Concomitant Celiac Sprue and Crohnʼs Disease Presenting as Bilateral Tibial Pain Secondary to Vitamin D Deficiency

Abstract

Purpose: A 28 year-old female with an eight-year history of Crohn's Disease complicated by multiple small bowel obstructions and fistulectomies was referred to our office for a second opinion regarding leg pain requiring narcotics. She presented with a three-year history of constant bilateral lower extremity pain radiating from the knees, along the tibia to the dorsum of her feet. Her symptoms increased with weight bearing and were not altered by passive motion. She denied joint swelling, erythema, warmth or rash. She had daily, semi-formed bowel movements without cramping or evidence of bleeding. Her history was significant for Crohn's Disease requiring multiple partial small bowel resections and endometriosis. Family history was noncontributory. Medications included Mesalamine 1 gm Q. I.D, but she had previously been treated with 6-MP and three doses of Infliximab, with no effect on her leg pain. To explore a possible diagnosis of Crohn's associated tenosynovitis she was referred to Rheumatology. Her Vitamin D level was checked and was 26 (normal 20–100) and a bone scan demonstrated abnormal increased uptake in both tibia. An endoscopy performed for persistent anemia showed normal appearing mucosa without scalloping, but small intestinal biopsy noted marked villous blunting and increased intraepithelial lymphocytes. Her TTG IgG level was elevated at 122 (<20) and IgA 90 Crohn's disease and Celiac Sprue are both chronic immune mediated inflammatory processeswhich can cause malabsorption and Vitamin D deficiency. Both disease processes can effect the proximal bowel and can also result in an anemia. Here we report a case of celiac sprue disease presenting as Vitamin D deficiency in a patient with concomitant Crohn's disease. Previous prospective analysis have found small but increased prevalence of concomitant celiac disease with Crohn's Disease. Bone pain is a described presenting symptom of Celiac Disease secondary to Vitamin D deficiency In patients with bone pain and a history Crohn's Disease, consideration should be given to the presence of concomitant celiac sprue and Vitamin D deficiency.