436
Journal of the Royal Society of Medicine Volume 84 July 1991
Insulin dependent diabetes mellitus and coeliac disease
A R Harnden MRCP MRCGP R S Brown FCP FRCP Department of Paediatrics, Stoke Manderville Hospital, Aylesbury HP21 8AL Keywords: insulin-dependent diabetes mellitus; coeliac disease
A 3%-year-old girl, who initially presented with insulindependent diabetes mellitus (IDDM) 12 months previously, developed coeliac disease. We report this case to highlight the increased prevalence of coeliac disease in children with IDDM.
Case report A 2%-year-old girl presented with a 2-week history of polyuria, polydipsia and lethargy. She had suffered recent vaginal and perianal candidiasi. Her stools were occasionally bulky. Her father was a baker; there was no family history of diabetes. Examination revealed her height was on the 25th centile and her weight less than the 3rd centile. There were no signs of infection. Blood glucose was 26.9 mmol/l. She responded well to subcutaneous insulin; her weight increased to the 25th centile 6 weeks after diagnosis of IDDM. Insulin dosage fell from 7 units to 4 units of monotard insulin after 3 months. Rising blood glucose levels 5 months after the diagnosis of IDDM required increases in the dose of monotard insulin (6 units at 6 months) by doctors in consultation with her parents. Glycaemic control remained good. At the age of 3% years her mother complained that, she was miserable and when unwell her blood glucose became low. She had always been a poor eater and continued to pick at her food. Mealtimes were often difficult for the famiy. During the next few months she lost weight and her insulin requirements fell to zero and remained so for 2 weeks. Her pale bulky stools became more frequent and she developed marked peripheral oedema and abdominal distension. Her serum albumin was 26 g/l. A small intestinal biopsy revealed villous atrophy, and she was commenced on a gluten free diet. Her appetite increased, she became lively, gained weight and her stools returned to normal. Her peripheral oedema resolved and her insulin requirements rapidly increased. Nine months later her health was excellent.
Intestinal tuberculosis: an ongoing diagnostic dilemma
Th Lingenfelser MD G Adams E Steyn J Zak T Sole I N Marks Gastrointestinal Clinic, Department of Medicine, University ofCape Town and Groote Schuur Hospital, Cape Town, South Africa Keywords: intestinal tuberculosis; differential diagnosis
The diagnosis of intestinal tuberculosis (CB) is often difficult, even in patients in whom the diagnosis is strongly suspected. Case report A 22-year old woman from a rural area in the South Western Cape was admitted in August 1988 to Groote Schuur
Case presented The occurrence of IDDM and coeliac disease together in to Section of one child was first described by Walker-Smith in 19691. -Paediatrics, Since then studies have reported the incidence of coeliac 23 March 1990 disease in diabetic children as high as 3.5%2, although figures vary according to geographic region. Varying prevalence rates may have a genetic origin; both IDDM and coeliac disease are in part genetically determined and associated with HLA markers B8 and DR3. The age of onset of IDDM seems to be an important predictor of the chances of coeliac disease developing. In a literature pool of children with both conditions 26.7% developed diabetes before the age of 2 years, and another 23.3% before the age of 6 years3. Interestingly the age of diagnosis of coeliac disease was strikingly late when compared with the mean age for the diagnosis of coeliac disease in non-diabetic children; in addition there was a predominance of females. An important discovery has been the method for the detection of antigliadin antibodies in patients with coeliac disease4. The sensitivity of IgG antigliadin antibodies is close to 100% in children with florid coeliac disease and, if combined with IgA antibodies, show a specificity of 97%. It is important to note that transient false positive results may occur during the months after the diabetes manifests itself, and to ensure a high specificity, estimation of antibodies should be delayed for one year after the diagnosis of IDDM. We were happy to make the diagosis of coeliac disease on the basis of a single biopsy in view of recent recommendations'. We urge consideration of the diagnosis of coeliac disease in a young diabetic child with symptoms of malabsorption or an unexpected significant decrease in insulin requirements and prompt treatment with a gluten free diet to restore well being. Discussion
