Adult celiac disease presented with celiac crisis: severe diarrhea, hypokalemia, and acidosis

Life-threatening onset of coeliac disease: a case report and literature review

BACKGROUND

Coeliac disease (CD) results from an immune-mediated reaction to gluten in genetically predisposed individuals. In rare cases CD may occur with acute features deferring the diagnosis and exposing these patients to possible life-threatening complications. Herein we present the case of a young woman with a coeliac crisis, that is, a sudden clinical onset characterised by severe electrolyte imbalance due to an unknown (previously unrecognised) CD.

METHODS

This is a case report and literature review revealing that coeliac crisis is under-reported, with a total of 48 adult cases so far published. The diagnosis in our case was established by histopathological analysis of multiple duodenal biopsies. The patient's serum was tested by enzyme-linked immunoassay to detect antitransglutaminase IgA antibodies.

RESULTS

In contrast to cases reported in the literature, with male gender predominance and a mean age of 50±17 years, our patient was a young female case of coeliac crisis. However, like in our patient, a higher incidence of coeliac crisis was associated with the human leucocyte antigen (HLA)-DQ2 haplotype, versus HLA-DQ8, and a severe (Marsh-Oberhüber 3c) duodenal mucosa atrophy. Notably, there is no clear correlation between the antitissue transglutaminase 2 IgA antibody titre and coeliac crisis onset/severity, as confirmed by our case report.

CONCLUSIONS

The present case highlights that CD may manifest quite abruptly with a severe malabsorption syndrome, that is, electrolyte abnormalities and hypoproteinaemia. Our case should alert physicians, in particular those in the emergency setting, that even a typically chronic disorder, such as CD, may show life-threatening complications requiring urgent management.

Nutritional management of celiac crisis in an elderly adult: A case report of the rare presentation of celiac disease in a 75-y-old woman

In adults, a very uncommon presentation of celiac disease (CD) is a celiac crisis, a life-threatening and severe form of the disease having a dramatic onset with diarrhea and metabolic acidosis with electrolyte and fluid imbalance. Treatment of celiac crisis requires a gluten-free diet; however, the risk for refeeding syndrome (RFS) should be considered in patients showing marked malabsorption symptoms and important unintentional weight loss. Therefore, to avoid metabolic and potentially fatal complications of re-nutrition, nutritional management is crucial for a safe recovery after a celiac crisis. This review reports the rare onset of celiac crisis in a 75-y-old woman presenting with severe malnutrition resulting in >40% weight loss in 3 mo, after a period of severe diarrhea and vomiting. She arrived at the hospital showing electrolyte imbalance, hypoalbuminemia, lower limb edema, multiple bowel movements (>10/d) with steatorrhea, sarcopenia with profound asthenia, hyporexia due to intolerance to any food, and vomiting after meals. After being diagnosed with CD, the first approach was a gluten-free diet, which demonstrated only small and slow improvements of gastrointestinal symptoms. Therefore, a second approach was parenteral nutrition (PN) support that dramatically helped the patient's recovery. Here we describe the nutritional management during the inpatient stay for clinical stabilization and the following outpatient visits during and after the support with PN, until the patient's complete recovery to a regular follow-up.

Retrospective evaluation of the severity of and prognosis associated with potassium abnormalities in dogs and cats presenting to an emergency room (January 2014-August 2015): 2441 cases

OBJECTIVE

To determine the severity, concurrent clinical signs, and disease processes associated with potassium abnormalities in dogs and cats presenting to a veterinary emergency department and associated mortality.

DESIGN

Retrospective and descriptive study over 20 months.

SETTING

University teaching hospital.

