ESPE Abstracts

Background: Celiac disease (CD) is a chronic immune-mediated intestinal inflammatory disease due to gluten intolerance in genetically predisposed patients leading to mal-absorption followed by short stature, frequently associated to immune-mediated diseases (IDDM, autoimmune-thyroiditis, Addisson), syndromes (Down, Williams, Turner, selective IgA deficiency) and increased risk of non-Hodgkin and T-cell lymphoma. Its diagnosis is based on serological antibodies confirmed by intestinal biopsy. CD treatment consists of gluten free diet (GFD) resulting in rapid catch-up growth. CD can be unusually associated with growth hormone deficiency (GHD). Therefore, IGF1 and GH stimulation should be performed after GFD since their levels are affected by nutritional status.

Cases: A 2-year-old-male presented with failure to thrive, vomiting, diarrhea, abdominal pain and distention, weight: 9 kg (0.1percentile) and length: 80cm (2percentile). Laboratory studies showed positive CD antibodies confirmed by intestinal biopsy. At 4 years and after 2 years of GFD, no improvement was seen in weight: 12 kg (0.3percentile) and height: 91cm (0.4percentile). Along with low IGF 1 (31.7ng/ml), GH studies showed GHD (GH<3.4ng/ml). At 10 years, weight and height increased to 24 kg (4.9percentile) and 132cm (14.3percentile) respectively following GH therapy. A 9 year-5-month-old-female presented for short stature, without other symptoms, with Tanner Stage 1, weight: 19 kg (0.1percentile), length: 112cm (0percentile). CD antibodies and intestinal biopsy were positive. GH studies showed GHD (<5ng/ml). We started GFD, GH therapy and Triptorelin to delay puberty. An excellent improvement was found at 11 year-old in weight: 37 kg (49percentile) and height: 135cm (10.7percentile).

Discussion: In children presenting with short stature, CD should be ruled out by serological antibodies or intestinal biopsy. CD children should not be investigated during active disease because IGF1 and GH studies could be falsely low due to low nutritional status. After one year of strict GFD without good catch-up growth, GH studies should be considered to rule out GHD. The association of CD-GHD is rare but should be considered with a complete evaluation of all pituitary hormones and pituitary-MRI

Conclusion: CD should be ruled out in every child presenting with short stature. After one year of strict GFD without a good catch-up growth, an association with GHD could be possible and GH stimulation with pituitary-MRI should be done. In such cases, GH therapy should be started at standard doses to reach complete catch-up growth. During GH therapy, we should monitor GFD, auto-immune and malignancy diseases. In both cases presented, one showed good response while the other had an acceptable response.