Coeliac disease: a cause of various associated diseases?

Gluten Intolerance and Its Association With Skin Disorders: A Narrative Review

Gluten sensitivity is defined as a chronic intolerance to gluten ingestion in genetically predisposed individuals. The etiology is thought to be immune-mediated and has a variable dermatologic presentation. Celiac disease (CD) is one of the most common forms of gluten intolerance and encompasses a wide range of extra-intestinal pathology, including cutaneous, endocrine, nervous, and hematologic systems. Psoriasis, another long-term inflammatory skin condition, has been linked to significant symptomatic improvement with a gluten-free diet (GFD). Palmoplantar pustulosis (PP), a variant of psoriasis, and aphthous stomatitis, which causes recurrent oral ulcers, have also exhibited beneficial results after the dietary elimination of gluten. In addition to this, dermatitis herpetiformis (DH), another immune-mediated skin disorder, is genetically similar to CD and has, therefore, shown tremendous improvement with a GFD. Another highly prevalent long-term skin condition called atopic dermatitis (AD), however, has revealed inconsistent results with gluten elimination and would require further research in the future to yield concrete results. Hereditary angioedema (HA) has shown an association with gluten intolerance in some patients who had symptomatic benefits with a GFD. Similarly, vitiligo and linear IgA bullous dermatosis have also shown some clinical evidence of reversal with a GFD. On the contrary, rosacea enhances the risk of developing CD. This narrative review emphasizes the potential impact of gluten intolerance on different cutaneous conditions and the potential therapeutic effect of a GFD on various symptomatic manifestations. There is a need for additional clinical and observational trials to further expand on the underlying pathophysiology and provide conclusive and comprehensive recommendations for possible dietary interventions.

Frequency of Celiac Disease in Children with Peptic Ulcers

AIM

The aim of the present study is to investigate the frequency of celiac disease in children with peptic ulcers and to compare it with that of non-celiac peptic ulcers in terms of clinical and laboratory values.

METHODS

Upper gastrointestinal endoscopy was performed in 1769 patients at the Department of Pediatric Gastroenterology, The Faculty of Medicine, Cukurova University, Turkey, between January 2012 and January 2017. These cases consisted of subjects presenting with various GIS symptoms and indicated for endoscopy (with chronic diarrhea, delayed growth and development, abdominal pains, GIS bleeding, etc.). The levels of immunoglobulin A (IgA) serum anti-tissue transglutaminase antibodies, IgA anti-endomysial antibodies (EMA), and IgA serum were estimated in the patients with peptic ulcers.

RESULTS

Celiac disease was diagnosed with serology, endoscopy, and histopathology in 250 (14%) of all cases undergoing endoscopy. Peptic ulcers were diagnosed in 74 patients (4.2%) of all cases undergoing endoscopy. tTGA and EMA (+) levels were determined in 22 (29%) of the 74 patients with peptic ulcers, and then the presence of peptic ulcers was investigated in the upper gastrointestinal system using gastrointestinal endoscopy, followed by histopathological confirmation of celiac disease. HP infection was present in 14 (63%) of the patients with celiac disease and in 23 (44%) of non-celiac peptic ulcers; the difference was not statistically significant (p = 0.12). In the total ulcer group, 10.8% (8/74) of patients with celiac peptic ulcers were negative for HP infection, whereas 21% (8/37) of HP-negative patients with ulcers had celiac disease.

CONCLUSION

There exists a high risk of celiac disease in children with peptic ulcers. We thus recommend celiac disease to be investigated, particularly in HP-negative patients with peptic ulcers but with no history of NSAID use.

Celiac disease prevalence in a large series of patients with Behçet's disease

AIM

There are common findings between Behçet's disease (BD) and celiac disease (CD) based on similar immunological pathogenesis and there is only limited data available investigating the link between these two diseases. Furthermore, documented gastrointestinal (GI) involvement with marked upper GI symptoms in BD has been rarely reported. The aim of this study was to assess the prevalence of CD and to evaluate endoscopic findings in Turkish BD patients.

METHODS

A total of 210 BD patients were included in the study. All patients underwent serological testing for anti-gliadin and tissue transglutaminase antibodies. Endoscopic examinations were performed in 190 patients who accepted upper GI system endoscopy. Multiple biopsies were taken from the second portion of the duodenum in patients with positive serological assessment for CD.