ANIMALS

1916 dog and 525 cat visits.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Medical records from patients with a potassium concentration measured within 24 hours of admission were identified. Hypokalemia and hyperkalemia were defined as a potassium concentration <3.5 mmol/L [3.5 mEq/L] and >5 mmol/L [5 mEq/L], respectively. Associated disease processes and pathophysiologic risk factors for potassium abnormalities were reviewed for moderate to severe potassium abnormalities (<3 mmol/L or ≥6 mmol/L) [<3 mEq/L or ≥6 mEq/L]. Mortality associated with normokalemia, mild, and moderate to severe dyskalemia were evaluated. Overall prevalence of abnormal potassium concentration was 27% in dogs and 40% in cats. Moderate to severe hypokalemia and hyperkalemia were present in 3% of dogs and 8% of cats, and 2% of dogs and 7% of cats, respectively. Moderate to severe hypokalemia was most commonly associated with gastrointestinal disease (48% of dogs and 44% of cats) while moderate to severe hyperkalemia was most commonly associated with urinary tract disease (60% of dogs and 97% of cats). Dogs with hypokalemia and dogs and cats with hyperkalemia (P < 0.001) had significantly greater mortality than those with normokalemia. Dogs with mild hypokalemia and mild hyperkalemia (P < 0.0001) had higher mortality than dogs with normokalemia, but this was not found in cats.

CONCLUSIONS

Dyskalemia was common in this population and was associated with greater mortality. Moderate to severe potassium abnormalities were uncommon in this population and occurred most frequently in animals with gastrointestinal and urinary tract disease.

Celiac crisis, a rare occurrence in adult celiac disease: A systematic review

BACKGROUND

Celiac crisis (CC), a potentially life-threatening condition, is one of the rare clinical presentations of celiac disease (CD). Several cases have been documented in the literature, mostly in children.

AIM

To perform a review of CC cases reported in adult CD patients.

METHODS

A systematic search of the literature was conducted in two databases, PubMed/MEDLINE and EMBASE, using the term "celiac crisis" and its variant "coeliac crisis", from January 1970 onwards. Altogether, 29 articles reporting 42 biopsy-proven cases were found in the search. Here, we summarized the demographic, clinical characteristics, laboratory and diagnostic work-ups, and therapeutic management in these patients.

RESULTS

Among the 42 CD cases, the median age was 50 years (range 23-83), with a 2:1 female to male ratio. The majority of patients (88.1%) developed CC prior to CD diagnosis, while the remaining were previously diagnosed CD cases reporting low adherence to a gluten-free diet (GFD). Clinically, patients presented with severe diarrhea (all cases), weight loss (about two thirds) and, in particular situations, with neurologic (6 cases) or cardiovascular (1 case) manifestations or bleeding diathesis (4 cases). One in four patients had a precipitating factor that could have triggered the CC (e.g. trauma, surgery, infections). Laboratory workup of patients revealed a severe malabsorptive state with metabolic acidosis, dehydration, hypoalbuminemia and anemia. The evolution of GFD was favorable in all cases except one, in whom death was reported due to refeeding syndrome.

CONCLUSION

Celiac crisis is a rare but severe and potentially fatal clinical feature of CD. A high index of suspicion is needed to recognize this clinical entity and to deliver proper therapy consisting of supportive care and, subsequently, GFD.

Celiac Crisis: an unusual presentation of gluten-sensitive enteropathy

Celiac disease (CD)—also known as gluten-sensitive enteropathy—is a chronic, genetically predisposing and autoimmune entity with a wide range of clinical manifestations triggered by gluten ingestion, which affects 1% of the general population. Currently, up to 60% of the diagnosis of CD is in adults due to the atypical course of the disease. The severe acute onset of CD—also called celiac crisis—is very uncommon and is still not well documented in adults. We report the case of a 58-year-old man who presented a 45-day history of subtle-onset diarrhea followed by malabsorption syndrome with progressive weight loss, anasarca, and electrolyte disturbances. The diagnostic work-up included an upper digestive endoscopy, which showed scalloping of the duodenal mucosa with pathological features confirmed on biopsies. Specific antibodies were positive, and a satisfactory clinical response was obtained once a gluten-free diet was started. Celiac crisis is a rare initial presentation of CD characterized by severe diarrhea, dehydration, weight loss, hypoproteinemia, and metabolic and electrolyte disturbances. Although rare, it should be considered in patients with apparently unexplained chronic diarrhea.

