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Case Report
Revised

Case Report: Cerebral venous thrombosis revealing celiac disease

[version 2; peer review: 2 approved]
PUBLISHED 10 Sep 2021
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OPEN PEER REVIEW
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Abstract

Celiac disease (CD) is an autoimmune enteropathy resulting from intolerance of an individual genetically predisposed to gluten. It has a large clinical polymorphism ranging from a classic digestive clinical presentation due to the malabsorption syndrome to extra-intestinal symptoms. Among the hematologic abnormalities, venous thromboembolic disease (VTE) has been reported, and they are most often located in the abdomen or lower limbs, but the cerebral localization was exceptionally described. We report a case of CD revealed by cerebral thrombophlebitis.
A 44-year-old patient with no medical history and no drug intake, presented with hemiplegia followed by a status epilepticus in a context of apyrexia, initially hospitalized in intensive care. Magnetic imaging resonance displayed a cerebral venous thrombosis of the sigmoid sinus requiring anticoagulant treatment, then transferred to our department for the etiological investigation. On questioning, the patient reported chronic diarrhea and weight loss with no other associated symptoms. The examination revealed an underweight patient with pale conjunctiva, improvement of her deficit symptoms, and no other abnormalities.
Laboratory tests noted biological signs of malabsorption. The thrombophilia assessment revealed a protein C deficiency with a slight increase in anticardiolipin antibodies and anti-Beta 2 glycoprotein 1 antibodies. Immunological tests noted positives anti-transglutaminase and IgA anti-endomysium antibodies. Duodenal biopsy demonstrated villous atrophy. After ruling out the other causes of VTE, the diagnosis of cerebral venous thrombosis secondary to CD was retained.
Early diagnosis and treatment of CD improves the quality-of-life for patients and may spare them various long-term or even fatal complications.

Keywords

Celiac disease; venous thromboembolic disease; malabsorption syndrome; Hypercoagulability.

Revised Amendments from Version 1

I would like to express my sincere thanks to the reviewers for their constructive comments and suggestions for improving the manuscript .
This versions respond to the reviewer’s advices and includes the rest of thrombophilia assessment which is negative factor 2 mutation and lupus anticoagulant, and immunological test which is negative antinuclear antibodies.
I mentioned that protein C deficiency has been reported in previous studies related to CD and due to vitamin K deficiency and particularly malabsorption.
I added two new paragraphs about thromboembolic and cardiovascular complications associated with CD and a proportion of CD is nowadays found while screening in-at risk groups.

To read any peer review reports and author responses for this article, follow the "read" links in the Open Peer Review table.

Introduction

Celiac disease (CD) is an autoimmune enteropathy resulting from intolerance of an individual genetically predisposed to gluten. It affects 0.6–1.0% of the world population.1 It has a large clinical polymorphism ranging from a classic digestive clinical presentation due to the malabsorption syndrome; diarrhea and abdominal pain; to extra-intestinal symptoms.2 It requires lifelong adherence to a gluten-free diet.

Among the hematologic abnormalities, venous thromboembolic disease (VTE) has been reported in the literature, with a 25% higher risk in patients with CD compared with the general population.3 VTE is most often located in the abdomen or lower limbs, but the cerebral localization has been exceptionally described.4

Here, we report a case of CD revealed by cerebral venous thrombosis discovered while exploring a status epilepticus. This clinical situation remains exceptional and unusual during CD.

Case report

A 44-year-old Tunisian female patient, housewife, with no medical history and no drug intake, presented with hemiplegia followed by a status epilepticus in a context of apyrexia, initially hospitalized in intensive care. Neuroimaging displayed a cerebral venous thrombosis of the superior sagittal sinus (Figure 1) requiring anticoagulant treatment (low-molecular -weight -heparin 100 IU/kg × 2/24 h followed by Warfarin for 6 months. After treatment, the patient was transferred to our department of Internal Medicine for the etiological investigation.

c50af9f5-fbae-4c74-83a3-5b0ed7b86c92_figure1.gif

Figure 1.

