Question

A 23-year-old Caucasian woman presents with weakness, fatigue, and occasional palpitations starting 6 months ago. She took a multivitamin supplement with transient improvement. In the last 3 months, blisters appeared on her elbows, which were associated with intense itching. Her only medication is an implantable contraceptive inserted 3 years ago. There is no relevant past medical history, and her family history is also unremarkable. Vital signs are BP 120 / 80 mm Hg, HR 94 bpm, RR 18 rpm temperature 36.3° C (97.2° F). On physical examination, she is alert and oriented, with no dyspnea or cyanosis. Examination of the skin reveals bullous lesions in her elbows. The remainder of the examination shows no abnormalities. A complete blood count shows hemoglobin 12 g/dL, hematocrit 31%, Mean Corpuscular Volume (MCV) 78 fl, Mean Corpuscular Hemoglobin Concentration (MCHC) 29 pg/L, Leukocytes 7.400 /mm3 w/normal differential, and platelets 218,000 /mm3. A skin biopsy reveals a neutrophilic infiltrate, with fibrin and microblisters, most dense at the tips of the dermal papillae and containing IgA on immunofluorescence staining.

What finding is most probable on subsequent workup?

1 Positive transglutaminase antibodies
2 Positive ASCA antibodies
3 A warm spot on scintigraphy with 99mTc-labelled red cells
4 Positive stool guaiac test
5 Reduced serum erythropoietin

Answer 1

Given the patient's presentation with itchy blisters, a biopsy showing IgA deposits, and other nonspecific symptoms, positive transglutaminase antibodies would likely be the next finding, indicating the presence of celiac disease and its associated dermatitis herpetiformis.

Step-by-step explanation:

The clinical presentation suggests the patient may have dermatitis herpetiformis (DH), which is a skin manifestation of celiac disease. This is supported by the symptoms of weakness, fatigue, palpitations, the appearance of itchy blisters on the elbows, and the histopathology findings from the skin biopsy showing neutrophilic infiltrate and IgA deposits. Moreover, the gastrointestinal symptoms often associated with celiac disease could be masked or absent.

The most probable subsequent workup finding for this patient would be positive transglutaminase antibodies. These antibodies are indicative of celiac disease and would correlate with the skin biopsy findings and the patient’s symptoms. A gluten-free diet is the primary treatment for DH and, consequently, would likely lead to the resolution of the skin lesions as well as the systemic symptoms of celiac disease.