History and clinical findings: A 67 year old female patient presented herself to our emergency room with paraesthesia in both hands, chronic diarrhea and continuous weight loss. From the past medical history, only an autoimmune hypothyroidism was known. On initial, examination leading features were carpopedal spasms and a pulse deficit. Her general condition, especially the nutritional status was low.
Investigations: Serum levels of potassium (2.2 mmol/l) and calcium (1.45 mmol/l) were low, as well as the levels of total protein (5.1 g/dl) and albumin (2.94 g/dl). Clotting time was prolonged (Quick 51%). The ECG showed a ventricular bigeminus and a prolonged QT-period (120% rel). Endoscopy and biopsy showed a total villous atrophy suggesting celiac disease as probable cause. This was emphasized by the high antibody levels against gliadin (1:80) and endomyosin (1:40). Furthermore, the Human Leukocyte Antigen molecules HLA-B8 and HLA-DR3 showed increased expression.
Treatment and course: After normalizing the electrolyte imbalance intravenously the neurological symptoms disappeared as well as the arrhythmia. The QT-period went back to normal. Under initial drip feeding and a strict gluten-free diet the general condition improved quickly and the diarrhea stopped. A follow-up investigation 3 months later showed the woman in a good condition having gained 10 kg weight and an improvement in histological findings, so that diagnosis of celiac disease could be proved.
Conclusions: The possibility of ventricular arrhythmia and a prolonged QT-period in the ECG should be taken into account for patients diagnosed with celiac disease, especially in case of electrolyte imbalance. In these cases addition to a strict gluten free diet a rapid correction of the electrolyte imbalance is necessary because of the risk of sudden cardiac death. Furthermore associated disorders like autoimmune diseases expressing the same HLA-antigens (HLA-B8 and HLA-DR3) must be considered. Combined incidence of celiac disease and autoimmune hypothyroidism is well documented. For patients with celiac disease we therefore recommend a routine testing of thyroid hormone levels.