References 1 Walker-Smith JA, Grigor W. Coeliac disease in a diabetic child. Lancet 1969;i:1021 2 Savilanti E, Simeil 0, KoslimiesA, et aL Celiac disease in insulindependent diabetes mellitus. J Pediatr 1986;108:690-3 3 Koletzko S, Burgin-Wolff A, Koletzko B, et aL Prevalence of coeliac disas in diabetic children and adolescents. Eur JPediatr 1988;148:113-17 4 Burgin-Wolff A, Bertele RM, Berger R, et aL A reliable screening test for childhood celiac disease: fluorescent immunosorbent test for gliadin antibodies. J Pediatr 1983;102:655-60
(Accepted 5 February 1991. Correspondence to A R Harnden, 24 Purcell Road, Wadham Park, Marston, Oxford OX3 OHB)
0141-0768/91/ 070436-01402.00/0 @ 1991 The Royal Society of Medicine
Hospital with a 6-month history of watery diarrhoea, abdominal pain, mild fever and weight loss (from 56 to 48 kg). Since 1985, she had insulin-dependent diabetes mellitus which had become poorly controlled in recent months. There was a strong family history of pulmonary TB. Physical examination revealed only weight loss and mild fever. The erythrocyte sedimentation rate (ESR) was 65 mm/h, sigmoidoscopy normal and repeated stool cultures were negative. An X-ray of the chest showed a calcified hilar lymph node, but evidence for TB proved negative (sputum, gastric aspirate and early morning urine specimens). The Mantoux was negative. A tentative diagnosis of early-onset diabetic diarrhoea was difficult to sustain in the face of equivocal tests for autonomic neuropathy and, of course, the mild fever and raised ESR. The patient was discharged at her own request. Her second admission in January 1989 was prompted by continuing diarrhoea and weight loss (from 48 to 36 kg). The patient was obviously ill, but physical examination was again unremarkable apart from mild pyrexia. The ESR was 56 mm/h. A CT-scan of the chest verified the calcified hilar
0141-0768/91/ 070436-02402.00/0 © 1991 The Royal Society of Medicine
5 European Society of Paediatric Gastroenterology and Nutrition. Revised criteria for the diagnosis of coeliac disease. Arch Dis Child 1990;65:909-11
Journal of the Royal Society of Medicine Volume 84 July 1991
Insulin dependent diabetes mellitus and coeliac disease
A R Harnden MRCP MRCGP R S Brown FCP FRCP Department of Paediatrics, Stoke Manderville Hospital, Aylesbury HP21 8AL Keywords: insulin-dependent diabetes mellitus; coeliac disease
A 3%-year-old girl, who initially presented with insulindependent diabetes mellitus (IDDM) 12 months previously, developed coeliac disease. We report this case to highlight the increased prevalence of coeliac disease in children with IDDM.
Case report A 2%-year-old girl presented with a 2-week history of polyuria, polydipsia and lethargy. She had suffered recent vaginal and perianal candidiasi. Her stools were occasionally bulky. Her father was a baker; there was no family history of diabetes. Examination revealed her height was on the 25th centile and her weight less than the 3rd centile. There were no signs of infection. Blood glucose was 26.9 mmol/l. She responded well to subcutaneous insulin; her weight increased to the 25th centile 6 weeks after diagnosis of IDDM. Insulin dosage fell from 7 units to 4 units of monotard insulin after 3 months. Rising blood glucose levels 5 months after the diagnosis of IDDM required increases in the dose of monotard insulin (6 units at 6 months) by doctors in consultation with her parents. Glycaemic control remained good. At the age of 3% years her mother complained that, she was miserable and when unwell her blood glucose became low. She had always been a poor eater and continued to pick at her food. Mealtimes were often difficult for the famiy. During the next few months she lost weight and her insulin requirements fell to zero and remained so for 2 weeks. Her pale bulky stools became more frequent and she developed marked peripheral oedema and abdominal distension. Her serum albumin was 26 g/l. A small intestinal biopsy revealed villous atrophy, and she was commenced on a gluten free diet. Her appetite increased, she became lively, gained weight and her stools returned to normal. Her peripheral oedema resolved and her insulin requirements rapidly increased. Nine months later her health was excellent.