RESULTS

A total of 4.2% of patients with BD had positive anti-gliadin and tissue transglutaminase antibody immunoglobulin A (IgA) and IgG antibodies. The prevalence of biopsy-confirmed CD was 1.05% in Turkish BD patients. The most common endoscopic findings of patients with BD were found to be antral gastritis, duodenitis and esophagitis.

CONCLUSION

Although BD and CD share many similar clinical manifestations, our results did not support a possible association between these two diseases.

Coeliac disease as a potential cause of idiopathic portal hypertension: a case report

Idiopathic portal hypertension is a disorder that has various clinical features. It is mostly characterized by bleeding oesophageal varices, obvious splenomegaly, anaemia and, occasionally, jaundice and ascites. Here we described an interesting case of idiopathic portal hypertension caused by coeliac disease in a 38-year-old woman. By putting this patient on a gluten-free diet, liver function tests became normal and portal vein diameter returned to normal range. This report indicates that, in coeliac disease, repetitive stimulation by antigens along the portal vein-and immune responses to them-can result in the development of idiopathic portal hypertension.

Unrecognized Celiac Disease in Children Presenting for Rheumatology Evaluation

BACKGROUND AND OBJECTIVES

Current clinical guidelines do not consider patients with rheumatic conditions to be at high risk for celiac disease (CD) despite numerous reported associations between the two in adults and children. The objective of this study was to evaluate the prevalence of CD among patients presenting for pediatric rheumatology evaluation.

METHODS

A total of 2125 patients presenting for initial evaluation by the Division of Pediatric Rheumatology at the Hospital for Special Surgery between June 2006 and December 2013 were screened for CD as a part of the standard initial serologic evaluation. The charts of these patients were evaluated retrospectively at the end of this period.

RESULTS

36 patients (30 girls, 6 boys, mean age 9.4 ± 4.3 years, range 2-16 years) received a diagnosis of CD after serologic testing and evaluation by pediatric gastroenterology. Eight additional patients with known diagnoses of CD presented during this time period. The total prevalence of CD over this 6.5-year period was 2.0%. The most common presenting complaints among patients diagnosed with CD were myalgias, arthralgias, and rash. Less frequently, patients reported gastrointestinal complaints including abdominal pain, nausea, and diarrhea. All patients reported improvement or complete resolution of their musculoskeletal symptoms after initiation of a gluten-free diet.

CONCLUSIONS

This study identified 36 new cases of CD among children presenting for rheumatology evaluation, for an overall prevalence rate of 2.0%. The majority of patients who ultimately received a diagnosis of CD presented with extraintestinal manifestations. These results underscore the importance of screening children presenting for rheumatology evaluation for CD.

Celiac disease with pure red cell aplasia: an unusual hematologic association in pediatric age group

Anemia in Celiac disease (CD) is usually hypoproliferative, reflecting impaired absorption of essential nutrients like iron and various vitamins. We report a 2-year-old boy with Celiac disease and severe anemia due to pure red cell aplasia, diagnosed by bone marrow biopsy. This rare, unexplained extra digestive manifestation responded to gluten free diet.

Celiac disease and dermatologic manifestations: many skin clue to unfold gluten-sensitive enteropathy

Cutaneous manifestations of intestinal diseases are increasingly reported both in the adult and in the children, and this association cannot longer be considered a simple random. Besides the well-known association between celiac disease (CD) and dermatitis herpetiformis (DH), considered as the cutaneous manifestation of gluten-dependent enteropathy, is more frequently reported also the association with other mucocutaneous diseases. Among these there are both autoimmune, allergic, and inflammatory diseases, but also a more heterogeneous group called miscellaneous. The knowledge about pathogenic, epidemiological, clinical, and diagnostic aspects of CD is increasing in recent years as well as those about DH, but some aspects still remain to be defined, in particular the possible pathogenetic mechanisms involved in the association between both CD and DH and CD and other immunological skin diseases. The aim of this paper is to describe the skin diseases frequently associated with CD, distinguishing them from those which have a relationship probably just coincidental.

Celiac-associated peptic disease at upper endoscopy: how common is it?

