NYU Medical Grand Rounds Clinical Vignette

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NYU Medical Grand Rounds Clinical Vignette

• Sanam Yaghoubian MD, PGY-2
• September 23, 2009

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Chief Complaint
A 50-year-old man presents with the complaints of
weight loss and bloating for one week.
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History of Present Illness

• The patient was in his usual state of health
  until one week ago when he began to note
  progressive generalized weakness affecting his
  ability to ambulate.

• He estimates a 15 pound weight loss over this
  period.

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History of Present Illness

• The patient complains that after eating he feels
  bloated and as if he has to defecate.

• He also noted the development of perioral
  numbness and tingling in his hands.

• Prior to these symptoms, the patient reports
  walking his dog 2 miles every day to his
  methadone clinic.

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Additional History

• Past Medical History
• Hepatitis C
• Iron deficiency anemia
• Normal colonoscopy
• 2 years ago
• By patient report
• Depression
• Past Surgical History
• Left rotator cuff repair

• Family History
• Non-contributory
• Social History
• Lives with mother and sister
• Former bus driver
• On disability
• Smoker
• 19-pack-year history
• Denies alcohol use
• Intravenous heroin abuse,
• Last use 4 months ago

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Outpatient Medications
Ferrous sulfate 325mg three times
daily Fluoxetine 20mg daily Methadone 50mg daily
Allergies No known drug allergies
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Physical Examination
General Cachectic, disheveled-appearing man in
no acute distress
Vital Signs T 98.0 F, BP 134/88, HR 91, RR 16 O2
Sat 100 on room air
HEENT Bi-temporal wasting, dry mucous membranes,
poor dentition
The remainder of the physical exam was normal.
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Laboratory Findings

• CBC
• Hemoglobin 11 g/dL, Hematocrit 34, MCV 71 fL
• The remainder of the CBC was within normal limits

• Basic metabolic panel
• Urea nitrogen 23 mg/dL
• Calcium 7.9 mg/dL
• Phosphate 0.5 md/dL
• The remainder of the basic metabolic was within
  normal limits

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Laboratory Findings

• Hepatic panel
• AST 78 U/liter
• ALT 50 U/liter
• Alkaline phosphatase 354 U/liter (39-117
  U/liter)
• GGT 131 U/liter (8 37 U/liter)
• The remainder of the hepatic panel was within
  normal limits

• Additional studies
• Iron 23 µg/dL (60 150 µg/dL)
• Ferritin 8 ng/mL (29 270 ng/mL)
• TIBC 330 µg/dL (250 450 µg/dL)
• Transferin saturation 6.9
• B12, Folate, TSH were within normal limits

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Other Studies

• Chest X-Ray within normal limits
• Abdominal CT
• Prominence of the common bile duct
• Minimal prominence of the pancreatic duct
• No definite pancreatic head lesions
• Prominent mesenteric lymph nodes

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Working Diagnosis
Malabsorption syndrome
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Hospital Course

• EGD was performed and demonstrated
• Small grade I esophageal varices
• Erythema of the gastric mucosa
• Erythematous duodenopathy without gross lesions

• Gastric biopsies consistent with mild chronic
  inactive gastritis (antrum) and portal
  hypertensive gastropathy (body).

• Duodenum biopsy demonstrated severe blunting of
  the villi and moderate chronic inflammation
  consistent with sprue.

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Hospital Course

• The patient was admitted to medical ward where
  his electrolytes were aggressively repleted

• Celiac disease was suspected and the following
  labs were sent
• Endomysial Ab (undetectable)
• Gliadin IgA 119 U/mL (0-10 U/mL)
• Gliadin IgG 60 U/mL (0-9 U/mL)

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Hospital Course

• The patient was discharged with nutrition
  counseling regarding a gluten-free diet.

• He was recently seen in gastroenterology clinic,
  and reports an improved appetite and a stable
  weight.

• Colonoscopy is scheduled for later this month.

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Final Diagnosis
Celiac disease
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