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Introduction
Celiac disease (CD) is a chronic, small intestinal, immune-mediated enteropathy that is precipitated by dietary gluten in genetically predisposed individuals. In most adult cases, even untreated CD has an indolent course with gastrointestinal symptoms and nutritional abnormalities. Like childhood CD, many adults with CD present with diarrhea, steatorrhea, bloating, flatulence, and weight loss. However, CD can rarely present as an acute, life-threatening syndrome referred to as a celiac crisis, manifested by profuse diarrhea, hypoproteinemia, and severe metabolic disturbances significant enough to require hospitalization [1, 2]. The term “celiac crisis” was first used in 1953 by Andersen and Di Sant’Agnese when reporting a case series of 35 children with acute diarrheal illness attributed to a celiac crisis [3, 4]. In this series, a case fatality rate of 9% was reported. A celiac crisis is associated with a high morbidity [5] which makes an immediate identification and treatment imperative. As celiac crisis is not well documented, it remains a frequently underrecognized entity and is rarely considered in adults presenting with acute severe diarrheal illness, even after the exclusion of infectious etiologies. A celiac crisis is often precipitated by a general immune stimulus such as surgery, trauma, infection, or pregnancy [6-8]. It is unclear whether a celiac crisis in adults heralds the onset of CD or is an acute manifestation of previously undiagnosed CD. The initiation of a gluten-free diet (GFD) and parenteral fluid, along with nutritional support, and in most cases corticosteroids, remains the mainstays in the treatment of a celiac crisis. We report the case of a 26-year-old woman who presented with severe, acute, and unremitting diarrheal illness. After excluding common etiologies, she was diagnosed with CD presenting as celiac crisis.
Case Presentation
A 26-year-old Caucasian woman presented to the emergency department with a 3-week history of nausea, vomiting, anorexia, and diarrhea. She reported 6–12 daily episodes of watery brown stools, associated nausea, and multiple episodes of non-bloody and non-bilious emesis. She had not been travelling recently, has had no sick contacts, or hospitalization. She had been treated for uncomplicated urinary tract infection (UTI) with 3 days of levofloxacin, 3 days prior to the onset of her current symptoms. Her vital signs revealed a blood pressure of 98/68 mm Hg, a heart rate of 102...