1. Introduction

Celiac disease (CD) can be diagnosed at any age ^[1]. Some important complications include osteoporosis, iron and vitamin deficiencies and enteropathy-associated T-cell lymphoma were reported ^[2]. We report a CD patient in which a dietitian support is absolutely necessary.

2. Case Report

A 62-years-old patient known with CD for about 10 years without strict adherence to the diet in the past year, with chronic ischemic cardiopathy, with angina pectoris of effort, with left ventricular failure, with asthma, with advanced osteoporosis, was admitted in our medical unit for diarrhea (6 stools / day), weight loss (3-4kg / 6 months), asthenia, erythematous plaques, itchy, cracked on the dorsal hands, proximal (Figure 1).

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Figure 1. Dermatitis Herpetiformis?

Physical examination on admission showed a influenced general condition, erythema of the cheeks, dry skin, degenerative changes of the bilateral interphalangeal joints, blood pressure = 100/70 mm Hg, pulse rate = 60 / min, supple and elastic abdomen, epigastric and right hypochondrium tenderness.

We found WBC=3.20 [4-10 10*3/μl], LYM=0.90 [1.5-4 10*10*3/μl], HGB=10.3 [11.7-16g/dL), the blood cell analysis with anisocytosis, microcytic, ESR = 32 [2-7 mm], Magnesium = 1.56 [1.60-2.40 mEq / L], Iron = 19 [50-170 / g / dL /]. The initial diagnosis of CD has been based on duodenal biopsy, which showed mucosal changes suggestive of villous atrophy. We determined at this clinical reassessment only IgA anti-tissue transglutaminase antibodies that were positive. Coproculture showed a negative result for Shigella, Salmonella, Yersinia. Rapid test for Clostridium was negative. Pulmonary function report showed severe obstructive ventilatory dysfunction on small pathways (Figure 2).

Prick test showed no cutaneous sensitization to inhaled and food tested allergens. Colonoscopic examination showed internal hemorrhoids. His suspected diagnosis of dermatitis herpetiformis was excluded. Abdominal ultrasonography showed biliary dyskinesia.

The diagnosis of our patients was CD, chronic ischemic cardiopathy, NYHA II left ventricular failure, stage III controlled asthma, advanced osteoporosis, iron deficiency anemia, internal hemorrhoids, hypomagnesemia, and depressive disorder

3. Discussions

CD has a cure - gluten free diet ^[3], therefore IgA anti-tissue transglutaminase antibodies was performed to our patient ^[4]. For the diarrheal stools and weight loss of our patient, we searched through stool analysis and Clostridium testing, bacterial species that can persist in the microbiota of CD patients ^[5] and we also searched, through biochemical exams, nutritional deficiencies that should be periodically studied in CD follow-up ^[6]. But what attracts attention is ischemic cardiomyopathy and depressive disorder. The association of CD in adults with chronic ischemic cardiomyopathy has been described in recent years only to persons under 30 years ^{[7, 8]} but never the people of the third age. The association would be fatal in some cases and the clinicians revealed the need for a rapid diagnosis of CD with nutritional deficiencies correction ^[9]. Unfortunately, about depressive disorder in this patient, we do not know much, the diagnosis was taken from another clinic after a psychiatric examination, but in recent years the medical literature draws attention on these psychiatric manifestations in CD ^{[10, 11]}. Some authors have said that depression should more common in patients with CD ^[12], we say that to our patient depressive disorder could have a variety of causes including associated diseases or gluten-free diet. But on the background of gluten-free diet, we believe that the support of a psychiatrist is absolutely necessary.

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Figure 2. Pulmonary function report

4. Conclusions

This case describes a rare association in the third age in literature, namely the association of CD with ischemic cardiomyopathy. We also believe that besides dietary support, the psychiatric examination should be part of the evaluation of CD patients.

References

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