A Case of Celiac Crisis in an Elderly Male

Abstract

Celiac disease (CD) has many faces and can present in many ways. Celiac crisis is one such rare manifestation of the disease. Celiac crisis is characterized by watery diarrhea and life-threatening electrolyte abnormalities requiring hospitalization. We present a case of the diagnostic dilemma in an elderly male, who presented with anemia and was diagnosed with celiac disease only after developing so-called celiac crisis. A 76-year-old male with a history of alcoholism, chronic pancreatitis and rheumatoid arthritis was admitted to our hospital with anorexia and significant weight loss. Initial work-up revealed marked microcytic anemia with a hemoglobin of 6g/dl. History did not suggest gastrointestinal bleeding, however patient reported lifetime constipation. Other laboratory work-up showed a low iron level, ferritin >2000, and an elevated ESR and CRP. A subsequent upper endoscopy and colonoscopy was unremarkable with no identifiable bleeding source. There were no mucosal changes noted and no biopsies were performed. The patient underwent extensive testing in the hospital looking for the etiology of the anemia and weight loss. At the end of two weeks, he developed profuse watery diarrhea with severe electrolyte derangements. Infectious work-up including a stool Clostridium difficile toxin was negative. Stool studies were consistent with secretory diarrhea. Patient underwent repeat upper endoscopy and colonoscopy, which showed cobblestoning of duodenal mucosa and mucosal edema throughout the colon. TTG of the serum was positive for celiac disease. Histopathology of the biopsy showed villous blunting of the duodenum consistent with celiac disease. The patient received parenteral fluid and nutrition replacement and his diarrhea resolved with a gluten free diet. CD is known for its atypical presentations and it still remains under-diagnosed. Celiac crisis is a rare life-threatening syndrome where celiac disease causes acute diarrhea and severe metabolic derangements. General immune stimuli such as infection, surgery or pregnancy have been known to precipitate celiac crisis. It is unknown why a small subset of patients with CD develops celiac crisis.2581_A Figure 1. Normal appearing duodenal mucosa on Endoscopy #12581_B Figure 2. Cobblestoning apperance of Duodenal mucosa on endoscopy #2, 2 weeks later.2581_C Figure 3. Histopathology of Duodenal Biopsy showing Villous blunting and lymphocytesOur case is an example of the heterogeneous clinical course of CD and emphasizes the need to consider it in the differential diagnosis in elderly presenting with anemia and weight loss. Delay in diagnosis can lead to complication such as celiac crisis. Treatment for Celiac crisis is gluten free diet and steroids.