Julia is 28 years old. She is 5′6″ tall and weighs 103 pounds. She has had intermittent bouts of diarrhea, painful abdominal cramping, bloating, and a lot of flatus. She is tired all the time and her...

Julia is 28 years old. She is 5′6″ tall and weighs 103 pounds. She has had intermittent bouts of diarrhea, painful abdominal cramping, bloating, and a lot of flatus. She is tired all the time and her boss has reprimanded her for not completing her assigned work in a timely manner. Julia has a hard time keeping warm. She wears a sweater all the time even in the middle of the summer. Julia is quite discouraged and her mom suggests that she go to the doctor for a complete physical. Her blood workup reveals hemoglobin level at 8.2 g/dL, red cell count 3.8 million/mm3, hematocrit 30%, ferritin 18 µg/ml, red cell folate 200 nmol/L, and B12 100 pg/L. The doctor orders a bone scan using DEXA and this reveals a measure of osteoporosis. The doctor then suggests that Julia fill out a food intake form. A dietitian evaluates the results and cannot find any indication that Julia is inadequately nourished. The doctor scratches his head for an appropriate diagnosis when suddenly, while Julia is in his office, she has to make a rush visit to the lady’s room. For some reason, Julia had failed to mention her gastrointestinal problems. Now it becomes obvious that an endoscopy and biopsy of the intestine is needed. The endoscopy examination reveals that the villi of the small intestine are shortened and in some areas are flattened and inflamed. Now the doctor needs to know why this occurred, so he orders a scraping of the lining of the intestine as well as an immune system workup. The results of these tests show an increase in MHC class II molecules, and these molecules do not have a normal shape. Further tests show that these molecules react to the proteins in wheat, rye, and barley but not to corn or rice.

1. Based on your reading and your Internet searches, what do you think is Julia’s problem?
2. Why is her diarrhea intermittent?
3. How do you explain her clinical results?
4. What strategies would you suggest that will make Julia’s life more comfortable?