A 43-year-old woman with long-standing arthritis treated with methotrexate is evaluated for diarrhea lasting 4 months, has evolved without rectal bleeding, accompanied by marked loss of rectal bleeding (10 kg).
Physical examination was normal.
Mild iron deficiency anemia (hemoglobin 9.2 g/dl, ferritin 2 ng/ml) was detected with tumor markers in normal range.
Ileocolonoscopy was performed with normal biopsies at both levels.
Upper endoscopy showed the presence of nodular mucosa with millimetric erosions patched in the duodenal bulb, while in the 2nd and 3rd duodenal portion there were longitudinal erosions and minimal superficial folds erosions.
In the directed interview, the patient reported aspirin or non-steroidal anti-inflammatory drugs (NSAIDs).
Helicobacter pylori infection was ruled out by patched gastric biopsies.
Coprocultives for parasites, bacteria and viruses were negative, while gastrin levels and multislice abdominal CT ruled out the existence of Zollinger-Ellison syndrome.
Histological examination of duodenal biopsies showed severe vesicular and non-malignant lesions caused by intraepithelial lymphocytes, suggestive of CD stage 3b in the Marsh-Oberhuber classification.
Antibody determination was also compatible with CD (Ig A anti- tissue transglutaminase 112 IU, normal range < 7).
The patient achieved clinical, endoscopic and histological remission after 6 months of gluten-free diet.
