Hypoparathyroidism and co-existing celiac disease

Eye disorders in patients with celiac disease and inflammatory bowel disease: A study using clinical data warehouse

BACKGROUND AND AIM

To analyze the prevalence of ophthalmic manifestations in patients with celiac disease, Crohn's disease and ulcerative colitis in Munich/Germany.

METHODS

A total of 272,873 patients of Ludwig Maximilians Universitat Ophthalmological Hospital with eye disease were evaluated between 2003 and 2019. The International Classification of Diseases, 10th revision (ICD-10) of celiac disease Crohn's disease, ulcerative colitis, and all medical records which had the diagnosis of these diseases were analyzed.

RESULTS

A total of 272,873 patients were analyzed, with a mean age of 53 years, with approximately 48% female patients, and 51% male patients. We selected 72 patients with celiac disease (68% women and 32% men), with a minimum age of 8 years, maximum of 103 years, and an average of 52 years. The most common diagnoses were dry eye (32%) and cataract (12%). The mean intraocular pressure of patients with celiac disease was 15 mmHg. During the same study period, 103 patients with Crohn's disease were analyzed, with an average intraocular pressure of 14 mmHg.The minimum age of the patients was 12 years and a maximum of 93 years with an average age of 55 years, with 57% of females and 43% of males. The most common diagnoses were cataract (22%) and dry eye (19%). During the same study period, 99 patients with ulcerative colitis were analyzed, with an average intraocular pressure of 14 mmHg.The minimum age of the patients was 6 years and a maximum of 96 years, with an average age of 61 years, with 36% of females and 64% of males. The most common diagnoses were cataract (29.2%) and dry eye (12%).

CONCLUSIONS

The main ophthalmological manifestations of patients requiring eye follow-up were dry eye and cataract for all the diseases analyzed, which can be considered as coincident complications. None of the three diseases had increased intraocular pressure. Thus, celiac disease presented a profile of ophthalmological manifestation similar to the other intestinal inflammatory diseases studied.

Celiac Disease and the Autoimmune Web of Endocrinopathies

Gluten-sensitive enteropathy or Celiac disease (CD) is a disease that has become very prevalent in most parts of the globe especially in the western world. Resulting from a chaotic interplay between the backgrounds of autoimmunity and genetics, this disorder targets primarily the gastrointestinal tract with ominous extraintestinal counterparts that have a very discrete presentation. Among those counterparts, the one that has been reviewed in this article is the involvement of the endocrine system as concurrence of hormonal disorders with CD possesses numerous challenges that lead to a refractory treatment and a dull prognosis. This review article aims to feature the effect of the CD and endocrine disorders on one another, especially if either of the diseases is asymptomatic, explore the clinical dilemma faced by clinicians in various specialties, and, hence, further pave a path into the importance of rigorous screening and diagnosis.

The spectrum of clinical and subclinical endocrinopathies in treatment-naïve patients with celiac disease

INTRODUCTION

Strong association exists between celiac disease and autoimmune endocrinopathies such as type I diabetes and hypothyroidism; there is a lack of data on the involvement of other endocrine organs such as pituitary-gonadal axis. Furthermore, there is lack of data on the spectrum of involvement of endocrine organs varying from organ autoimmunity to subclinical and clinical disease. We evaluated consecutive treatment-naïve patients with celiac disease (CeD) for clinical and subclinical endocrinopathies.

METHODS

Of 154 screened, 74 treatment-naïve patients with CeD were recruited. They underwent hormonal and/or functional assessment of beta cell of pancreas, thyroid gland, pituitary-gonadal axis, and parathyroid glands.

RESULTS

Of the 74 patients with CeD, 31 (41.9%) had at least one clinical or subclinical endocrinopathy and 9 (12.2%) had multiple endocrinopathies. Most common of them were clinical or subclinical type I diabetes and autoimmune thyroid disease. Interestingly, 8 (10.8%) patients also were found to have functional hypopituitarism and 7/54 (12.9%) having isolated hypogonadotropic hypogonadism.

