CD-Skills – Case report, Medical University Graz, Austria
Patient’s history:
An adolescent female was admitted with severe pneumonia, complicated by pulmonal embolism.
While both her family history and her own previous history were uneventful (= no history for any autoimmune disorders nor any chronic gastrointestinal, hepatic, respiratory nor neurological disease), her very pronounced iron deficiency anaemia was of concern (please see the original below):
| Erythrocytes | 4.41 10^12/L | 4.10-5.10 |
| Haemoglobin | 7.3 ; TI/- g/dL | 12.0-15.3 |
| Haematocrit | 27.4/- % | 35.0-45.0 |
| MCV | 62.1/– fL | 80.0-98.0 |
| MCH | 16.6/- pg | 28.0-33.0 |
| MCHC | 26.6/- g/dL | 33.0-36.0 |
Iron
| Iron | 27/- μg/dL | 50.0-160.0 |
| Transferrin | 3.740/+ g/L | 2.000-3.600 |
| Transferrin saturation | 5/- % | 16-45 |
| Ferritin | 7 ng/mL | 4-114 |
Careful history taking revealed that the patient was in regular control by the gynaecologist with normal results and there were no hints to any chronic and / or occult blood loss.
The patient’s diet consisted of a normal mixed diet including meat and chicken, in fact the girl was fond of steaks.
In consequence, coeliac serology was ordered in a timely manner by the attending physician, even including the request for HLA-typing:
The first results of coeliac serology were as follows (copy of the original):
| IgA | 1.41 g/L | 0.61-3.48 |
| Transglutaminase-antibiotied, IgA | 360/+++ U/mL | 0-16 |
| Endomysium-antibodies | 1:10 +++ |
During her stay as an inpatient lasting 3 weeks in total, celiac specific serology was repeated and results of HLA-typing received.
When being discharged, the patient received her diagnosis of Celiac Disease according to the current ESPGHAN guidelines, as follows:
I) Highly suspicious symptom/finding: Iron deficiency anaemia (no obvious other causes)
II) Repetitive positive results of tTG-AB >> 10 times the upper limit of our test’s range
III) Repetitive positivity of EMA-Abs
And: In addition we received her HLA-type as being is associated with Celiac Disease.
The patient was already started on a strictly gluten free diet upon individual counselling and tolerates this die very well.
Conclusion: Even when treating a patient for an acute and severe disease regarding as in this case an organ system beyond the GI-tract, the ordering of coeliac disease-specific diagnostics upon a “CD-leading symptom” (iron deficiency anaemia w/o other explanation) was very straightforward and attributable to the ordering physician (not a Paed Gastroenterologist) being well informed.