Cerebral CT scan (A, B: axial plane, C: Sagittal plane) showing a venous thrombosis of superior sagittal sinus (A, C) and a left temporoparietal porencephalic cyst (B).

On examination, the patient reported chronic diarrhea and weight loss with no other associated symptoms. Physical examination revealed an underweight patient (BMI:16.9) with pale conjunctiva, improvement of hemiparesis, and no other abnormalities. Laboratory tests noted biological signs of malabsorption. [(Hemoglobin: 10 g/dl (normal range > 12 g/dl), Albumin: 17.9 g/L, cholesterol: 2.8 mmol/l (normal range < 5,1 mmol/l).]

Thrombophilia assessment revealed a protein C deficiency 57% (normal range: 70-120%), a slight increase in anticardiolipin antibodies 11 IU/ml (normal range <7 UI/ml) and anti-Beta 2 glycoprotein 1 antibodies 18 IU/ml (normal range < 8 IU/ml) in two tests with 12 weeks apart, normal levels of protein S, antithrombin III and homocysteinemia, and negative factor II mutation, factor V Leiden and lupus anticoagulant. Immunological tests noted positive anti-transglutaminase >50 IU/ml (normal range < 8 U/ml) and anti-endomysium antibodies at 0.6 g/L (normal range < 0.2 g/L) with negative antinuclear antibodies.

From examination and laboratory results, VTE was diagnosed and CD as the cause was suspected. Duodenal biopsy demonstrated villous atrophy, meaning that the diagnosis of CD could be retained after ruling out the other causes of VTE as the neoplastic aetiologies; gynaecologic examination didn’t show a lesion, neither chest radiography or colonoscopy.

The outcome of the patient was deemed favorable with anticoagulant therapy (low-molecular weight Heparin followed by Warfarin for 6 months without bleeding complications), combined with a gluten-free diet during the follow-ups over a period of 3-years in our outpatient consultation.

Discussion

CD is defined as a chronic immune-mediated small intestinal enteropathy caused by gluten intolerance in genetically predisposed individuals.5 The activation of both the innate and adaptive response of the immune system, following the ingestions of gluten leads to damage to the proximal mucosa of the small intestine, resulting in the malabsorption of nutrients and the appearance of extra-intestinal manifestations.

CD is a systemic disorder, with different forms of clinical manifestations, from a classic digestive clinical presentation to extra-intestinal symptoms. The intestinal form of CD is more commonly found in the pediatric population6 and rarely in adults. It includes diarrhea, which is a common presenting sign, in addition to malabsorption symptoms.

Nevertheless, extra-intestinal manifestations are being increasingly recognized, most likely due to better awareness of atypical presentations. They can include chronic fatigue, anemia, osteoporosis, recurrent aphthous stomatitis, elevated liver enzymes, joint or muscle pain, epilepsy, peripheral neuropathy, and infertility7 Therefore, it is reported that extra-intestinal manifestations may appear before the diagnosis of CD, as shown in our case.

It has been recognized that chronic inflammation is also an independent risk factor for VTE as the consequence of inflammatory cytokines and oxidative stress on the coagulation cascade is demonstrated.8

Our patient presented a deficiency of protein C; which has been reported in previous studies related to CD and due to vitamin K deficiency and particularly malabsorption,9 results in the over activity of coagulation factors V and VIII thus increasing the risk for thrombotic events.9 We noted also a slight increase in anticardiolipin antibodies and anti-Beta 2 glycoprotein 1 antibodies but it didn’t respond to antiphospholipid syndrome criteria which was reported to be associated to CD10 and as shown in several studies where a higher prevalence of autoantibodies among patients with CD, including anti-phospholipid antibodies (see review of studies in9). It is possible that these anti-phospholipid antibodies might also contribute to hypercoagulability.

VTE as a presentation of CD is unusual and rarely reported, especially since this thrombosis is located in the cerebrum and its first manifestation is a status epilepticus.

