Flatulence and carpopedal spasm: more than social embarrassment.

Correspondence Flatulence and carpopedal spasm: more than social embarrassment Sir, A 61-year-old female of mixed Asian and African descent was admitted to our institution in December 2001, because of carpopedal spasms. She had been well until 13 months prior to admission, when she began to lose weight progressively, to a total of 20 pounds. She denied any loss of appetite, change in vision or bleeding. On examination, her vital signs were stable. Her abdomen was unremarkable. There were spasms of her hands and feet, and slight ankle oedema. Her stools were negative for occult blood on many occasions. Her blood results were as with an MCV of 62 fl, white blood cell count 7000/mm 3 , phosphate 1.23 mmol/l (3.8 mg/dl), and a prothombin time of 15 s (N 11–13). An electrocardiogram revealed sinus bradycardia at 60 bpm and a prolonged QT interval. Intravenous calcium gluconate was administered. Serum 25-hydroxy vitamin D was 12.48 nmol/l (N 20–200). Vitamins D and K were administered. The patient denied ever having diarrhoea or any loose bowel movements. She had severe flatulence that was persistently foul-smelling, causing social embarrassment. She was evaluated for coeliac sprue. Her serum antigliadin antibodies, both IgG and IgA, were markedly elevated. Endoscopic evaluation of her gastrointestinal tract revealed a normal colon and stomach. A proximal jejunal biopsy (Figure 1) showed severe villous flattening with crypt hypertrophy, and chronic inflammatory infiltrate in the lamina propria. No granulomas, parasites or malignant cells were seen. The patient was placed on a gluten-free diet. Her clinical response to treatment was dramatic: 18 months after discharge, she had gained 35 pounds, had little flatulence that was no longer malodorous and her laboratory values had returned to the normal range. Coeliac sprue is a relatively common disease in patients of Northern European ancestry, with a prevalence rate of 1:300, but its epidemiology is not well established in patients of African or Asian origin. 1 It is strongly associated with selected HLA class II antigens HLA-DR3 and HLA-DQw2. In the genetically-susceptible host, gluten (found in wheat, rye, barley and oats but not rice and corn) triggers both humoral and cell-mediated inflamma-tory responses that result in mucosal destruction. The diagnosis is often delayed because of the variable presentation. 2 The diarrhoea and weight loss often seen in children is rarely seen in adults. 2 In a series of 30 consecutive patients, 25 had no gastrointestinal complaints and …