Musculoskeletal Complications of Celiac Disease: A Case-Based Review

Abstract

Primary diagnosis of celiac disease (CD) in rheumatology department is not common in daily clinical practice, due to the fact that diarrhoea is usually the dominant symptom. Extra-intestinal manifestations, such as arthralgia, myalgia, osteomalacia, and osteoporosis are not rare in these patients. We present a case of a 66-year-old man, who came to the outpatient rheumatology clinic, complaining of back and knee pain. Osteopenia was observed in plain radiographs, whereas extensive laboratory testing revealed celiac disease, vitamin D deficiency, and extremely low bone mineral density (BMD) due to osteomalacia. Gluten-free diet (GFD) initiation and administration of vitamin D and calcium supplements resulted in significant symptom and BMD improvement over 6 months. A significant proportion of CD patients might present with arthralgia, arthritis, back pain, myalgia, or bone pain. Importantly, up to 75% of patients might have reduced BMD, due to osteoporosis or osteomalacia, while they also carry a significant risk for fracture. However, the introduction of GFD and calcium/vitamin D supplementation significantly ameliorates symptoms and BMD in most cases. Increased awareness of CD's musculoskeletal manifestations by rheumatologists is important for early recognition and management of this condition and its complications.

Keywords: arthralgia; back pain; celiac disease; osteomalacia; osteoporosis.

Figure 1.

Plain radiographs of thoracic (A), lumbar (B) spine and pelvis-hips (C), showing diffuse osteopenia.

Figure 2.

Bone scintigraphy depicting increased intake of Tc-99m in the skull, spine, anterior edge of the left 8th pleura, posterior edge of the right 5th pleura and the middle of the left clavicle (arrowheads), due to severe osteomalacia.