OBJECTIVE

Recently, several publications in adults have shown an increased incidence of non-Helicobacter pylori (HP), non-non-steroidal anti-inflammatory drug (NSAID) peptic disease (PD). There are only a few case reports linking celiac disease (CD) to PD. We therefore aimed to review our experience of CD presenting with PD.

MATERIAL AND METHODS

We retrospectively reviewed all the endoscopies performed for children and young adults diagnosed with CD between 1 January, 2004 and 31 October, 2008. The diagnosis of CD was based on accepted guidelines. Patients with a doubtful diagnosis of CD were excluded.

RESULTS

We had 240 patients with the diagnosis of CD. We had 29 (12.0%) patients [15 males (52%), 14 females (48%)] for whom the diagnosis of PD was ascertained. The age range was 1-50 years (mean 16.9 +/- 12.1 years). Twenty-three of the 29 patients (79%) were HP-negative. Duodenal PD was noted in 22 patients (76%) and 16 (73%) were HP-negative. Gastric PD was noted in eight patients (28%) and 7 (87%) were HP-negative. The PD group was significantly older at diagnosis (p < 0.001) compared to the whole CD group.

CONCLUSIONS

PD is not uncommon in the presentation of CD. It is more likely to be found in the second decade of life. CD should be included in the differential diagnosis of patients with non-HP PD and we suggest routine CD serology and small bowel biopsy in patients with unexplained PD.

Prevalence of celiac disease among patients with Behcet's disease in Iran

BACKGROUND

Behcet's disease and Celiac disease, both common in Iran, share many immunopathogenic and clinical features. Based on the possible association between these two diseases, this study is designed to determine the frequency of non-diagnosed celiac disease in patients with Behcet's disease.

METHODS

The sera of 288 consecutive patients with Behcet's disease were screened with anti-endomysial antibody and anti-tissue transglutaminase antibody for celiac disease. Those with a positive test underwent upper gastrointestinal endoscopy and duodenal biopsies to confirm the diagnosis of celiac disease. The patients with celiac disease were put on a gluten free diet to evaluate its efficacy on the improvement of their lesions.

RESULTS

Fourteen patients had positive anti-tissue transglutaminase antibody test (two with positive anti-endomysial antibody as well). Duodenal biopsies showed findings compatible with Marsh 3 in one and Marsh 1 in three other patients. All the diagnosed patients with celiac disease responded to the gluten free diet.

CONCLUSION

Our findings didn't support any association between celiac disease and Behcet's disease in Iranian patients compared to the general population of Iran.

Deposits of plasma proteins in the skin during treatment with carbamazepine and diphenylhydantoin

Biopsies from skin of normal appearance from 18 patients treated with carbamazepine and diphenylhydantoin were investigated by a direct immunofluorescence technique. Seventeen had deposits of plasma proteins at the dermoepidermal junction, 16 had deposits in the vessel walls, and one had autofluorescence of the nuclei in the epidermis and vessel walls. These findings did not correlate with changes in serum IgG, IgA, IgM, IgD, IgE or alpha 2-macroglobulin. Eight patients had elevated alkaline phosphatase, 4 elevated IgG and one elevated IgA. Three had low values of IgA, and all had normal values of IgM, IgD and IgE, and blood cells. In three patients, carbamazepine was withdrawn, whereupon the deposits disappeared in two and decreased in the third, who changed to another drug. The changes were quantitatively and qualitatively similar to those seen in systemic lupud erythematosus induced by these drugs.

IgM deposition in skin biopsies from patients with primary biliary cirrhosis

Immunofluorescence studies on skin biopsies from 14 patients with primary biliary cirrhosis (PBC) showed granular papillary deposition of IgM in all. In addition, 6 patients had C3 deposition. Control patients with various other liver diseases, idiopathic high plasma levels of igM and extrahepatic cholestasis were only sporadically positive for IgM and not at all for C3. IgM deposition in dermal papillae in PBC does not merely reflect high plasma IgM levels or cholestasis but probably represents an immunochemically abnormal IgM population.

