Diagnostic Challenges of SLE & Celiac Sprue

Patients with celiac disease can also have anti-single- and anti-double-stranded DNA antibodies, as well as anti-cardiolipin antibodies.² In a 2008 study, 2.4% of patients out of 246 biopsy-proven celiac disease patients were found to have SLE, diagnosed anywhere from two to 10 years after the diagnosis of celiac disease had been made.³

Initially, only our patient’s ANA was positive, but three weeks later the double-stranded DNA antibody became positive. His complements were low since the time of our initial encounter. His oral ulcers, transaminitis and subsequent liver biopsy results all could have been due to celiac disease. It was not until his cytopenia worsened, despite an unremarkable bone marrow biopsy, that we started to consider an SLE diagnosis, which was confirmed by renal biopsy.

It was surprising how ill he became over the course of three weeks, even while taking high doses of prednisone. His third-degree atrioventricular block was thought to be due to lupus, although this is very rare. Complete heart block has been reported in only a handful of case reports of adult patients with SLE or Sjögren’s syndrome; interestingly, not all of the patients in these reports had anti-Ro or anti-La antibodies.

This case demonstrates that patients with SLE may present with gastrointestinal complaints or symptoms of malabsorption. Conversely, if a patient with celiac disease presents with signs or symptoms that might be better explained by a diagnosis of SLE, it would be prudent to consider that diagnosis.

Leslie Pack Ranken, MD, completed her rheumatology training at Wake Forest Baptist Medical Center and serves as an assistant professor in the Department of Internal Medicine at Carolinas Medical Center in Charlotte, N.C.

References

1. Marsh MN. Gluten, major histocompatibility complex, and the small intestine. A molecular and immunobiologic approach to the spectrum of gluten sensitivity (‘celiac sprue’). Gastroenterology. 1992 Jan;102(1):330–354.
2. Lerner A, Blank M, Lahat N, Shoenfeld Y. Increased prevalence of autoantibodies in celiac disease. Dig Dis Sci. 1998 Apr;43(4):723–726.
3. Freeman HJ. Adult celiac disease followed by onset of systemic lupus erythematosus. J Clin Gastroenterol. 2008 Mar;42(3):252–255.