Celiac disease Associated with therapy for lymphoma: case report and review of the literature

Background: Celiac disease is an autoimmune enteropathy characterized by a reaction to gluten leading to autoantibodies that have deleterious effects on several organs. Most commonly, celiac disease affects the small bowel causing an inflammatory reaction that leads to villous atrophy and thus malabsorption. While post-chemotherapy side effects are varied and affect several organ systems, one of the more common effects seen in patients is diarrhea. However, in some cases diarrhea is not an isolated event but rather a manifestation of new onset celiac disease. We propose that while celiac disease is a relatively rare condition, there may be an association with chemotherapy. Case Presentation A 66-year-old woman with a history of diffuse large B-cell lymphoma (DLBCL), immune idiopathic thrombocytopenia, and hypothyroidism, developed diarrhea and severe hypokalemia two years after completing a 6 cycle EPOCH-R chemotherapy regimen. EPOCH-R consisted of rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin. Evaluation of the patient showed villous blunting and increased intraepithelial lymphocytes in the small intestine as well as increased levels of anti-TTG antibodies, endomysial IgA antibodies, and gliadin IgG antibodies indicating a diagnosis of celiac disease. The patient had no family history of celiac disease or other enteropathies and outside of a brief case of Clostridium difficile colitis, had not experienced any side effects in the immediate post-chemotherapy period. The patient responded well to a gluten-free diet with resolution of her diarrheal symptoms. Conclusions: Celiac disease developing after completion of chemotherapy for DLBCL is a rare phenomenon with only a few examples found in the medical literature. Although diarrhea is a common side effect of chemotherapy for lymphoma, patients with delayed onset of diarrhea with failure to improve despite conventional management, should be evaluated for celiac disease.