Chronic giardiasis with intestinal growth failure and pubertal delay in dysgammaglobulinemia

A 10-years-old, previously healthy Swiss boy suffered from repeated episodes of watery diarrhea for some months following a summer camp holiday. No etiology was found, and except for symptomatic treatment no other therapy was necessary. Five years later he was investigated because of growth failure, with a bone age of 11.5 years, but the correct diagnosis was not established. Only when he was reinvestigated at the age of 20 years, because of persistent growth failure and a bone age of 14 years, were Giardia lamblia trophozoites seen microscopically on the surface of duodenal mucosa biopsy specimens. At the same time dysgammaglobulinemia was detected which may have predisposed the gastrointestinal tract to chronic giardiasis. After a 10-day course of metronidazole the patient experienced catch-up growth and completed his pubertal development. The dysgammaglobulinemia persisted after therapy. This case shows that in patients with intestinal growth failure, catch-up growth and completion of pubertal development are possible even after the age of 20 years if nutritional supply is sufficient. Bone age determinations serve to indicate remaining growth potential.