2 Case Reports in Gastrointestinal Medicine Figure 1: The thorax X-ray shows a cardiomegaly. Figure 2: Villous atrophy grade 3c according to Marsh’s classiﬁca- tion. 3. Discussion Celiac disease is predominantly a disease of the small intes- tine that develops in genetically susceptible individuals after dietary exposure to grains containing gluten. Ingestion of gluten results in inﬂammation of the intestinal mucosa along with hyperplasia of the crypts and atrophy of the villi of the small intestine. The inﬂammatory response is believed to be mediated by immune mechanisms. Classical ﬁndings of CD usually begin at 1–3 years of life. Toddlers and young children classically present with chronic diarrhea, vomiting, poor appetite, abdominal distension, abdominal pain, irritability, and failure to thrive after the introduction of gluten in the diet [6]. Other manifestations include osteomalacia, coagu- lopathy, and peripheral neuropathy. A gluten-free diet usu- ally results in complete resolution of the symptoms and cor- rection of the metabolic abnormalities. Dilated cardiomyopathy is the most commonly seen type of cardiomyopathy. Regarding its etiology, genetic causes, endocrine disorders, collagen vascular diseases, drugs, con- genital metabolism diseases, muscular dystrophies, struc- tural heart diseases, acute and chronic myocarditis, and toxins can be present. However, 50% of cases remain idio- pathic. An increased incidence of CD in patients with idio- pathic dilated cardiomyopathy as well as in patients with sec- ondary cardiomyopathy has been reported recently [10]. In our case, dilated cardiomyopathy was diagnosed with echo- cardiography. Cardiomyopathy associated with celiac disease is infre- quent. A study of 52 patients reported an incidence of celiac disease (5.8%) in patients with dilated cardiomyopathy [11]. Figure 3: Macroscopic view of the heart at autopsy. In another study of 275 patients with heart failure, the incidence of celiac disease was 1.9% versus 0.35% in the control group [12]. Frustaci et al. reported a greater than 4% incidence of celiac disease in 277 consecutive patients with myocarditis [10]. In a study of 60 people with celiac disease aged greater than 65 years, 5% died secondary to heart failure, signiﬁcantly higher than in the nonceliac disease population [10]. Barrio et al. presented a ﬁrst case of a severe progressive dilated cardiomyopathy that required heart transplantation in young woman with celiac disease [14]. Regarding pediatric population there are only few cases of celiac disease and associated myocarditis or cardiomy- opathy reported [15, 16]. Frustaci et al. reported few cases of lymphocytic myocarditis and celiac disease in childhood [10]. Dogˇan et al. reported one 8-year-old girl with stroke and dilated cardiomyopathy [15]. Lakhhdar et al. reported the case of two brothers (25 and 23 years) and their sister (who died at 14) presenting a DCM and for whom the celiac disease was discovered whereas they presented no digestive symptoms [17]. The discovery of celiac disease in subjects presenting a DCM of nondetermined etiology raises the question of its possible relation of cause and eﬀect in particular when the situation occurs in the same family [17]. Several mechanisms have been proposed for the devel- opment of cardiomyopathy in celiac disease. Nutritional deﬁciencies secondary to chronic malabsorption may lead to cardiomyopathy. A study in patients with cardiomyopathy associated with celiac disease showed a greater decrease in serum total carnitine levels than in patients with isolated cardiomyopathy [18, 19]. Celiac disease causes increased systemic absorption of various luminal antigens and infec- tious agents, which may cause myocardial damage secondary to immune-mediated mechanisms [20]. Myocardial injury can also be attributed to immune response cross-reactivity against antigens present in the small intestine and the myocardium [10, 12, 16]. In a case study of cardiomyopathy with celiac disease, similar cellular changes were found in intestinal microvilli and cardiac muscle [21]. However, a study to investigate celiac disease in patients with cardiomy- opathy and their relatives concluded that celiac disease