A 16 years old male, who was diagnosed as celiac disease by family screening. Anti TTG levels were 89 Ru/ml (normal: up to 20) with normal total IgA (without any gastrointestinal symptom). Upper endoscopy was done and nodularity in bulb and second part of duodenum was observed (biopsy was obtained). Pathological examination showed marsh 3a. Laboratory tests also showed low levels of 1, 25(OH) D3 < 8, Hb: 12.4 g/dL, AST: 31 U/L, ALT: 15 U/L, ALP: 905 U/L, TSH: 1.9 mIU/L, Anti TPO: 24 IU/Ml, calcium: 10 mg/dl, and phosphore: 6.8. In his genetic study DQ2 was positive and DQ8 was negative. His TTG levels approached to the near normal levels of TTG (27 Ru/ml) after 2 years of gluten free diet (GFD). He started to have a regular diet arbitrarily and anti TTG levels got back to 110 Ru/ml without any symptom of gastrointestinal problem. After one more year of regular diet, he referred with chief complains of weight loss (about 10 kg), polyuria, and polydipsia. Blood sugar was 570 and he admitted to the hospital with an insulin therapy. He started the GFD and regular and long acting insulin to decrease blood sugar. He had no familial history of diabetes. After about 3 months, he had episode of hypoglycemia and we started dose reduction of insulin in 1 month. Finally, his FBS got back to the normal level by low dose of insulin (anti TTG level was 56 Ru/ml). Two months after GFD, we stopping insulin and after 2 months of follow up he still had normal FBS: 99 and HbA1C was 7%, but level of anti-islet cell was 7.3 IU/ml and glutamic acid decarboxylase was 200 IU/ml. He started to have gluten few times a week after about 4 months and TTG raised, and again he got symptomatic T1D. Now he is on insulin for control of FBS even with strict GFD and his Hb A1C is 7.7.
Sister of first case who was 14 years old female, had been referred with chief complains of dyspepsia, anemia, and oral aphtha. Level of anti TTG was 274 RU/ml with a normal total IgA. Endoscopy with duodenal biopsy was also done for this case and there was scalloping and fissuring in bulb and second part of duodenum. Duodenal biopsy was obtained and pathological tests showed marsh 3c. Other laboratory tests also showed Hg: 8.8, SGOT: 18 U/L, SGPT: 15 U/L, ALP: 308 u/l, 1, 25(OH) D3: 4 ng/mL, Ca: 9.8 mg/dl, TPO: 69 IU/ml, and normal TSH level. DQ2 was positive and DQ8 was negative. She had low levels of selenium (80 μg/L) and zinc was normal (899 μg/L). She started a gluten free diet and levels of TTG dropped to 50 Ru/ml. HCT was 35.7% and her symptoms were getting much better without any abdominal pain. After 2 years, she started on regular diet arbitrarily and after 1 year she referred to the clinician by chief complains of weight loss and tremor. In her laboratory tests, anti TTG level was more than 200 Ru/ml, TSH < 0.005, T3: 360 ng/ml, T4: 16.4 mμg/dl. After 4 months of GFD her symptoms got better and TSH get back to normal and methymazol was tapered without any problem. After 1 year she is in GFD and low level of anti TTG and she is still on remission of hyperthyroidism without any treatment.