CONCLUSIONS

Patients with CeD have high percentages of not only clinical endocrinopathy including pituitary-gonadal axis dysfunction but also subclinical endocrinopathy. Whether commencement of gluten-free diet will lead to reversal of subclinical endocrinopathies requires further follow up studies.

Prevalence of coeliac disease in idiopathic hypoparathyroidism and effect of gluten-free diet on calcaemic control

BACKGROUND

Patients with idiopathic hypoparathyroidism (IH) require variable doses of calcium and 1-α-(OH)D. The reasons for such variability are not clear. As autoimmune mechanisms may play a role in IH, there is a possibility of coexistent coeliac disease with calcium/vitamin D malabsorption.

OBJECTIVE

We assessed the prevalence of coeliac disease and antitissue transglutaminase autoantibodies (anti-tTGAbs) in IH and analysed the effect of a gluten-free diet on calcaemic control.

METHOD

A total of 171 patients with IH and 126 healthy controls were screened for anti-tTGAb. IH patients with anti-tTGAb >20 RU/ml underwent duodenoscopy and intestinal biopsy; those with biopsy-proven coeliac disease were followed up on a gluten-free diet.

RESULTS

Eleven of 171 (6·4%) patients with IH and seven of 126 (5·6%) controls had anti-tTGAb (P = 0·81). There was no difference in the clinical and biochemical parameters at diagnosis and during long-term follow-up of 7·2 ± 4·8 year (mean serum total calcium = 1·88 ± 0·16 vs 1·82 ± 0·36 mmol/l, P = 0·52; phosphorus = 1·81 ± 0·17 vs 1·87 ± 0·36 mmol/l, P = 0·53) in IH patients with and without anti-tTGAb. Although CaSRAb positivity was comparable in the two groups, IH patients with anti-tTGAb had higher TPOAb positivity (45·5% vs 12·8%, P = 0·02). Coeliac disease was diagnosed in only 2/9 patients with IH on biopsy, both of whom showed improved calcaemic control with a gluten-free diet.

CONCLUSION

The prevalence of coeliac autoimmunity (6·4%) and coeliac disease (1·2%) in patients with IH seems to be similar to that in the general population. Notwithstanding this modest prevalence, it is important to be aware of the potential occurrence of coeliac disease with IH and the beneficial effect of a gluten-free diet on calcium control.

Ophthalmologic manifestations of celiac disease

Celiac disease is an autoimmune disorder that affects the small intestine of genetically predisposed individuals. Ophthalmic manifestations are within the extra-intestinal manifestations, and can be divided into those of autoimmune disorders or those due to absorptive disabilities. This article reviewed the ophthalmologic manifestation of celiac disease. Ophthalmic symptoms are rare, but should be investigated in patients with celiac disease and taken into consideration as the first systemic manifestation.

Digestive manifestations of parathyroid disorders

The parathyroid glands are the main regulator of plasma calcium and have a direct influence on the digestive tract. Parathyroid disturbances often result in unknown long-standing symptoms. The main manifestation of hypoparathyroidism is steatorrhea due to a deficit in exocrine pancreas secretion. The association with celiac sprue may contribute to malabsorption. Hyperparathyroidism causes smooth-muscle atony, with upper and lower gastrointestinal symptoms such as nausea, heartburn and constipation. Hyperparathyroidism and peptic ulcer were strongly linked before the advent of proton pump inhibitors. Nowadays, this association remains likely only in the particular context of multiple endocrine neoplasia type 1/Zollinger-Ellison syndrome. In contrast to chronic pancreatitis, acute pancreatitis due to primary hyperparathyroidism is one of the most studied topics. The causative effect of high calcium level is confirmed and the distinction from secondary hyperparathyroidism is mandatory. The digestive manifestations of parathyroid malfunction are often overlooked and serum calcium level must be included in the routine workup for abdominal symptoms.