Symposium on 'The challenge of translating nutrition research into public health nutrition'. Session 3: Joint Nutrition Society and Irish Nutrition and Dietetic Institute Symposium on 'Nutrition and autoimmune disease'. Recent advances in genetic understanding of coeliac disease

Over the past 20 years major advances have been made in the diagnosis and understanding of pathogenic mechanisms relating to coeliac disease. Recently-identified genetic markers support the immunological-inflammatory nature of the disease. It is hoped that these newly-identified genes will assist further dissection of the inflammatory pathways in coeliac disease and give insight into why certain individuals develop intolerance to dietary gluten.

Celiac disease as a potential cause of idiopathic portal hypertension: a case report

Introduction

Idiopathic portal hypertension is a disorder of unknown etiology, clinically characterized by portal hypertension, splenomegaly and anemia secondary to hypersplenism.

Case presentation

A 54-year-old man was admitted to our hospital for evaluation of malaise, weight loss, abdominal swelling and lower limb edema. His paraclinical tests revealed pancytopenia, large ascites, splenomegaly and esophageal varices consistent with portal hypertension. Duodenal biopsy and serologic findings were compatible with celiac disease. His symptoms improved on a gluten-free diet, but his clinical course was further complicated with ulcerative jejunoileitis, and intestinal T-cell lymphoma.

Conclusion

It seems that celiac disease, by an increased immune reaction in the splenoportal axis, can result in the development of idiopathic portal hypertension in susceptible affected patients.

Perinatal risk factors and coeliac disease in children and young adults: a record linkage study

BACKGROUND

Little is known about perinatal risk factors and coeliac disease.

AIM

To investigate the relationship between perinatal risk factors and subsequent coeliac disease among offspring.

METHODS

Record linked abstracts of birth registrations, maternity, in-patient and day case records in a defined population of southern England.

RESULTS

Using univariate analysis, coeliac disease in the child was associated with maternal coeliac disease (odds ratio = 20.6; 95% CI = 5.04-84.0; based on two cases in both mother and child) and with social class, year of birth, maternal smoking and parity. Multivariate analysis confirmed an increased risk of coeliac disease of 3.79 (95% CI = 1.85-7.79) for classes IV and V compared with I and II, an increased risk of 1.92 (1.06-3.49) for births during 1975-1979 compared with 1970-1974 and an increased risk of 1.80 (1.05-3.09) for 'subsequent' compared with 'first' births. Smoking during pregnancy was no longer associated with coeliac disease. Because numbers were small, maternal coeliac disease was excluded from the multivariate analysis.

CONCLUSIONS

This study shows increased risks of coeliac disease for manual social classes, births during the late 1970s and 'subsequent' births. Overall, perinatal risk factors seem to have a limited role in the aetiology of coeliac disease in children and young adults.

Searching for genes influencing a complex disease: the case of coeliac disease

Recently, a few genes have been reported to be causative in inflammatory diseases. Still, we are waiting for the vast majority to be discovered. New tools for genotyping and statistical analysis have been developed and emphasis has been put on study design. Coeliac disease (CD) is a disorder, where prolamins in dietary wheat gluten and related proteins from rye or barley are not tolerated. It is one of the most common chronic diseases in humans exceeding a population prevalence of 1%. In this article, we will summarise what is currently known about the genetics influencing CD with the emphasis on the non-HLA genetic component. We will discuss some difficulties when searching for susceptibility genes in disorders with complex inheritance patterns.

Cutaneous manifestations in celiac disease

Celiac disease (CD) is an autoimmune gluten-dependent enteropathy characterized by atrophy of intestinal villi that improves after gluten-free diet (GFD). CD is often associated with extra-intestinal manifestations; among them, several skin diseases are described in CD patients. The present review reports all CD-associated skin manifestations described in the literature and tries to analyze the possible mechanisms involved in this association. The opportunity to evaluate the possible presence of CD in patients affected by skin disorders is discussed.

Association of celiac disease with non-cirrhotic portal fibrosis

Both celiac disease and non-cirrhotic portal fibrosis are known to be associated with various autoimmune diseases and have numerous immunological abnormalities. Herein two patients with celiac disease having associated non-cirrhotic portal fibrosis are reported. An autoimmune link between the two conditions is likely to explain coexistence in the same patient.

The prevalence of coeliac disease in rheumatoid arthritis

OBJECTIVE

To determine the prevalence of coeliac disease in rheumatoid arthritis.

METHODS

One hundred and sixty patients with seropositive rheumatoid arthritis were tested for the endomysial antibody. Those found positive were studied further with endoscopic small bowel biopsy.

