Diffuse coronary ectasia and acute coronary syndrome in a young man. Who is guilty? Cannabis, smoking or dyslipidemia?

with tachycardia. The electrocardiogram showed diffuse repolarization abnormalities. There was a significant rise of the troponin, serum creatine kinases, and lactate dehydrogenase levels. Cardiac ultrasound confirmed the diagnosis of myocarditis. Physical examination revealed intense face paleness, mild paresis in lower limbs and abdominal distension. There was no abnormality in heart and lung auscultation. The electrocardiogram was normal. Biological analysis revealed, a malabsorption syndrome (hypoalbuminaemia 20 g/L, lipid 0.7 g/L, iron deficiency anemia: Hb 6 gr/dL), a spontaneously low prothrombin-time and elevated liver enzymes (2 times normal). The folate and vitamine B12 were normal. An esophagogastroduodenoscopy with histological examination showed “stage IV of Marsh villous atrophy” (Fig. 1). Abdominal ultrasound and salivary gland biopsy were normal. Anti-gliadins, anti-endomysial antibodies were positive by ELISA. Antinuclear antibodies, anti-ENA, the anti-LKM1, anti-smooth muscle and anti-mitochondrial were negative. The diagnosis of celiac crisis was accepted. The gluten-free diet has been started and the patient has gained 2 kg after 10 days of diet with normalization of the biologic parameters within one month. Myocarditis (2-4) and involvement of the hepatobiliary tract are (5) exceptional complications of celiac disease. It is important for the physicians to be aware of this association to better management of these patients.