Muzammil Jamil, Syed Irfan Ahmed, M Naseemullah.
Selective IgA Deficiency with Coeliac Disease.
J Rawal Med Coll Jan ;5(1):38-40.

Miss F.F., a 25 year old lady was admitted in the Department of Medicine, Holy Family Hospital Rawalpindi for the evaluation of chronic diarrhoea. This had persisted for more than ten years. She had been asymptomatic till her eleventh birthday after which she started to have episodes of cough and wheezing as well as recurrent upper respiratory tract infection (URTI). She was diagnosed to be suffering from bronchial asthma and started on oral bronchodilators and inhaled steroids. The symptoms of asthma improved but she required frequent courses of oral antibiotics for recurrent URTI. At the age of 15 years she developed a diarrheal illness of variable frequency and duration. Usually the daily frequency remained between five to eight episodes with diarrhoea also occurring at night. On most occasions the episodes persisted for two to three weeks followed by a diarrhoea-free period of four to six weeks after which she again relapsed. Stools did not contain blood or mucus and she remained afebrile. However she complained of generalized pruritis with the occasional appearance of an urticarial, erythematous rash that responded to anti-histamines. Stools were usually of small volume, did not stick, were accompanied by abdominal cramps and the frequency decreased in the fasting state. However they were watery at times, with the patient developing significant dehydration to warrant intravenous fluids and electrolytes. Repeated stool examinations were normal. Despite repeated courses of metronidazole prescribed by her father, a doctor, and other physicians, she remained symptomatic. Two years later, at age 17, she developed relapsing polyarthritis of the large joints. This manifested without a preceding history of sore throat, burning micturition or morning stiffness. She was given various NSAIDs and responded well. However the other problems continued unabated and despite being seen by various specialists over the years she remained symptomatic. At the time of presentation she weighed 40 Kg. Positive findings on clinical examination were mild pallor, leuconychia and a few scattered rhonchi on auscultation of the chest.

Investigations revealed Hb. 9.9 g/dl, PCV 35.7, MCV 79.5 fl, MCH 24.3 pg and MCHC 30.5 g/dl. The TLC was 5700/cmm with a normal DLC, platelet count 290.000/cmm and ESR 04 mm. She had a serum albumin of 2.7 g/ dl, prothrombin time 15 seconds, APTT 26 seconds, serum urea 36 mg/dl and serum creatinine 1 mg/dl. Serum calcium was 8.8 mg/dl, the corrected calcium level being normal. Serum sodium was 142 meq/I and serum potassium 3.4 meq/l. Stool examination showed cysts of Giardia lamblia. She was given a course of Tinidazole and responded to a degree, only to relapse after ten days. A repeat stool examination was normal. The 24 hours faecal fat was 5.7 g.

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