Vol 44 # 4 December 2012 - Kma.org.kw
Vol 44 # 4 December 2012 - Kma.org.kw
Vol 44 # 4 December 2012 - Kma.org.kw
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335<br />
KUWAIT MEDICAL JOURNAL<br />
<strong>December</strong> <strong>2012</strong><br />
Case Report<br />
Celiac Disease as Uncommon Cause of Death in<br />
Type 1 Diabetes Mellitus: A Case Study<br />
Yasser Mohamed Abd Elraouf Ibrahim<br />
Department of Internal Medicine, Al Sabah Hospital, Ministry of Health, Kuwait<br />
Kuwait Medical Journal <strong>2012</strong>; <strong>44</strong> (4): 335 - 337<br />
ABSTRACT<br />
Celiac disease (CD) is one of the most common immune<br />
mediated diseases. This disease is triggered by ingestion of<br />
wheat gluten and related other cereal proteins, particularly<br />
those in rye and barley. The prevalence of CD in type 1<br />
diabetes in children is 1:6 to 1:103 and in adults 1:16 to<br />
1:76. In-spite of that, there is no current clinical evidence<br />
supporting routine screening of adult type 1 diabetic patients<br />
for CD. Most patients who have diabetes and CD have nonclassic<br />
forms of CD, with various presentations such as short<br />
stature, sideropenic anemia, or hypertransaminasemia; in<br />
many cases, patients are totally symptom free. CD elevates<br />
the mortality risks of a wide array of diseases in CD patients.<br />
This case had an atypical presentation of CD, and died<br />
unexpectedly because of the disease. We report this case to<br />
emphasize on the value of high index of suspicion of CD in<br />
type 1 diabetes mellitus.<br />
KEY WORDS: diet, gluten free, immune-mediated diseases, tissue, transglutaminase<br />
INTRODUCTION<br />
Celiac disease (CD) is one of the most common<br />
immune-mediated diseases [1] . Atypical asymptomatic<br />
form and absent gastrointestinal manifestations, are<br />
common, and a case may be discovered on duodenal<br />
biopsy for any other reason or immunology screening [2] .<br />
Studies in the United States and Europe show the<br />
prevalence of the disease approaching 1% [3,4] .<br />
Based on small bowel biopsy diagnosis, the<br />
prevalence of CD in type 1 diabetes in children is 1:6<br />
to 1:103 and in adults 1:16 to 1:76 [5] . CD is most often<br />
present before the onset of diabetes. Most patients who<br />
have both diabetes and CD have non-classic forms of<br />
CD, with various presentations such as short stature,<br />
sideropenic anemia, or hypertransaminasemia; in many<br />
cases, patients are totally symptom free [6] . In-spite of<br />
that, there is no current clinical evidence supporting<br />
routine screening of an adult type 1 diabetic patient for<br />
CD [7] .<br />
CASE HISTORY<br />
A twenty-two-year old Kuwaiti single female<br />
presented to us in the outpatient department with<br />
abdominal pain, bilateral lower limb edema and skin<br />
pigmentation of two months duration. She was known<br />
case of type 1 diabetes mellitus for 13 years on intensive<br />
insulin regimen, but non-compliant to her medication<br />
and with poor glycemic control. She had irregular<br />
menstruation and good scholastic performance. Her<br />
body weight was 42 kg, height was 158 cm and body<br />
mass index was 16.8 kg/m 2 . On clinical examination,<br />
she was conscious, alert and oriented. Her BP was<br />
110/70 mmHg, pulse rate was 75 bpm, temperature<br />
was 36.8 ºC and respiratory rate was 22/min. General<br />
examination revealed bilateral lower limb pitting<br />
edema with brownish, patchy and scaly pigmentation<br />
on the extremities but without pruritus. There was<br />
neither lymphadenopthy nor thyroid enlargement.<br />
Examination of the chest, heart, abdomen and CNS<br />
was unremarkable. Routine urine examination was<br />
unremarkable. Liver function tests showed an elevation<br />
of ALT ( 85 IU/l, normal up to 45 IU/l), AST ( 58 IU/<br />
l, normal up to 40 IU/l) and ALP (181 IU/l, normal<br />
up to 132 IU/l), with decreased plasma albumin to (18<br />
g/l, normal 35 - 50 g/l). Total bilirubin was 11 μmol/<br />
l (normal upto 17 μmol/l) and direct bilirubin was 3<br />
μmol/l (normal upto 5 μmol/l). INR was elevated to<br />
2.3. 24-hour urinary protein was normal (160 mg/day).<br />
Complete blood picture showed a hemoglobin level of<br />
123 g/l (normal female range 135 - 150 g/l), WBC count<br />
was 7400/mm 3 (normal range 4000 – 11,000/mm 3 ) and<br />
platelets were 230,000/mm 3 (normal range 150,000 –<br />
450,000/mm 3 ). Abdomen and pelvic ultrasonography<br />
was unremarkable, Investigations for hepatitis A, B<br />
Address correspondence to:<br />
Dr Yasser Mohamed Abd Elraouf Ibrahim, MD, Department of Internal Medicine, Tanta Faculty of Medicine, Tanta, Egypt. Tel: 0020409115886,<br />
Mob: 0020102717656, E-Mail: masyasser@yahoo.com