Intestinal tuberculosis: an ongoing diagnostic dilemma
Th Lingenfelser MD G Adams E Steyn J Zak T Sole I N Marks Gastrointestinal Clinic, Department of Medicine, University ofCape Town and Groote Schuur Hospital, Cape Town, South Africa Keywords: intestinal tuberculosis; differential diagnosis
The diagnosis of intestinal tuberculosis (CB) is often difficult, even in patients in whom the diagnosis is strongly suspected. Case report A 22-year old woman from a rural area in the South Western Cape was admitted in August 1988 to Groote Schuur
Case presented The occurrence of IDDM and coeliac disease together in to Section of one child was first described by Walker-Smith in 19691. -Paediatrics, Since then studies have reported the incidence of coeliac 23 March 1990 disease in diabetic children as high as 3.5%2, although figures vary according to geographic region. Varying prevalence rates may have a genetic origin; both IDDM and coeliac disease are in part genetically determined and associated with HLA markers B8 and DR3. The age of onset of IDDM seems to be an important predictor of the chances of coeliac disease developing. In a literature pool of children with both conditions 26.7% developed diabetes before the age of 2 years, and another 23.3% before the age of 6 years3. Interestingly the age of diagnosis of coeliac disease was strikingly late when compared with the mean age for the diagnosis of coeliac disease in non-diabetic children; in addition there was a predominance of females. An important discovery has been the method for the detection of antigliadin antibodies in patients with coeliac disease4. The sensitivity of IgG antigliadin antibodies is close to 100% in children with florid coeliac disease and, if combined with IgA antibodies, show a specificity of 97%. It is important to note that transient false positive results may occur during the months after the diabetes manifests itself, and to ensure a high specificity, estimation of antibodies should be delayed for one year after the diagnosis of IDDM. We were happy to make the diagosis of coeliac disease on the basis of a single biopsy in view of recent recommendations'. We urge consideration of the diagnosis of coeliac disease in a young diabetic child with symptoms of malabsorption or an unexpected significant decrease in insulin requirements and prompt treatment with a gluten free diet to restore well being. Discussion
References 1 Walker-Smith JA, Grigor W. Coeliac disease in a diabetic child. Lancet 1969;i:1021 2 Savilanti E, Simeil 0, KoslimiesA, et aL Celiac disease in insulindependent diabetes mellitus. J Pediatr 1986;108:690-3 3 Koletzko S, Burgin-Wolff A, Koletzko B, et aL Prevalence of coeliac disas in diabetic children and adolescents. Eur JPediatr 1988;148:113-17 4 Burgin-Wolff A, Bertele RM, Berger R, et aL A reliable screening test for childhood celiac disease: fluorescent immunosorbent test for gliadin antibodies. J Pediatr 1983;102:655-60
(Accepted 5 February 1991. Correspondence to A R Harnden, 24 Purcell Road, Wadham Park, Marston, Oxford OX3 OHB)
0141-0768/91/ 070436-01402.00/0 @ 1991 The Royal Society of Medicine
Hospital with a 6-month history of watery diarrhoea, abdominal pain, mild fever and weight loss (from 56 to 48 kg). Since 1985, she had insulin-dependent diabetes mellitus which had become poorly controlled in recent months. There was a strong family history of pulmonary TB. Physical examination revealed only weight loss and mild fever. The erythrocyte sedimentation rate (ESR) was 65 mm/h, sigmoidoscopy normal and repeated stool cultures were negative. An X-ray of the chest showed a calcified hilar lymph node, but evidence for TB proved negative (sputum, gastric aspirate and early morning urine specimens). The Mantoux was negative. A tentative diagnosis of early-onset diabetic diarrhoea was difficult to sustain in the face of equivocal tests for autonomic neuropathy and, of course, the mild fever and raised ESR. The patient was discharged at her own request. Her second admission in January 1989 was prompted by continuing diarrhoea and weight loss (from 48 to 36 kg). The patient was obviously ill, but physical examination was again unremarkable apart from mild pyrexia. The ESR was 56 mm/h. A CT-scan of the chest verified the calcified hilar
0141-0768/91/ 070436-02402.00/0 © 1991 The Royal Society of Medicine
5 European Society of Paediatric Gastroenterology and Nutrition. Revised criteria for the diagnosis of coeliac disease. Arch Dis Child 1990;65:909-11