The parathyroids and the gut

This review discusses gastrointestinal manifestations of parathyroid diseases. Parathyroid hormone is the primary regulator of calcium physiology. Hypoparathyroidism can be idiopathic, hereditary, or secondary to surgery in the neck. Hyperparathyroidism is usually from adenomas or hyperplasia. Hypoparathyroidism is associated with steatorrhea that may improve with medium-chain triglycerides, correction of the hypoparathyroidism, or administration of vitamin D. Hyperparathyroidism results in constipation because of reduction in neuromuscular excitability by high calcium levels. According to old literature, the incidence of peptic ulcer disease (PUD) in patients with hyperparathyroidism is 9% compared with autopsy rates of 4% to 5%. Any association is difficult to prove today, as hyperparathyroidism is usually mild due to early detection of cases through routine automated measurements of calcium. In addition, PUD is less prevalent now than before the advent of proton pump inhibitors. The presence of ulcers or ulcer symptoms may correct in some patients after parathyroidectomy, suggesting an association. The incidence of pancreatitis in patients with primary hyperparathyroidism ranges from 1.5% to 12% and may be because of the hypercalcemia. Complicating the issue is secondary hyperparathyroidism in response to hypocalcemia from pancreatitis. Pancreatitis may improve in some individuals after parathyroidectomy. Pancreatitis may follow parathyroid surgery because of an acute rise in calcium levels with manipulation of the parathyroid glands or to a blunted response of calcitonin-producing cells from fatigue. Parathyroid diseases have a few distinct effects on the gut: steatorrhea in hypoparathyroidism, and constipation, PUD, and pancreatitis in hyperparathyroidism.

Celiac disease and the endocrinologist: a diagnostic opportunity

OBJECTIVE

To review the association of celiac disease and various endocrine disorders and present the related clinical experience of a 3-physician adult endocrinology practice.

METHODS

We provide an overview of the pertinent literature, discuss the clinical manifestations, genetics, and pathogenesis of celiac disease, and describe our clinical experience during a 5-year period.

RESULTS

Celiac disease has been associated with numerous disorders, including several conditions treated by endocrinologists-type 1 diabetes mellitus, autoimmune thyroid disease, Addison disease, osteomalacia, secondary hyperparathyroidism, vitamin D or iron deficiency, fertility problems, hypogonadism in men, and autoimmune hypopituitarism. After our clinical awareness was raised about these potential comorbidities, 18 patients were newly diagnosed with celiac disease in our clinical practice during a 5-year interval. All patients had been referred for endocrine evaluation or were undergoing follow-up for ongoing management of endocrine disorders. When a "celiac-associated" endocrine disorder coexists with other factors associated with celiac disease, we recommend performance of IgA class antibody testing, and either antiendomysial or anti-tissue transglutaminase antibodies provide high specificity and sensitivity for the diagnosis of celiac disease.

CONCLUSION

Endocrinologists have an opportunity to diagnose celiac disease, a relatively common disorder with profound clinical implications that can often be associated with various endocrinopathies.

Occurrence of overt celiac disease in the elderly following total thyroidectomy

We report the case of a female patient in whom gluten-induced entheropathy was revealed at the age of 71 yr by resistance to treatment with levothyroxine (L-T4), calcium carbonate and alfacalcidol. Hypothyroidism and hypoparathyroidism were the consequence of a total thyroidectomy performed at the age of 65 yr for a large multinodular goiter. Six months after thyroid ablation the patient started to complain of abdominal pain, diarrhea and weight loss. Following, anemia and osteopenia were documented. A progressive increase of replacement therapy for hypothyroidism and hypoparathyroidism was necessary. The clinical presentation suggested a malabsorption syndrome: celiac disease (CD) was diagnosed by serological markers and duodenal biopsy. Following gluten-free diet a normalization of clinical and serological findings was observed, bone mass density improved and a reduction of L-T4, calcium and vitamin D requirements was observed.

Celiac Disease Occurring in a Patient with Hypoparathyroidism and Autoimmune Thyroid Disease

Patients with an underlying autoimmune endocrine disorder are at an increased risk of developing other autoimmune diseases. We describe a patient with idiopathic autoimmune hypoparathyroidism who developed hyperthyroidism due to Graves disease and subsequently was diagnosed with celiac disease. Malabsorption of L-thyroxine was the only clue regarding the presence of celiac disease. This particular association of these three autoimmune disorders occurring in the same patient has not, to our knowledge, been previously reported. The presentation, investigations performed, and treatment provided are discussed and the literature pertaining to similar cases is reviewed.