Firing of an Implantable Cardiac Defibrillator: An Unusual Presentation of Celiac Crisis

Celiac crisis, an atypical presentation of celiac disease, is characterized by acute diarrhea and severe metabolic derangements. This diagnosis is often missed in the differential of acute diarrheal illness. Our patient is a 69-year-old man who presented with ICD firing and was found to have profound metabolic derangements. Further evaluation revealed undiagnosed celiac disease and his symptoms resolved with a gluten-free diet. Celiac crisis should be considered in all patients presenting with acute diarrhea, metabolic acidosis, and severe electrolyte abnormalities as management can be life-saving.

Celiac Disease Presenting as Profound Diarrhea and Weight Loss - A Celiac Crisis

Patient: Male, 46

Final Diagnosis: Celiac crisis

Symptoms: Abdominal pain • chronic diarrhea • lightheadedness • weakness • weight loss

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

Refeeding syndrome in children in developing countries who have celiac disease

OBJECTIVES

The clinical presentations of celiac crisis and refeeding syndrome in celiac disease are almost similar, but information about refeeding syndrome is scarce. We are reporting for the first time 5 cases of refeeding syndrome in children with celiac disease that could have otherwise been labeled as celiac crisis.

METHODS

From January to December 2010, a chart review of hospital records of all celiac disease cases was performed, and refeeding syndrome was ascribed in those celiac patients who deteriorated clinically after initiation of a gluten-free diet and had biochemical parameters suggestive of refeeding syndrome such as hypophosphatemia, hypokalemia, hypocalcemia, and hypoalbuminemia.

RESULTS

Of the total 35 celiac disease patients, 5 (median age 6.5 [range 2.2-10] years, 3 boys) were identified as having refeeding syndrome. All 5 children were severely malnourished (body mass index <14 kg/m) and all of them had anemia, hypophosphatemia, hypokalemia, hypoalbuminemia, and hypocalcemia, meaning that they had the perfect setting for developing refeeding syndrome. At the same time, their clinical features fulfilled the criteria for celiac crisis except that their symptoms have worsened after the introduction of a gluten-free diet. Nevertheless, instead of using steroids, they were managed as refeeding syndrome in terms of correction of electrolytes and gradual feeding, and that led to a successful outcome in all of them.

CONCLUSIONS

Severely malnourished patients with celiac disease are at risk of developing potentially life-threatening refeeding syndrome, which may mimic celiac crisis, especially in developing countries. Early recognition and appropriate treatment are the keys to a successful outcome.

Quadriplegia due to celiac crisis with hypokalemia as initial presentation of celiac disease: a case report

Celiac crisis is a rare, life-threatening complication of celiac disease characterized by worsening of clinical symptoms, multiple metabolic derangements and shock. We report an 8-year-old girl with previously undiagnosed celiac disease who presented with flaccid quadriparesis secondary to severe hypokalemia associated with celiac crisis. Diagnosis was expedited by an elevated anti-tissue transglutaminase antibody titer. The patient improved with correction of hypokalemia, corticosteroids and gluten-free diet. In tropical countries such as India, where both acute flaccid paresis and diarrhea are usually of infective etiologies, this rare clinical condition should also be considered in the differential diagnosis of both.

Celiac crisis is a rare but serious complication of celiac disease in adults

BACKGROUND & AIMS

Celiac crisis is a life-threatening syndrome in which patients with celiac disease have profuse diarrhea and severe metabolic disturbances. Celiac crisis is rare among adults and not well documented. To improve awareness of this condition and to facilitate diagnosis, we reviewed cases of celiac crisis to identify presenting features, formulate diagnostic criteria, and develop treatment strategies.

METHODS

Cases of biopsy-proven celiac disease were reviewed. Celiac crisis was defined as acute onset or rapid progression of gastrointestinal symptoms that could be attributed to celiac disease and required hospitalization and/or parenteral nutrition, along with signs or symptoms of dehydration or malnutrition.

