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CASE 29


PD is a 38-year-old woman whom you see in follow-up for investigation of abnormal results of liver function tests and vague chronic fatigue. During an otherwise uneventful pregnancy, 2 years earlier, some transient moderate increase (twofold to threefold) in liver enzymes was noted, with simultaneous complaints of abdominal cramps and bloating.


At that time, stool cultures for Clostridium difficile toxin were positive and her symptoms resolved after treatment with metronidazole. She is currently experiencing diarrhea of 2 weeks’ duration, with fatty foul-smelling stools and frequent abdominal cramps, but on questioning she admits that these symptoms have been essentially intermittent for 10 years or more. However, she does casually mention that when she is on a lactose-free diet the abdominal cramps are less frequent and less severe.


On questioning she is emphatic that there is no family history of inflammatory bowel disorders, that she is not a drug user and that she does not drink alcoholic beverages, has taken no medications, has not been exposed to hepatoxins (as far as she knows), and has not traveled. Blood work revealed a moderate elevation (twofold) in liver enzymes and a deficiency in production of clotting factors synthesized exclusively by the liver. Stool culture was normal, and B cell and T cell numbers and function were normal, as were serum immunoglobulin titers. An enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) was negative.



QUESTIONS FOR GROUP DISCUSSION



1. Our investigation should begin by considering the possible causes for diarrhea and increase in liver enzymes. Explain why each of the following is not a likely explanation.
(a) Clostridium difficile infection

(b) Intestinal malignancy

(c) Cystic fibrosis

(d) Primary biliary cirrhosis

(e) Amyloidosis

2. Given the chronic nature of the disorder, evidence for malabsorption, and the relapsing/remitting nature of the disease, an intestinal biopsy was performed. What did this biopsy reveal?

3. Based on the clinical history and the intestinal biopsy, PD was diagnosed with celiac sprue. What causes this disease?

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Jun 18, 2016 | Posted by in IMMUNOLOGY | Comments Off on 29

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