In fact, other central nervous system manifestations were reported more associated to CD than cerebral thrombosis, including cerebellar ataxia, peripheral neuropathy, seizures, headache, cognitive impairment, and psychiatric symptoms.11 Seizures are nonspecific and can simply be a consequence of cerebral thrombosis.12,13

In addition, thromboembolic manifestations and cardiovascular disease events represent serious extraintestinal manifestations of CD due to malabsorption (vitamin B12 deficiency, vitamin B6 deficiency, folic acid deficiency, vitamin D deficiency, and carnitine deficiency), chronic inflammation, endothelial dysfunction, thrombocytosis, protein C and S deficiency, thrombophylic autoantibodies and atherosclerosis.14 So a thrombosis assessment should be considered in patients with CD.

The seriousness of these manifestations show that malabsorption syndrome should be systematically investigated to explore any symptoms due to systemic complications of malabsorption, for early diagnosis and better prognosis.15 These factors must be investigated and corrected by a gluten free diet.16

Furthermore, a long diagnostic delay may increase the risk of poor clinical response.17

A significant proportion of CD are found while screening in-at risk groups such as, type 1 diabetes T1D, autoimmune thyroidal and liver diseases, IgA deficiency, family risk, and Down, Turner, and Williams syndromes.15

Early diagnosis and treatment of CD improves the quality-of-life for patients and may spare them various long-term or even fatal complications like thromboembolic diseases.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.

Consent

Written informed consent for publication of the clinical details and associated images was obtained from the patient.

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Wiem R, Sondess A, Jihene C et al. Case Report: Cerebral venous thrombosis revealing celiac disease [version 2; peer review: 2 approved]. F1000Research 2021, 10:680 (https://doi.org/10.12688/f1000research.54233.2)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 2
VERSION 2
PUBLISHED 10 Sep 2021
Revised
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Reviewer Report 16 Sep 2021
Bouomrani Salem, Department of Internal Medicine, Military Hospital of Gabes, Gabes, Tunisia 
Approved
VIEWS 3
The authors have made the requested changes. The paper in ... Continue reading
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HOW TO CITE THIS REPORT
Salem B. Reviewer Report For: Case Report: Cerebral venous thrombosis revealing celiac disease [version 2; peer review: 2 approved]. F1000Research 2021, 10:680 (https://doi.org/10.5256/f1000research.77205.r94003)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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15
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Reviewer Report 13 Sep 2021
Juha Taavela, Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland;  Central Finland Central Hospital, Jyväskylä, Finland 
Approved
VIEWS 15
I accept the article by Wiem et al. entitled "Case Report: Cerebral venous thrombosis revealing celiac disease". The ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Taavela J. Reviewer Report For: Case Report: Cerebral venous thrombosis revealing celiac disease [version 2; peer review: 2 approved]. F1000Research 2021, 10:680 (https://doi.org/10.5256/f1000research.77205.r94004)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 1
VERSION 1
PUBLISHED 28 Jul 2021
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Reviewer Report 27 Aug 2021
Bouomrani Salem, Department of Internal Medicine, Military Hospital of Gabes, Gabes, Tunisia 
Approved with Reservations
VIEWS 22
The authors present an original case report of cerebral venous thrombosis occurring in a patient with celiac disease and discuss the causal link between these two pathologies. Indeed, thromboembolic complications are part of the possible extra-intestinal manifestations of this disease ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Salem B. Reviewer Report For: Case Report: Cerebral venous thrombosis revealing celiac disease [version 2; peer review: 2 approved]. F1000Research 2021, 10:680 (https://doi.org/10.5256/f1000research.57696.r91588)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Views
33
Cite
Reviewer Report 23 Aug 2021
Juha Taavela, Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland;  Central Finland Central Hospital, Jyväskylä, Finland 
Approved with Reservations
VIEWS 33
The authors have found celiac disease in a patient with venous thromboembolism. I especially like the conclusion that early diagnosis of CD is needed which is an important topic in CD (Popp et al., 2019). The case report is interesting, ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Taavela J. Reviewer Report For: Case Report: Cerebral venous thrombosis revealing celiac disease [version 2; peer review: 2 approved]. F1000Research 2021, 10:680 (https://doi.org/10.5256/f1000research.57696.r92258)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 2
VERSION 2 PUBLISHED 28 Jul 2021
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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