Journal of the Royal Society of Medicine Volume 83 June 1990

399

Case reports

Coeliac disease - a new cause for a high carcinoembryonic antigen

D M Melville DM FRCS R J Croft MChir FRCS I Woolf MA FRCP North Middlesex Hospital, Sterling Way, London N18 1QX Keywords: coeliac disease; carcinoma embryonic antigen; CEA

The serum concentration ofcarcinoembryonic antigen (CEA) is raised in about 30-60% of patients with colorectal carcinomas depending on the tumour stage'. It has been used particularly as a marker ofrecurrent disease following curative surgery2. Whilst slightly raised CEA levels have also been reported in some other conditions, this is the first reported case of a high CEA level in association with coeliac disease. In this case not only were the levels of CEA extremely high but they correlated with the disease activity. Case report A 43-year-old man was referred to surgical outpatients in February 1988 complaining of 4 months of bilateral ankle swelling unresponsive to diuretics. To direct questioning the patient also described a weight loss of 2 stone and some looseness of his stools. On examination the patient was thin and pale with bilateral ankle oedema but without evidence of heart failure. The patient's haemoglobin was 7.5 g/dl and the serum iron was very low (< 5 W/l [normal 9-30]) as was serum folate (1.6 ,g/l [normal 1.8-14]), albumin (27 g/dl [normal 35-50] ) and serum protein (51 g/dl [normal 62-82] ). The patient was admitted for further investigation. A sigmoidoscopy, gastroscopy, barium enema and abdominal CT scan were all normal as were three faecal occult blood tests. In view of the high suspicion of an intra-abdominal malignancy the serum CEA level was also measured and was found to be markedly elevated at 733 jg/l (normal 0-9). Despite the high CEA level, a malabsorption syndrome seemed a more likely explanation ofthe clinical picture and a small bowel meal was performed. This showed flocculation of barium in the small bowel consistent with malabsorption and a duodenal biopsy revealed the villous atrophy and crypt hyperplasia that are the hallmarks of coeliac disease. The patient was commenced on a gluten free diet, his diarrhoea

Persistent hypersecretion of ACTH in treated Addison's disease

D F Child FRCP F Lewis MB BCh C P William8 MD MRCPath Department of Medicine, Wrexham Maclor Hospital, Wre-xham, Clwyd LL13 7TD Keywords: pigmentation; ACTH; Addison's disease We report the case of a 69-year-old woman who has persistent hyperpigmentation and elevated ACTH levels

rapidly ceased and he started to regain his lost weight. Within 24 days his CEA level came down to 141 and by 4 months later it was within normal limits at 5 #g/l. The patient felt well at this stage, had gained 10 pounds in weight and his bowel habit had returned to normal. At the end of 1989 the patient remained well on a gluten free diet and with a normal CEA level.

Case presented to Clinical Section, 8 December 1989

Discussion CEA was originally identified by Gold and Freedman in

19643. They raised specific antibodies against antigens present in human colonic tumours but absent in normal colonic mucosa. It was initially thought that the detection of this antigen would be of value in screening patients. However, in a study of 553 patients who did not have a colorectal carcinoma on barium enema, 18 patients (3%) had levels of CEA that were greater than 5 itgfl4. Benign causes of a raised CEA level have been reviewed and include benign liver disease, inflammatory conditions particularly of the gastrointestinal tract, infections, trauma, infarction, collagen vascular disease, renal impairment and smoking'. Very high levels are however rare and rises in serum CEA above five times the limit of the reference range are usually thought to be diagnostic of carcinoma. We are unable to explain the association in this case between coeliac disease and a raised CEA level. It may simply be that the inflammation associated with the coeliac disease caused the rise in the CEA concentration. However, in view ofthe very high levels observed, there may have been a more direct connection between the aetiology ofthe coeliac disease and the rise in the CEA levels. Acknowledgments: We gratefully acknowledge the help of the Department of Medical Oncology at Charing Cross Hospital who performed the CEA assays. References 1 Begent RHJ. The value of carcinoembryonic antigen measurement in clinical practice. Ann Clin Biochem 1984;21:231-8 2 Mach J-P, Vienny H, Jaeger P, et al. Long-term follow-up of colorectal carcinoma patients by repeated CEA radioimmunoassay. Cancer 1978;42(suppl 3):1439-47 3 Gold P, Freedman SO. Demonstration of tumourspecific antigens in human colonic carcinomata by immunological tolerance and absorption techniques. J Exp Med 1965;121:439-62 4 Costanza ME, Das S, Nathanson L, Rule A, Schwartz RS. Carcinoembryonic antigen; report of a screening study. Cancer

1974;33:583-90 (Accepted 20 February 1990. Correspondence to Mr R J Croft)

in spite of 30 years' replacement therapy for Addison's disease.

Case report HG was diagnosed as having Addison's disease at the age of40 years in 1960. Her skin was pigmented at presentation and this pigmentation has remained unchanged apart from some lightness during the winter months. Hospital records are not available for 1960 but she was probably treated at this time with cortisone acetate 25 mg daily and fludrocortisone 0.1 mg daily and she was on this drug regimen when she was admitted with Salmonella enteritidis in 1970. Between 1970 and 1981 there are discrepancies in the casenotes regarding her medication. GP letters always refer to her taking cortisone acetate 25 mg daily and hospital

0141-0768/90/

060399-01/$02.00/0 © 1990 The Royal Society of Medicine

Case presented to Section of Endocrinology 24 May 1989

0141-0768/90/ 060399-02/402.00/0 © 1990 The Royal Society of Medicine

Coeliac disease--a new cause for a high carcinoembryonic antigen.

Journal of the Royal Society of Medicine Volume 83 June 1990 399 Case reports Coeliac disease - a new cause for a high carcinoembryonic antigen D...
202KB Sizes 0 Downloads 0 Views