IDDF2019-ABS-0013 Celiac crisis in an adult type 1 diabetes mellitus patient presenting with diarrhea, weight loss and hypoglycemic attacks- a rare entity

Abstract

Background Type 1 diabetes mellitus (T1DM) is an autoimmune disease, characterized by loss of insulin-producing beta cells of the islets of Langerhans in the pancreas, causing insulin deficiency. Celiac disease (CD) has been seen in 3 to 8% of T1DM patients. Celiac disease is characterized by impaired immunological response to ingested gluten. Gluten consumption might be a shared causative factor for the development of T1DM and CD. Celiac crisis is a life-threatening condition in which CD causes acute dramatic metabolic dysregulation. Methods A 52-year old lady with a 10-year history of type 1 diabetes mellitus presented with 2-months history of diarrhea associated with loss of appetite, nausea, pain abdomen, and weight loss of 13 kg. Initial laboratory findings revealed hyperglycemia, metabolic acidosis with hyperchloremia, hypokalemia, hypocalcemia, and hypoalbuminemia. She also had iron and folate deficiency. Haemoglobin level was 9.4 g/dl. HIV status and viral hepatitis serology were negative, and stool examination did not suggest an infectious etiology. For evaluation of diarrhea, serological blood test for celiac disease was done; antiendomysium antibodies of the immunoglobulin A (anti EA IgA) was 158.7 U/ml (normal: 0–20 U/ml), tissue transglutaminases of immunoglobulin A (tTGA IgA) was >200 U/ml (normal: 0–20 U/ml). Histological findings of duodenal biopsy post endoscopy were consistent with celiac disease grade 3 according to the Marshal classification. After the introduction of the gluten-free diet, she gained weight, her metabolic abnormalities resolved with better glycemic control. Results After excluding other reasons of acute diarrhea and based on the patient‘s findings including metabolic acidosis, hypoproteinemia, hypocalcemia, hypokalemia and weight loss of 13 kg, our patient was diagnosed with celiac crisis. Advising a gluten-free diet results in prompt and dramatic improvement in the patient‘s symptoms. Conclusions In the literature, celiac crisis in adults have rarely been notified, and for this reason, celiac disease rarely is considered in adults presenting with acute severe diarrheal illness, even when infectious etiologies have been excluded. A type 1 diabetic patient who presents with severe unexplained diarrhea and malabsorption should be tested for celiac disease.