiac disease.) The patient was started on a gluten-free diet. At six-week follow-up from her surgery, the patient had minimal if any pain in the left hip. X-rays showed acceptable placement of percutaneous pins in
the left hip, with no further signs of fracture or displacement. She had continued to not have any pain in the right sacral area, and x-rays including that area were normal. The incision healed well, without any infections or complications. At that time she was made weight-bearing as tolerated to
the left lower extremity. She was given clearance and instruction on how to slowly resume normal physical activity, including how to begin exercise. She returned three months from surgery with no physical limitations and only minor complaints of discomfort with long periods of activity. During follow-
up via telemedicine at seven months from the surgery, the patient had no further complaint of pain or discomfort and no physical limitations.
DISCUSSION
Celiac disease is an autoimmune condition with a genetic component, where ingestion of gluten results in
damage to the mucosa of the small intestine. Gluten is a protein found in wheat, barley, and rye. The immune- system reaction to the ingestion of gluten causes destruction of villi located in the small intestine; the site where nutrients, including vitamin D and calcium, are absorbed. Therefore, the disease leads to decreased plasma concentration of vitamin D and calcium, as well as other nutrients such as iron.3
Short-term complaints from celiac disease are primarily gastrointestinal. They include bloating and pain, chronic diarrhea, constipation, weight loss and fatigue, irritability, delayed growth, and failure to thrive. Long- term medical complications from celiac disease include iron deficiency anemia,
Figure 4
Post-op X-ray
vitamin and mineral deficiencies (including vitamin D and calcium), central and peripheral nervous system disorders, and neurological manifestations (ataxia, epileptic seizures, dementia, migraines, neuropathy, myopathy, etc).3
In this patient, there were none of
the usual complaints associated with celiac disease. She had no abdominal complaints or discomfort. Her only manifestation of the disease was musculoskeletal in nature. These kinds of manifestations are rare and make up only 0.6% of symptoms.4
Her undiagnosed celiac disease
caused chronic malabsorption of iron and vitamin D. This further led to
iron deficiency, osteomalacia with insufficiency fractures, and secondary hyperparathyroidism. Earlier routine laboratory evaluation, including CBC and vitamin D levels, might have led to earlier diagnosis and treament,
and possibly prevented the cascade of
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