The authors describe a new case of multiple cutaneous leiomyomata: a female patient aged 33 presents lesions in hundreds causing severe pain. The subjective symptoms are highly improved by the calcium antagonist nifedipine.

INTRODUCTION: Celiac disease is known to affect calcium homeostasis in various ways leading to osteoporosis and osteopenia. We present a case of active celiac disease complicated by hypocalcemia and osteoporosis. CASE DESCRIPTION/METHODS: The patient is a 74-year-old male with known Celiac disease diagnosed 25 years ago. He had known hypocalcemia with secondary hyperparathyroidism treated with calcium and calcitriol supplements to maintain calcium levels (Corrected Calcium: 8.5 mg/dl with PTH of 89 pg/ml and 25-hydroxy Vitamin D of 80 ng/ml). The patient had a mechanical fall, a few months ago and subsequent DEXA scan showed osteoporosis (Bone mineral density of L1-L4 vertebral bodies was 3.5 standard deviation below normal). The patient was treated with an infusion of zoledronic acid. A week later the patient presented with malabsorptive diarrhea likely due to reported non-compliance with a gluten-free diet. On admission labs, he was noted to have severe hypocalcemia (ionized 0.8, corrected calcium was 6.7). Of note, his PTH had increased to 385. Incidentally, his INR was also noted to be mildly elevated at 1.5. Despite this, he had no apparent symptoms of hypocalcemia. During the admission, the patient had an EGD and biopsies were done showing mucosal changes consistent with celiac disease confirming dietary non-adherence. Hypocalcemia was treated with IV infusion of Calcium and he was discharged on increased doses of Calcitriol and calcium supplements with close follow-up with endocrinology. DISCUSSION: Celiac disease affects the small intestine including duodenum, the primary site of absorption of divalent ions including calcium. The intraluminal dietary fats bind to this calcium decreasing the absorption of fat-soluble vitamins K & Vitamin D. The parathyroids release more PTH in an attempt to maintain serum calcium levels through increasing osteoclastic activity. Other mechanisms active in celiac disease also increases bone resorption (See Figure 2). Bisphosphonates are a standard treatment for preventing osteoporotic fractures, by reducing osteoclastic activity. In this patient with active celiac disease, with low availability of dietary calcium, this resulted in hypocalcemia. This can be mitigated with closer observation and adjustment of doses of vitamin D and calcium supplementation when administering bisphosphonates.