RESULTS

Only one patient was found to have coeliac disease, and that had already been diagnosed. Thus the prevalence of previously undiagnosed coeliac disease in rheumatoid arthritis is 0 (95% CI 0-0.24%) and the overall prevalence of coeliac disease is 0.63% (95% CI 0.1-3.5%). These prevalences are not significantly different from the reported prevalences of coeliac disease in the general population.

CONCLUSIONS

This study does not support an association between coeliac disease and seropositive rheumatoid arthritis or the screening of such patients for coeliac disease.

Is coeliac disease more prevalent in young adults with coexisting Type 1 diabetes mellitus and autoimmune thyroid disease compared with those with Type 1 diabetes mellitus alone?

AIM

It is known that patients with Type 1 diabetes mellitus are more prone to develop coeliac disease and that autoimmune thyroid disease occurs more frequently in patients with coeliac disease. We therefore assessed whether coeliac disease, either known or occult, occurs more frequently in young/middle aged adults with Type 1 diabetes and coexisting autoimmune thyroid dysfunction than in adults with Type 1 diabetes alone.

METHODS

The prevalence of known coeliac disease was assessed in 509 (301 males, aged 16-55 years) patients with Type 1 diabetes, 28 (5.5%) of whom had treated autoimmune thyroid disease. In a second study 38 patients with Type 1 diabetes and coexisting autoimmune thyroid disease along with 112 patients with Type 1 diabetes alone were then screened for coeliac disease using serum IgA endomysial antibodies and IgA gliadin antibodies.

RESULTS

Seven of the 509 patients (1.4%) had been diagnosed with coeliac disease and two of these had later developed autoimmune thyroid disease (both hypothyroid). The subsequent screening exercise found that one of the 38 patients with both Type 1 diabetes and thyroid disease had positive endomysial antibodies on screening. However, duodenal biopsy was negative for coeliac disease. There were two patients with positive endomysial antibodies in the group of 112 patients with diabetes only. Both had duodenal biopsy but only one was consistent with coeliac disease.

CONCLUSION

The prevalence of known coeliac disease in this young adult Type 1 diabetes clinic in North-west England was 7/509 (1.4%). Two of these seven patients with coeliac disease were from the group of 28 who had autoimmune thyroid disease as well. Therefore we suggest that patients with known coeliac disease and Type 1 diabetes should be screened for autoimmune thyroid disease. The second screening study then found 3/150 (2%) to have a serological marker for coeliac disease. However, patients with both Type 1 diabetes and autoimmune thyroid disease were not more likely to have occult coeliac disease compared with those with Type 1 diabetes only.

Coeliac disease: the cause of the various associated disorders?

The advent of the endomysial antibody test has allowed the true association between coeliac disease and at least 12 other disorders to be established. There is evidence suggesting that coeliac disease is a cause of these disorders; a mechanism for this is proposed.

Importance of gluten in the induction of endocrine autoantibodies and organ dysfunction in adolescent celiac patients

OBJECTIVE

It is well known that a high number of celiac patients may develop autoantibodies against endocrine glands, but it has not yet been clarified if this increased autoimmune response and the impaired organ function that can develop may be related to the presence or absence of gluten in the diet. The aim of the present study was to evaluate the effect of gluten on the autoimmunity and function of the endocrine glands in adolescent celiac patients.

METHODS

To clarify this aspect we investigated 44 patients (28 females), aged 11-20 yr (15.21+/-2.7 yr): 25 (mean age, 15.1+/-2.2 yr) on a gluten-free diet (treated patients) and 19 (mean age 15.4+/-2.9 yr) with a diet containing gluten (untreated patients). Forty adolescent subjects, aged 14-19 yr (mean age, 14.9+/-2.7 yr), of whom 20 were females, were studied as controls. Antibodies against the thyroid, adrenal, and pancreas were evaluated. Thyroid-stimulating hormone FT3, FT4, T3, T4, dehydroepiandrosterone sulphate, 17-OH progesterone, and cortisol, analyzed basally and 60 min after intravenous ACTH stimulation, were assayed to evaluate thyroid and adrenal function. The fasting glycemia level was used to evaluate the endocrine pancreas function. An ultrasonogram of the thyroid gland was performed on all patients. HLA class II typing for DR3 and DQB1 was performed in 32 of 44 patients.

