To describe a case series of four children* with celiac disease and rheumatic diseases.
A 10-year old male presented with a 6 month-history of left knee arthritis, with normal hemoglobin and CRP, ESR = 25; +ve HLA B27; -ve negative ANA, RF and Lyme. He was diagnosed as having juvenile rheumatoid arthritis, was started on NSAIDS and was given intra-articular steroid injection. Subsequently he lost 20 pounds, developed abdominal pain, fatigue, diarrhea and anorexia, and was diagnosed with celiac disease. He started the gluten-free diet; NSAIDS were discontinued with significant improvement in his left knee arthritis.
A 5-year-old male with celiac disease on a gluten free diet, presented with mild upper respiratory tract infection and migrating polyarthralgias causing him to limp. His CRP = 51 (0-4.9 mg/L); ESR, ASO, complete blood count (CBC), Lyme and ANA were within normal limits. Anti-deoxyribonuclease B = 1:170. The arthralgias subsided in two weeks. CRP normalized and currently the patient is asymptomatic.
A 10-year-old female presented at age 6 years with juvenile dermatomyositis for which she was started on Prednisone, which was weaned off over the next year. Two years later, she had a recurrence of dermatomyositis. Prednisone was restarted and methotrexate added. She was growing poorly and complained of abdominal pain. Diagnosis of celiac disease was made and she is currently off all medications and asymptomatic on a gluten free diet.
An 8-year-old thin female, small for her age, growing along 5th percentile presented with 4 month history of bilateral finger pain and stiffness, and 7 month history of fatigue and had diffuse polyarthritis on exam. Muscle strength was normal and there were no rashes or skin lesions. Her ANA = 1:640 and aldolase was found to be elevated at 11.9 U/L (1.2-8.8 U/L). She was tissue transglutaminase positive. Her anti-endomysial, anti-gliadin IgA, anti-reticulin IgA, and anti-gliadin IgG antibodies were all negative. MRI revealed diffuse inflammatory changes consistent with polymyositis. Duodenal biopsy confirmed celiac disease. On a gluten free diet and prednisone she improved significantly.
The possibility of celiac disease must be considered in children presenting with rheumatic diseases even without significant gastrointestinal complaints. Celiac disease may predispose patients to develop rheumatic diseases and this relationship requires further examination.
- The third and fourth cases were presented in the Pediatric Rheumatology Online Journal.
