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CASE REPORT. Dr Veselinka Djurisic Institute for Children ’s Disease s Montenegro. Female infant, 8 month old; Admitted to hospital due to: Diarrhoea ; Metabolic disbalance; With sings of enteropathy. . History of Present Illness.

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case report

CASE REPORT

Dr VeselinkaDjurisic

Institute for Children’s Diseases

Montenegro

slide2

Female infant, 8 month old;

  • Admitted to hospital due to:
    • Diarrhoea;
    • Metabolic disbalance;
    • With sings of enteropathy.
history of present illness
History of Present Illness
  • 15 min before admission to hospital present with sudden abdominal cramping, cyanosis of limbs, she was lethargic, with drooping head.
  • Day before admision, she was sleepless, agitated, inconolably crying, with non bilious, non-projectile vomiting (4 times/day), and she had 10 regular stools.
  • 9 days before she was addmited to hospital due to vomiting, diarrhoea and high fever.
personal hystory
Personal hystory:
  • Third child from regular pragnancy and term delivery completed with caesarean section.
  • Birth weight: 2830 g; Birth length: 53 cm; AS 9
  • Breastfeeded 3 mo, after that continued adapted milk formula, 1 month later started mixed non-milk nutrition.
  • No history of allergy, regularly vaccinated
family history
Family history
  • Older brother – convulsions trated with AET;
  • Father – epilepsy;
  • Mother – chronic enteropathy in childhood suggested gluten free diet, but she refused;
  • Grandfather – COPD;
clinical finding
Clinical finding
  • Weight 7 kg
  • Agitated, crying, groaning, dehydrated, afebrile (36,7⁰C), hemodynamically stable;
  • Vital sings: RR 36/min, CF 136/min, spO2 93%;
  • Skin: pale, marble, with limbs cyanosis.
  • Left torticollis, slight axial hypotonia.
  • Normal auscultatory findings of lungs and heart .
  • Abdominal examination: abdominal distension ,soft and nontender, without tumefacts and organomegaly.
slide9

Tissue transglutaminase antibody:

    • IgG 269;
    • IgA > 300;
  • Anti – gliadin antibodies:
    • IgG 6 ;
    • IgA > 300;
microbiology
Microbiology
  • Stool culture, ova and parasite testing, Rotavirus and Adenovirus: NEGATIVE.
  • Stool: positive for Candida sp.
  • Urin culture: negative.
radiology findings
Radiology findings
  • X-ray plain film
  • air-fluid levels
radiology findings1
Radiology findings
  • Ultrasound revealed mass suspected to intussusception in right hemiabdomen:
    • Target sign (also known as the doughnut sign)
    • Pseudokidney sign
radiology findings2
Radiology findings
  • Abdominal CT scan reveals dilated and fluid-filled loops of small bowel with air-fluid levelsthe classic ying-yang sign of an intussusceptum inside an intussuscipiens in right hemiabdomen.
slide14

Rectoscopy was performed: reveal normal.

    • The lining of the colon appears smooth and pink, with numerous folds.
    • No abnormal growths, pouches, bleeding, or inflammation is present.
course
COURSE
  • Treated with antibiotics:
    • metronidazole
    • gentamicin
  • Corticosteroids:
    • methylprednisolone
  • H2 blockers:
    • ranitidine
  • Transfusion of fresh frozen plasma, 3 times
slide16

After exclusion of acute abdomen, cow protein free diet was introduced, but without any improvement.

  • Spontaneus desinvagination.
  • After obtainig coeliac serology, gluten free diet has started, occurs clinical improvement with metabolic stabilisation.
conclusion
Conclusion
  • Case of rare but serious clinical presentation of celiac crisis.
  • It is important to recognize that CD may present in “crisis.”
  • The possible precipitating factors in present patient are unrecognized coeliac disease, hypokalemia and previous infection.
discussion
Discussion
  • Incidence of celiac disease is on rise in Montenegro.
  • Prevalence of CD is found to be........ dopuniti ukoliko postoje podaci.....
  • Celiac crisis is a life-threatening complication of CD.
  • Clinically, it is characterized by severe diarrhea, dehydration and metabolic disturbances like hypokalemia, hypomagnesemia, hypocalcemia, hypoproteinemia and metabolic acidosis.
definition of celiac crisis
Definition of celiac crisis
  • Acute onset or rapid progression of gastrointestinal symptoms attributable to celiac disease requiring hospitalization and/or parenteral nutrition along with at least 2 of the following:
slide22

Celiac crisis may not respond to a gluten-free diet alone. In severely ill children with celiac crisis, the use of corticosteroids may cause dramatic improvement. *

  • Lloyd-Still described 3 cases of celiac crisis successfully treated with corticosteroids. **
  • The role of steroids now is controversial as gluten free and good nutritional diet are considered good enough to tide over the crisis ***

* Mihailidi E, Paspalaki P, Katakis E, Evangeliou A. Celiac Disease: A Pediatric Perspective. International Pediatrics 2003;18:141-8.

** Lloyd-Still JD, Grand RJ, Khaw KT, Shwachman H. The use of corticosteroids in celiac crisis. J Pediatr. 1972; 81: 1074-1081.

*** Walia A, Thapa BR. Celiac crisis. Indian Pediatr. 2005; 42: 1169

g razie per l attenzione
Grazie per l'attenzione

Saluti da Montenegro