Patient Care

Gluten Allergy Masks Other Problem

Issue 7 and Volume 41.

Medic 71, an ALS ambulance, is dispatched on a Delta-level response for a 58-year-old female patient with a “hemorrhage” at about 9 p.m., with “blood in the patient’s stool following possible ingestion of gluten.” The paramedics wonder if the call has possibly been over-triaged as an emergent response. Nonetheless, they arrive at the single-family residence a few minutes behind a police officer who’s been sent to assist. The paramedics grab their ALS bag and cardiac monitor and are met by a woman who identifies herself as the patient’s daughter.

“She’s downstairs on the bed,” the daughter explains. “She was here babysitting the kids and called me when she got sick. She’s been on the toilet having diarrhea for a few hours and we thought there was maybe some blood in it.” As the paramedics walk down the tight turns of the stairs, they determine they aren’t able to get their stretcher to the patient.

They find the patient on a queen-sized bed. She’s laying in the fetal position under multiple blankets, conscious and responsive. The lead paramedic introduces himself and asks what happened.

“I ate a pizza and I didn’t check the label. It wasn’t gluten free and now I’m so sick that I don’t think I can move. I’m so cold. I’ve been having the worst diarrhea and throwing up for the last few hours and I just can’t get warm. This is the worst reaction I’ve ever had.” The patient stays covered as she talks and is observed to be shivering. The paramedic can’t find a radial pulse at the patient’s wrist and notes the patient’s skin to be cool to the touch and moist.

“You say you have a gluten allergy. What kind is it?” the paramedic asks. The patient replies she was diagnosed with celiac disease by her physician and has struggled with it for many years. Her symptoms following ingestion of gluten usually include “two hours on the toilet spent having terrible diarrhea, followed by getting freezing cold and having to cover up in bed to stay warm.”

Tonight’s reaction wasn’t following the patient’s usual pattern of symptoms. According to the patient, she’d never experienced blood in her stool, nor has she ever felt like she might lose consciousness or become faint. “I had my daughter call you because I wasn’t getting any better and I thought I was going to pass out,” she says.

While the patient kept trying to cover herself back up with blankets for warmth during the assessment, the lead paramedic performs an examination as his partner obtains further information from the patient’s daughter. The patient’s pupils are PERRL (pupils equal and round, responsive to light) and her HEENT (head, ears, eyes, nose and throat) are normal with good facial symmetry. She has no oral, nasal or otic discharge, and has moist mucous membranes. She has no jugular venous distension, her trachea is midline and mobile, and her chest has equal rise and fall with respirations and clear lung sounds throughout. The patient’s abdomen is soft, not distended, and not tender to palpation; however, she says she has mild diffuse abdominal pain and cramping with the diarrhea.

The patient’s extremities are cool to the touch but have good motor skills, sensation, and capillary refill within two seconds. She has very faint and thready distal pulses at the radial when assessed a second time.

Looking at the patient as a whole, she appears to be acutely ill and obtunded. She’s breathing silently and easily with no obviously increased work of breathing. Her skin doesn’t have any obvious urticaria or other rash present, and the patient denies any sensation of itching. She has no noticeable swelling, but complains of nausea.

Comparison of gluten-related disorders

An ECG shoes sinus tachycardia at 112 bpm without ectopy. Her blood pressure is 86/42, respirations are 18 and unlabored, and her pulse oximetry shows a low-confidence reading of 91%. The lead paramedic establishes an 18-gauge IV in the left lateral wrist and gives 4 mg ondansetron (Zofran) per standing protocol for the patient’s nausea. During this time the other paramedic and the police officer bring a stair chair and the stretcher to the top of the stairs.

A subsequent recheck of vital signs reveals a rise in the patient’s blood pressure to 96/68 and a decrease in pulse to 98. Before the medics are able to move the patient to the stair chair, she experiences an uncontrollable episode of watery, light brown diarrhea. The paramedics assist in removing her soiled garments, help her clean herself and dress her in a patient gown. They then wrap her in an impervious blanket for warmth and to protect their equipment from contamination.

As the paramedics move her to the stretcher, the patient loses consciousness. Her heart rate rises to 100 bpm and she’s quickly given a 1,000 mL bag of 0.9 normal saline.

Her blood pressure changes to 74/48, she’s in a sinus tachycardia at 122 bpm and her respirations are approximately 14 and unlabored. After a moment in the ambulance, she regains consciousness and responds appropriately to questions, and complains of increased nausea and dizziness and is surprised to learn she lost consciousness.

There’s no improvement in the patient’s blood pressure after 300 mL of saline has been infused. Acting on a hunch, the paramedic contacts medical control to collaborate with the ED physician and request orders. He explains that if the patient is having a reaction to gluten, it’s systemic and possibly atypical anaphylaxis. The ED physician agrees and orders the patient be given 0.3 mg 1:1000 epinephrine intramuscular and 50 mg diphenhydramine IV with dopamine to follow if the patient’s blood pressure doesn’t improve.