RESULTS

Twelve patients met preset criteria for celiac crisis; 11 developed celiac crisis before they were diagnosed with celiac disease. Eleven patients had increased titres of transglutaminase antibodies and 1 had immunoglobulin A deficiency. Results of biopsy analyses of duodenum samples from all patients were consistent with a Marsh 3 score (33% with total villous atrophy). Patients presented with severe dehydration, renal dysfunction, and electrolyte disturbances. All patients required hospitalization and intravenous fluids, 6 required corticosteroids, and 5 required parenteral nutrition. All patients eventually had a full response to a gluten-free diet.

CONCLUSIONS

Celiac crisis has a high morbidity and, although rarely described, occurs in adults and often has a clear precipitating factor. Patients who present with severe unexplained diarrhea and malabsorption should be tested for celiac disease; treatment with systemic steroids or oral budesonide should be considered. Nutritional support often is required in the short term but most patients ultimately respond to gluten avoidance.

[Celiac crisis with quadriplegia due to potassium depletion as presenting feature of celiac disease]

INTRODUCTION

Adult coeliac disease revealed by coeliac crisis and quadriplegia due to potassium depletion is an extremely rare situation.

CASE REPORT

A 26-year-old woman presented with a suddenly developed weakness of all four limbs and a severe diarrhea. Authors emphasize coeliac crisis, which is a presenting feature of coeliac disease, characterized by acute diarrhea with life-threatening acid base and electrolyte abnormalities. The patient improved with correction of hypokalemia and gluten-free diet.

CONCLUSION

A severe acute diarrhea with metabolic and systemic complications, the so-called coeliac crisis, is a possible presenting clinical feature of a previously undiagnosed adult celiac disease.

Celiac crisis in an adult on immunosuppressive therapy

'Celiac crisis' is a rare presentation of celiac disease with manifestations that include severe diarrhea, and severe metabolic and electrolyte abnormalities. It is most frequently seen in children younger than two years of age and has been rarely described in adults. A case of a 50-year-old woman who presented with diarrhea, severe dehydration, hypokalemia and metabolic acidosis is described. Based on positive serology and small bowel biopsy, she was diagnosed with celiac disease. She also had histological evidence of lymphocytic colitis. Microscopic colitis has not previously been described in association with celiac crisis, but it may have contributed to the presentation of celiac crisis in the current case. The patient was on corticosteroids and azathioprine for autoimmune hepatitis at the time of her presentation. The current case demonstrates that modest immunosuppression does not prevent a celiac crisis, although previous reports have shown that patients may respond rapidly to high-dose corticosteroids.

Coeliac crisis presenting with cytomegalovirus hepatitis

We present the case of a 23-year-old woman who presented with cytomegalovirus infection complicated by pancytopaenia, haemolysis and disseminated intravascular coagulopathy on a background diagnosis of coeliac crisis as the first presentation of coeliac disease. This is the first reported case of coeliac crisis presenting as cytomegalovirus infection.

Coeliac crisis in adults: report of two cases

Adult coeliac disease, in contrast to its childhood counterpart, almost always has an indolent course with a wider spectrum of clinical manifestations. Approximately half of the patients have no overt gastrointestinal symptoms and many are asymptomatic. A rare and life-threatening complication, affecting mainly children younger than 2 years of age, is the so-called coeliac crisis, a term that applies to profuse diarrhoea leading to dehydration, hypokalemia, and acidosis. We report here two cases of adult coeliac disease that presented as coeliac crisis. Coeliac disease should be a differential diagnosis in adult patients with severe acute diarrhoea and acidosis, although a rare presentation.

Celiac crisis

Celiac crisis is a life-threatening cause of acute diarrhea and multiple metabolic emergencies. It is extremely rare these days. We successfully managed a 5-year old girl with celiac crisis for multiple metabolic problems viz., hyponatremia, hypokalemia, metabolic acidosis, hyperglycemia and polyuria in Pediatric Intensive Care Unit. Steroid therapy was life saving. The case may serve as a reminder of the condition, which presents a difficult therapeutic challenge.