International Journal of Celiac Disease, 2016, Vol. 4, No. 4, 146-149 Available online at http://pubs.sciepub.com/ijcd/4/4/11 ©Science and Education Publishing DOI:10.12691/ijcd-4-4-11 A 21-year-old Man with Delayed Puberty Ketabimoghaddam Pardis 1 , Dadvar Zohreh 2,* , Salehi Babak 3 , Aletaha Najmeh 2 , Allameh Seyed Farshad 2 , Hassanpour Akbar 1 , Talayi M.A 3 1 Arak university of medical sciences, Internal medicine department 2 Tehran university of medical sciences,gastrointestinal department 3 Shahid Beheshty university of medical sciences, gastrointestinal department Tehran University of Medical Sciences, Iran *Corresponding author: zohrehdadvar.zd@gmail.com Abstract Delayed puberty is defined clinically by the absence or incomplete development of secondary sexual characteristics bounded by an age at which 95 percent of children of that sex and culture have initiated sexual maturation. The upper 95th percentile in the United States for age for boys is 14 (an increase in testicular size being the first sign) and for girls is 12 (breast development being the first sign). Delayed puberty pathophysiologically is classified according to the circulating levels of the gonadotropins luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in to two groups of high serum LH/FSH and low or normal serum LH/FSH concentrations which are related to primary hypogonadism and hypothalamic dysfunction respectively. Patient Presentation. A 21 year old boy presented with severe respiratory distress syndrome due to pneumonia and generalized edema. Laboratory studies showed pancytopenia which made clinicians work up for hematologic disorders, leading to bone marrow aspiration and biopsy which was consistent with megaloblastic anemia resulting from vit B12 deficiency. Another manifestation of this patient was delayed puberty which had been ignored over these years. Evaluation of delayed puberty revealed a low serum LH/FSH concentration. Accompaniment of delayed puberty resulting from hypothalamic origin with edema and hypoalbuminemia made clinicians work up for a malabsorption syndrome. Therefore upper endoscopy and colonoscopy were done and duodenal biopsies were consistent with celiac sprue. The unusual symptom of this patient was vit B12 deficiency which is rare in celiac disease. Conclusion. Neglected celiac sprue can be accompanied by vit B12 deficiency probably because of involvement of more distal parts of small intestine over the time. Keywords: delayed puberty, hematologic changes, celiac disease Cite This Article: Ketabimoghaddam Pardis, and Dadvar Zohreh, Salehi Babak, Aletaha Najmeh, Allameh Seyed Farshad, Hassanpour Akbar, Talayi M.A, “A 21-year-old Man with Delayed Puberty.” International Journal of Celiac Disease, vol. 4, no. 4 (2016): 146-149. doi: 10.12691/ijcd-4-4-11. 1. Introduction The patient was admitted in Arak Amir-Al-Momenin Hospital because of fever & chills, progressive dyspnea on exertion followed by orthopnea, paroxysmal nocturnal dyspnea, cough and black sputum during the past week and a progressive edema leading to generalized edema in recent year. He was born in the suburb of Arak city (one of the cities of Iran), in a low socioeconomic family, living with his mother, father and smaller brother. His childhood was spent with mild intermittent diarrhea (Soft stool sometimes watery but not bloody or fatty, without response to fasting, without significant abdominal pain), loss of appetite and failure to thrive. His immunization was complete. His adolescence was associated with delayed puberty, short stature and poor presentation at school. He was jobless, without any addiction to illicit drugs, alcohol and cigarettes. There wasn't any special disease or similar problem in his first degree relatives. No special environmental and occupational exposure was detected. Reported condition didn't make him demand a consult with healthcare units until he was encountered a progressive edema starting from lower limbs accompanied by scrotal, sacral, abdominal wall and periorbital edema during recent year with severe exacerbation in recent months and finally fever & chills and progressive dyspnea on exertion followed by orthopnea, paroxysmal nocturnal dyspnea, cough and sputum since the past week which took him to the emergency room. On the admission day, he was ill and cachectic, with pale conjunctiva, periorbital edema and severe exhaust. His vital signs were: Blood Pressure =125/85 mmhg, Body Temperature = 39.5oc, Pulse Rate = 140, Respiratory Rate = 34. Heart sounds were normal but tachycardia was detected. In lung auscultation there was a decrease in breath sound in the basis of the two lungs predominantly in the right side. Chest X Ray showed bilateral pleural effusion which was predominant in the right side. Abdominal examination showed positive shifting dullness test and abdominal wall edema without any tenderness and organomegaly. Deep and broad edema was detected in both lower limbs, distal pulses were bilaterally symmetric but were weaker than normal because of severity of edema. Scrotal examination revealed scrotal edema and small testicles. No axillary and