As the ambulance arrives at the hospital several minutes later, the patient’s blood pressure has risen to 124/82 and her skin has become pink, warm and dry. She’s regained full alertness and says she feels much better. She’s discharged from the ED approximately two hours later.

Discussion

Gluten is a substance found in wheat, rye and barley. It’s made of two proteins found within the grain and is responsible for the chewiness, elasticity and texture of bread and other baked goods. Although ingestion of gluten is completely harmless for the vast majority of the population, it can cause an immune response and adverse reaction in persons with celiac disease, which affects approximately 1 in 141 people in the United States.1

In more contemporary times, gluten has been implicated as a cause for all manner of maladies ranging from behavioral challenges, skin conditions, chronic fatigue syndrome and fibromyalgia. These less-scientifically backed conditions have been grouped into terms such as “non-celiac gluten sensitivity” and even “celiac-light” by people who claim their existence. These claims have yet to be proven by any of the studies that have investigated them. Nonetheless, the gluten-free product industry generated $8.8 billion in 2013 and is on pace to continue growth.2

Celiac disease, also known as “celiac sprue” or “gluten-sensitive enteropathy,” is a chronic disorder that affects the body’s ability to tolerate gliadin, the alcohol-soluble protein component of gluten. People with celiac disease have an autoimmune response that causes inflammation and damage to the mucosal lining of the small intestine, particularly the villi, which are the small, fingerlike projections that line the intestinal tract and provide for the bulk of nutrient absorption. This process initially results in the poor absorption of nutrients from foods and also in the poor digestion of food that passes through the damaged intestinal tract.3

Symptoms of gluten exposure in persons with celiac disease initially include gastrointestinal upset such as diarrhea, abdominal pain, flatulence and borborygmus (i.e., abdominal gurgling), but become more serious depending on the time elapsed, amount of exposure and the person’s affliction by the disease.

More serious and longer-term symptoms include malnutrition, skin conditions, neurological symptoms, hormonal imbalances and other complications that can negatively impact many aspects of a person’s health and well-being.

Celiac disease is often misdiagnosed as other similar diseases such as irritable bowel syndrome, anemia, chronic fatigue syndrome, infection and lactose intolerance. However, laboratory testing of the blood and intestinal biopsy is available to affirmatively diagnose patients with true celiac disease. It’s important to note that no definitive test exists for any other possibly gluten-related conditions.

Although symptoms of celiac disease often overlap with an allergy to wheat, they’re not the same. A wheat allergy is a reproducible, specific response usually caused by allergic antibodies. Exposure to wheat in an allergic patient causes the more recognizable symptoms of allergic reaction and can lead to anaphylaxis.4

Conclusion

In the case presented, the paramedic misconstrued the patient’s symptoms as her usual reaction to gluten and missed the patient’s evolving anaphylactic reaction to the wheat in the pizza crust. He believed the diarrhea and abdominal pain were more related to the patient’s celiac disease and assumed the symptoms would resolve on their own with conservative treatment.

An anaphylactic reaction doesn’t require the classic symptoms, like itching, hives and airway swelling. It can present with life-threatening hypotension, diarrhea and other atypical symptoms. In this case, the patient was having a systemic allergic reaction to the wheat but wasn’t presenting with symptoms that were immediately apparent to her caregivers.

With all of the attention given to gluten in recent years, it’s easy for healthcare providers to get complacent when faced by patients claiming a gluten allergy and a subsequent reaction to an exposure. However, there are patients who do, in fact, have anaphylactic reactions that rise to the level of being true medical emergencies. These people need the same immediate care we might associate with other severe food allergies, such as peanuts and shellfish.

The fact that a celiac-type gluten reaction has symptoms that often overlap with atypical anaphylaxis can confound the patient diagnosis and lead to improper treatment. Be aware of this in your care and be prepared to aggressively medicate and treat such reactions if suspected.

References

1. National Institute of Diabetes and Digestive and Kidney Diseases. (June 2015.) Celiac disease. Retrieved April 10, 2016, from www.niddk.nih.gov/health-information/health-topics/digestive-diseases/celiac-disease/Pages/facts.aspx.

2. Gelski J. (July 25, 2015.) Getting a grip on gluten-free growth. Food Business News. Retrieved April 10, 2016, from www.foodbusinessnews.net/articles/news_home/Research/2015/07/Getting_a_grip_on_gluten-free.aspx?ID={E8451798-7423-451F-87A2-14FC80AA6B5D}.

3. Goebel SU. (n.d.) Celiac disease (sprue). MedScape. Retrieved April 10, 2016, from http://emedicine.medscape.com/article/171805-overview.

4. UCLA Division of Digestive Diseases. (n.d.). Celiac vs gluten-sensitivity vs wheat allergies. UCLA Health. Retrieved April 10, 2016, from http://gastro.ucla.edu/site.cfm?id=281.