Iron-deficiency anemia as the main presenting symptom of gluten-sensitive enteropathy in a 16-year-old girl

We report on a 16-year-old girl who presented with a severe iron deficiency anemia (hemoglobin level 6.2 g/dl, mean red cell volume (MCV) 66.4 fl, ser um iron concentration 19 mug/l). Her past medical and family history were n ot suggestive of celiac disaese. Because oral iron substitution did not cau se a significant increase in hemoglobin concentration, endoscopic examinati on of the upper and lower gastrointestinal tract was performed to rule out occult bleeding. Duodenal biopsy revealed severe villous atrophy with hyper plasia of the crypts and intraepithelial lymphocytosis. Titers of anti-glia din (IgG 375 U/ml, IgA 647 U/ml), anti-transglutaminase (743 U/ml), and ant i-reticulin (1:5120) antibodies were elevated. Gluten-free diet and ongoing oral iron administration led to an increase in hemoglobin concentration up to 10.9 g/dl within 2 months. Although anemia is one of the characteristic features of celiac disease, it is relatively rare as the main presenting s ymptom. The full-blown clinical picture of celiac disease with malnutrition , distended abdomen, diarrhoea and fatigue is readily recognized in childre n. However, a mono-oligosymptomatic presentation may result in a prolonged clinical course with undue diagnostic and therapeutic procedures. In order to avoid delayed diagnosis, one should bear in mind the possibility of glut en-sensitive enteropathy as a cause of iron-deficiency anemia in children.