S2888 Tetany and Carpopedal Spasm as the Initial Presentation of Celiac Disease

Abstract

INTRODUCTION: Celiac disease (CD) presents with a wide variety of symptoms, with gastrointestinal manifestations being the most common. We discuss a rare case of celiac disease diagnosed by severe hypocalcemia and carpopedal spasm. CASE DESCRIPTION/METHODS: A 25 year old male with no significant medical history presented with complaints of paresthesias in his hands and arms and a few weeks of diarrhea. Physical exam revealed carpopedal spasm. Initial lab work was significant for severe hypocalcemia (ionized calcium level of 0.66), hypomagnesemia and undetectable vitamin D 25-hydroxy level, along with elevated PTH (583.2). His electrolytes were aggressively replaced intravenously, and after stabilization, transitioned to oral supplementation. Vitamin D supplementation was also initiated. Patient was found to have elevated tissue transglutaminase IgA antibodies and gliadin peptide levels. EGD demonstrated scalloped mucosa with complete flattening of villi in the duodenum consistent with celiac disease, which was also confirmed on biopsy. Patient was initiated on calcium and vitamin D replacement and a gluten-free diet on discharge. DISCUSSION: CD usually presents with diarrhea and weight loss. However, >40% of patients present with atypical manifestations, many of which are secondary to malabsorption from a loss of absorptive area and the presence of immature surface epithelial cells whose have impaired absorptive and secretory functions. Hypocalcemia in CD occurs due to intestinal malabsorption of calcium, both from loss of villous surface area and depletion of calbindin from enterocytes leading to decreased active intestinal calcium transport mechanisms. Concurrent malabsorption of vitamin D may also play a role, although there have been reported cases with hypocalcemia despite a normal vitamin D. Hypocalcemia in CD is common, with studies demonstrating that average serum calcium is 0.02 mmol/l lower in asymptomatic CD patients that the general population. However, there are few reports, especially in the developed world, of severe hypocalcemia and neurological symptoms being the initial presentation of CD. Management includes intravenous or oral calcium replacement, with replacement of other electrolytes (magnesium, phosphorous and potassium) and vitamin D as well. These levels should be monitored at follow up visits, but it is expected that they will normalize after management of CD. It is important for a clinician to recognize atypical presentations of CD, especially in countries with high prevalence.Figure 1.: Endoscopic view of duodenal bulb showing scalloped mucosa and complete flattening of villi.Figure 2.: Microscopic view showing villous blunting and increased intraepithelial lymphocytes, H&E staining.