Probiotic supplement and gluten withdrawal in gluten allergy Patients may lead to gluten tolerance: first case report

Probiotic species such as lactobacillus and bifidobacteria are known to have a major role in gluten digestion and regulation of proper functioning of gastrointestinal system however these are found to be missing in gluten allergy patients. So, here in this case we aimed to find the effect of probiotic supplementation along with gluten free diet in celiac disease patient. A case of an 8-year-old female child admitted to civil hospital, Faridkot with chief complaints of vomiting, diarrhea, weight loss, retarded growth, and malnutrition was studied. When she first visited the hospital, based on her symptoms, she was advised celiac disease workup and was found to be highly tTG IgA positive (10.62). The subject was shifted to a strict gluten free diet along with probiotic supplementation. The subject was regularly followed up for the period of four and half years in order to find improvement in her symptoms. After 4 years, gluten diet was gradually reintroduced in a phased manner; the patient remained well even on full gluten diet. This may be due to probiotic supplementation to the subject along with gluten free diet. Present case report describes the spontaneous recovery of celiac disease patient after strict adherence to gluten free diet and probiotic supplementation for a specified period. It is suggested that there should be a proper monitoring and detailed evaluation of clinical and histological markers of recovery in a patient after strict adherence to gluten free diet and probiotic supplementation in order to evaluate the possible role of probiotic supplements in the management of CD.

Adrenal Insufficiency Presenting as Hypoglycemia & Hyponatremia in a Patient With Liver Cirrhosis; Hepatoadrenal Syndrome

Hepatoadrenal syndrome is described as a progressive impairment in the adrenocortical reserve in advanced liver disease resulting in relative adrenal insufficiency (AI). This can present as critical hypoglycemia and hyponatremia as in the case described. 54 year old male with past medical history of hypothyroidism, pericardial effusion, liver cirrhosis and prior alcohol use disorder presented to the hospital with altered mental status. He felt lethargic and complained of recurrent diarrhea for a month. His blood sugar was 30 mg/dl (n=70–140 mg/dl) for which he received dextrose and his mentation improved. He was hypothermic with stable vitals otherwise. There was no skin hyperpigmentation. Labs demonstrated sodium of 123 mmol/L (n=136–145 mmol/L) and pancytopenia. TSH, ammonia, renal and hepatic functions were within normal limits except mildly elevated AST and total bilirubin. Total protein, albumin, HDL, Insulin and cortisol levels were low. Hepatitis panel was negative. CT Chest, abdomen and pelvis revealed massive abdominopelvic ascites, hepatic cirrhosis and splenomegaly. Adrenal glands appeared normal. Urine studies were consistent with salt-wasting nephropathy. Patient was started on intravenous fluids as well as dexamethasone. Diagnostic and therapeutic paracentesis was performed. Cosyntropin stimulation test revealed a baseline AM cortisol of 2.0 ug/dl (n=4.3–22.4 ug/dl), 30 min value of 4.0 ug/dl and 60 min value of 5.8 ug/dl (n=18-22ug/dl). Delta cortisol level was also low. Treatment with hydrocortisone was initiated until ACTH levels became available. To rule out sarcoidosis, ACE levels were obtained, which were normal. Dihydroxy 1,25 Vitamin D levels were low. ACTH returned as 21.7 pg/ml (n=7.2–63.3 pg/ml). 21 hydroxylase antibody was negative. MRI brain with IV contrast demonstrated no pituitary mass or abnormality. Blood cultures, body fluid cultures, AMA and ASMA were negative. Anti- tTG and Anti Gliadin antibodies were positive confirming celiac disease. Patient was started on gluten free diet which resolved his diarrhea. He responded well to steroids however, he remained intermittently confused which was thought to be related to hypoglycemic brain injury. Patient was converted to hydrocortisone PO 20 mg in AM and 10 mg in PM and advised to follow up outpatient with endocrinologist and gastroenterologist. Hepatoadrenal syndrome is an important differential to consider in patients with liver disease presenting with hypoglycemia and hyponatremia. It is a potentially life-threatening condition requiring immediate treatment and appropriate work up. The condition improves with corticosteroid replacement therapy. Reference: Anastasiadis SN, Giouleme OI, Germanidis GS, Vasiliadis TG. Relative adrenal insufficiency in cirrhotic patients. Clin Med Insights Gastroenterol. 2015;8:13–17. Published 2015 Mar 2. doi:10.4137/CGast.S18127

Genome Sequence of Kocuria polaris Strain CD08_4, an Isolate from the Duodenal Mucosa of a Celiac Disease Patient

ABSTRACT We report here the 3.8-Mb genome sequence of Kocuria polaris strain CD08_4, an isolate from the duodenal mucosa of a celiac disease patient. The genome consists of specific virulence determinant genes, antibiotic resistance genes, genes for coping with oxidative stress, and genes responsible for iron acquisition and metabolism, suggestive of its pathogenic attributes.