Bilateral vestibulopathy disclosing the diagnosis of celiac disease

Abstract

A 22-year-old previously healthy woman presented to the dizziness clinic with gait unsteadiness of 1-month duration. During the last 5 years, she suffered from recurrent episodes of vertigo lasting minutes for which she did not seek medical assistance. The last vertigo attack was unusually long and was accompanied by severe disequilibrium. She reported blurring of vision during head movements, especially during walking when the surrounding seemed to “jump” in front of her. She denied headache, hearing, autonomic or other neurological symptoms or exposure to chemicals, benzodiazepines, lithium, or ototoxic drugs. A family history of neurotological or autoimmune diseases was negative. On examination her gait was ataxic. The eye movements, including smooth pursuit and saccades, were normal. The remaining cranial nerves were intact. The vestibulo-ocular reflex showed catch up saccades on both sides. On the dynamic visual acuity test, her visual acuity dropped three lines. There were no motor, sensory, or cerebellar findings. An audiogram was normal and chest X-ray was unremarkable. AMRI of brain and ears with special attention to the pontocerebellar angle (T1 with and without gad, T2, DWI, FLAIR sequences) was normal. An ENG (electronystagmogram) showed bilateral 100% caloric weakness. Laboratory tests, including glucose, electrolytes, thyroid functions, colagenogram including tests for vasculitis, hypercoagulability battery, vitamin levels, hormonal panel, and tumor markers were within normal limits. Despite the absence of any gastrointestinal symptoms, a tTG (tissue transglutaminase) test was performed and found highly positive (above 100 U/ml, normal less than 25 U/ml). A duodenum biopsy demonstrated mucosal atrophy with crypt hyperplasia and chronic inflammatory infiltrate consistent with celiac disease.