Chvostek’s and Trousseau’s signs were also positive

Chvostek’s and Trousseau’s signs were also positive. be performed if there is strong clinical suspicion. Introduction Celiac disease (CD) is a disease entity characterized by damage of the small intestinal mucosa caused by Lumefantrine the gluten contained in wheat and similar alcohol-soluble proteins of barley and rye, in genetically susceptible individuals [1]. The presence of gluten leads to self-perpetuating mucosal damage, whereas elimination of gluten results in full mucosal recovery [1]. The clinical manifestations of CD are protean in nature and vary markedly with the age of the patient, duration and extent of Lumefantrine disease and presence of extra-intestinal pathological conditions [1]. In addition to the classical gastrointestinal form, a variety of other clinical manifestations of the disease have been described, including atypical and asymptomatic forms [1]. Thus, the diagnosis of CD can occasionally become Lumefantrine extremely challenging [1]. The presence of Marsh 3 lesion (villous atrophy) on intestinal biopsy together with a positive antibody profile is currently internationally accepted as celiac disease [2,3] however, a European multicenter series reported antibody-negative celiac disease accounting for 6.4% of all celiac disease cases [4]. We present a case of a serology-negative celiac disease in Pakistan in a young woman, in whom the diagnosis would have been missed, had there not been a strong medical suspicion. Case demonstration A 20-year-old unmarried woman student, resident of a slum part of Karachi, offered in July 2008 in the out-patients medical center of a government-run tertiary-care hospital in Karachi, Pakistan, with complains of rash for the last 15 years and diarrhea (on and off) for the last 8 years, generalized weakness, fatigue, occasional spasm of both hands and twitching of the face for the last 4-5 weeks. The rash developed when she was 5 years of age, was initially papular, progressed to fluid-filled Rabbit Polyclonal to PRRX1 vesicles and was associated with severe itching. It occurred mostly along the back of her arms and trunk and at the front of the thighs, persisted for 1-2 weeks, and gradually improved to some extent by topical steroids and oral anti-histamines prescribed by a doctor in the local primary Lumefantrine health care centre, only to recur after a period of 2-3 weeks. At 11 years of age, patient developed symptoms of severe watery diarrhea, which adopted a 1-2 week program, occurred 4-5 instances in a day, unassociated with any particular food intake, settled down without treatment, only to recur after a symptom-free period of 2-3 days. There was no connected fever, nausea, dyspepsia, bloating, anorexia, excess weight loss, arthralgias or any neurological manifestations. The patient refused any history of smoking or alcohol intake. Family history was also unremarkable. The patient consulted numerous doctors in her locality who prescribed her multivitamins, calcium and multiple programs of a variety of antibiotics with no alleviation of symptoms. During the last 2 weeks, her symptoms improved in severity and she lost 4 kilograms excess weight. On examination, patient had a thin, lean built (height: 5 ft, 2 ins and excess weight: 42 kg). She appeared pale and experienced papulovesicular rash; specially within the extensor surfaces of her thighs, legs, arms and trunk, and multiple hyperpigmented areas all over her body; residues of older healed lesions. Her systemic exam exposed coarse pores and skin and hair and cheilosis round the mouth. Chvostek’s and Trousseau’s indications were also positive. On the basis of clinical features, patient was suspected to have a malabsorption syndrome. Laboratory investigations exposed hemoglobin of 10.8 g/dl (hematocrit: 32%, MCV: 105cu-m). Total leukocyte count (TLC), platelets, urea, creatinine, electrolytes, liver functions, serum proteins, prothrombin time, partial thromboplastin time, detailed reports of urine and stool, serum thyroid stimulating hormone (TSH) and parathyroid levels were all within normal ranges. In the light of decreased hemoglobin with high MCV, serum vitamin B12 and reddish cell folate levels were performed. Vitamin B12 levels were normal Lumefantrine while reddish cell folate levels were at a lower normal range (200 ng/ml). Therefore, folate deficiency was suspected to be the cause of the macrocytic blood picture. Serial serum calcium done in the last two months remained persistently low (6.9 mg/dl-7.5 mg/dl). Vitamin D3 levels were also low (28.8 n/ml). Chest X-ray was normal and X-rays of wrist and hands showed minor osteopenia. In the light of history and exam, complemented by papulovesicular skin lesions, a provisional analysis of celiac disease with dermatitis herpetiformis was made and anti-tissue transglutaminase (anti-TTG) antibodies (IgA and IgG) and anti-endomysial antibodies (anti-EMA) were performed. They were within the normal range. Serum total IgA levels were also normal. Even though serology was bad, an endoscopy was performed on basis of.