Bone Abstracts

Background: Bone health is negatively affected in children with celiac disease. Alterations in calcium and vitamin D metabolism are frequently encountered in children with celiac disease but rickets is rarely a presenting complaint.

Presenting problem: The patient was first admitted at the age of 13 due to waddling gait and weight loss for 3 years.

Clinical management: Detailed history revealed that loss of appetite and intermittent diarrhea were apparent since 3–4 years of age. His past medical history was otherwise unremarkable. Physical examination revealed a listless child with a height of 130.7 cm (SDS, −3.6), weight 16.5 kg (SDS, −5.6), BMI 9.7 (SDS, −11.6), genu valgum, rachitic rosary, and pubertal stage Tanner I. Laboratory studies showed iron deficiency anemia, mildly elevated AST and ALT, hypocalcemia, hypophosphatemia, low vitamin D, and elevated levels of alkaline phosphatase and parathormone. Left hand X-ray revealed metaphyseal widening and fraying. Rickets due to malabsorption was considered. Positive celiac antibodies resulted in endoscopic and pathological evaluation, which confirmed the diagnosis. Gluten-free diet was introduced and intramuscular vitamin D (a single dose of 600 000 IU) along with oral calcium (75 mg/kg per day for 1 week) was given. Evaluation after 3 months revealed a contented and alert child with a weight gain of 13 kg (29.5 kg, SDS −3.0; BMI 17.1, SDS −0.78) and normal levels of calcium, phosphorus, alkaline phosphatase, 25-OH vitamin D, and parathormone.

Discussion: Undiagnosed celiac disease may result not only in vitamin D and calcium deficiency but also in rickets. Intramuscular administration of high dose of vitamin D is effective along with gluten-free diet and oral calcium.