Iron-deficiency anemia due to silent celiac sprue.

BUMC PROCEEDINGS 2002;15:16–17 Celiac sprue, a gluten-induced enteropathy, was once considered primarily an immunologic disease of infants and children. Gluten is a protein found in grains, primarily wheat and barley. The ingestion of gliadin, a component of gluten, causes gastrointestinal symptoms including malabsorption and multiple nutritional deficiencies. Our understanding of this disorder has become more refined in recent years, as the case studies demonstrate. • • • Case 1: A 14-year-old male student presented for a routine athletic physical examination. He reported no cardiovascular or gastrointestinal symptoms and had gained weight. His examination was normal; however, his blood hemoglobin was 11.6 g/dL, with microcytic red blood cells and a ferritin level of 5 ng/mL. Upper and lower endoscopic findings were macroscopically normal. Biopsy of the proximal duodenum showed villous atrophy and lymphocytic infiltrate in the lamina propria. Subsequent serologic studies revealed an anti-immunoglobulin A (IgA) tissuetransglutaminase antibody level of 6.88 units (normal is <1.0), and the anti-IgA endomysial antibody titer was positive (1:640). A gluten-free diet was instituted, and after 1 year the blood hemoglobin was 15.7 g/dL with restoration of ferritin and all serologic levels to normal. The student remains without symptoms and plays linebacker on his varsity football team. Case 2: In 1992, a 41-year-old woman, referred by her gynecologist, presented with a blood hemoglobin of 6.7 g/dL. She was on hormone replacement therapy with no menstrual bleeding. Her ferritin was unmeasurable. The patient denied any symptoms or weight loss, and except for pallor, her examination results were normal. Iron repletion with oral elixir increased her blood hemoglobin to 12 g/dL in 1 year, without elevation of the ferritin. In November 2000, a bone mineral density study revealed severe osteoporosis requiring therapy with alendronate. She remained asymptomatic. Serologic studies for celiac sprue were obtained. The anti-IgA tissue transglutaminase antibody level was 5.1 units. The anti-IgA endomysial antibody titer was positive (1:320). After 5 months on a gluten-free diet, her study results returned to normal and she remained without symptoms. • • • In recent decades, the pathophysiology of celiac sprue has been clarified. Environmental, immunologic, and genetic factors are responsible for the histologic findings of flattening and atrophy of the small intestinal mucosal villi, crypt elongation, and lymphoid proliferation in the lamina propria. These changes may Iron-deficiency anemia due to silent celiac sprue