title: Celiac disease: A missed cause of metabolic bone disease.
abstract: BACKGROUND
  Celiac disease (CD) is a highly prevalent autoimmune disease. The symptoms of CD are varied and atypical, with many patients having no gastrointestinal symptoms. Metabolic bone disease (MBD) is a less recognized manifestation of CD associated with spectrum of musculoskeletal signs and symptoms, viz. bone pains, proximal muscle weakness, osteopenia, osteoporosis, and fracture. We here report five patients who presented with severe MBD as the only manifestation of CD.
  
  
  METHODS
  Records of 825 patients of CD diagnosed during 2002-2010 were retrospectively analyzed for clinical features, risk factors, signs, biochemical, and radiological parameters.
  
  
  RESULTS
  We were able to identify five patients (0.6%) of CD who had monosymptomatic presentation with musculoskeletal symptoms and signs in the form of bone pains, proximal myopathy, and fragility fractures without any gastrointestinal manifestation. All the five patients had severe MBD in the form of osteopenia, osteoporosis, and fragility fractures. Four of the five patients had additional risk factors such as antiepileptic drugs, chronic alcohol consumption, malnutrition, and associated vitamin D deficiency which might have contributed to the severity of MBD.
  
  
  CONCLUSIONS
  Severe metabolic disease as the only presentation of CD is rare. Patients show significant improvement in clinical, biochemical, and radiological parameters with gluten-free diet, calcium, and vitamin D supplementation. CD should be looked for routinely in patients presenting with unexplained MBD.
authors.affiliation: Department of Endocrinology, PGIMER, Chandigarh, India.
authors.forename: Ashu
authors.initials: A
authors.lastname: Rastogi
authors.forename: Sanjay K
authors.initials: SK
authors.lastname: Bhadada
authors.forename: Anil
authors.initials: A
authors.lastname: Bhansali
authors.forename: Rakesh
authors.initials: R
authors.lastname: Kochhar
authors.forename: Ramakrishnan
authors.initials: R
authors.lastname: Santosh
keywords: Celiac disease; fractures; metabolic bone disease; osteomalacia; osteoporosis