A 52–year–old male with a past medical history of right sided nephrectomy for clear cell renal carcinoma was admitted for evaluation of a 6 month history of occasional parasthesias and acute onset of left arm and left leg weakness. Review of symptoms was also significant for a 60 pound unintentional weight loss over the same period of time as well as occasional polyarthralgia of his wrists and knees, pruritic skin rash, abdominal pain, nausea, vomiting and diarrhea. Physical examination showed a thin and ill appearing gentleman. Neurologic exam was within normal limits with the exception of decrease strength (3/5) in his left upper and lower extremities. Abdomen was diffusely tender without guarding or rebound. The rest of the examination was unremarkable. Patient ruled out for acute stroke. An EMG was performed and revealed peripheral neuropathy with decreased vibratory sensation in both lower extremities. Given his significant weight loss and other symptoms, a whole body PET CT scan was performed to evaluate for malignancy and was significant only for a small amount of perinephric fluid collection. During the course of his hospitalization he subsequently developed bilateral conjunctival erythema and a skin rash on his upper arms and right leg with numerous erythematous pinpoint 1–3 mm papules with central hemorrhagic crust on both upper arms and right leg. Given the constellation of symptoms a comprehensive battery of rheumatologic serologies were drawn which came back negative except for an mildly elevated SSA level. A presumptive diagnosis of Sjogren’s syndrome was made. To further explore his abdominal complaints an EGD was performed; mucosal biopsies from duodenum were taken that showed increased intraepithelial lymphocytes as well as patchy villous blunting consistent with celiac disease. Serologic evaluation for celiac disease was sent and revealed markedly elevated levels of gliadin and transglutaminase IgA antibodies confirming the histological diagnosis of celiac disease. Patient was started on a gluten free diet and steroid eye drops with subsequent improvement of his symptoms.
Celiac disease is an increasingly prevalent disease in North America and can present with abdominal pain, weight loss and nutritional deficiencies as well as a myriad of other signs and symptoms including skin rash (dermatitis herpetiformis), seronegative arthritis and neurologic manifestations . An association between Sjogren’s and Celiac Disease has also been reported. This case also demonstrates the challenge that physician’s often face while struggling to search for a unifying diagnosis (Occam’s Razor) in a patient with multiple diseases (Hickam’s Dictum).
Patients with a variety of symptoms with unexplained weight loss or nutritional deficiencies should be tested for celiac disease. Patient’s with Sjogren’s disease with unexplained weight loss should also be tested for Celiac Disease.