RESULTS

Seven of 44 (15.9%) patients were positive for antibodies against peroxidase. Six of 44 (13.6%) were positive for antibodies against thyreoglobulin and four of them also showed positive antibodies against peroxidase. Therefore, in nine of 44 at least one antibody directed against thyroid tissue was positive. Seven of 44 (15.9%) were positive for antibodies against islet cell, one of 44 (2.3%) positive for antibodies against glutamic acid decarboxilase, one of 44 (2.3%) positive for antibodies against insulin, and none for antibodies against islet cell- 512bdc. In 15 of 44 (34%) at least one antibody against an endocrine tissue was positive. The genotype DR3 was found in 21 of 32 (65.6%) celiac patients (10 in the untreated and 11 in the treated group, respectively) and the genotype DQB1*02 (DQ2) was found in 30 of 32 (93.8%) patients (16 in the treated and 14 in the untreated group, respectively). DHA-S values were significantly lower in the untreated (30.5+/-28.5 microg/dl) than in the treated group (61.3+/-59.4 microg/dl, p < 0.05), and both showing significantly (p < 0.01) lower levels with respect to the controls (161+/-52 microg/dl). One patient showed diabetes, another one clinical hypothyroidism (thyroid-stimulating hormone > 6), and two patients showed preclinical hypothyroidism. Interestingly, at least one antibody was positive in 10 of 19 untreated patients (52.6%) but only in five of 25 treated patients (20%), with a significantly different distribution (p < 0.001) between the two groups and without differences in the HLA genotype. The ultrasonographic evaluation of the thyroid resulted in a pathological score in six patients of the 44 examined (13.6%), suggesting the presence of thyropathy.

CONCLUSIONS

The main results of this study are the high incidence of thyroid and pancreatic antibodies, and the possible role of gluten in the induction of the antibodies as well as, in few cases, the consequent organ dysfunction.

Massive bleeding from multiple gastric ulcerations in a patient with lymphocytic gastritis and celiac sprue

Uncontrolled hemorrhage and multisystem organ failure developed in a patient with celiac sprue, lymphocytic gastritis, and diffuse gastric ulceration. A proximal small bowel biopsy showed villous atrophy and lymphoplasmacytic infiltration consistent with celiac sprue. At autopsy, there were no gross or histologic findings to suggest lymphoma. The intestinal lymphocytic infiltrate was not monoclonal, and gene rearrangements were not detected. Lymphocytic gastritis is a rare cause of upper gastrointestinal hemorrhage, which may be the result of sensitivity to gluten or other luminal antigens. This diagnosis should be considered in cases of diffuse gastric ulceration with bleeding in which the endoscopic appearances are not typical of peptic ulcer disease or drug-induced erosions. Ideally, biopsies of gastric and duodenal mucosa should be performed to establish the diagnosis.

Addison's disease and selective IgA deficiency in two coeliac patients

Coeliac disease is associated with selective IgA deficiency and various autoimmune disorders. An association between Addison's disease and coeliac disease has been documented previously in the literature but never heretofore in coeliac patients with selective IgA deficiency. From a coeliac registry of over 700 biopsy-proven coeliac patients, studied closely over a 25-year period at University College Hospital, Galway, we now report the finding of Addison's disease and selective IgA deficiency in two patients with established coeliac disease. Previous reports of Addison's disease in coeliac patients were sporadic, and it was felt that the association between the two conditions was fortuitous. We now believe that coeliac patients, especially those who are selectively deficient in serum IgA, should be followed up with increased vigilance, as the association between IgA-deficient coeliac patients and Addison's disease is greater than can be explained by chance. Furthermore, we suggest that patients with established Addison's disease may have subclinical coeliac disease and should be screened with anti-reticulin or anti-endomyseal antibodies.

Clinical aspects of coeliac disease in children with insulin-dependent diabetes mellitus

Coeliac disease (CD) is heterogeneous in its clinical presentation and pathological expression. Silent, latent and potential forms represent the submerged part of the so-called "coeliac iceberg". The association of insulin-dependent diabetes mellitus (IDDM) and CD has been widely reported. For the screening of CD in diabetic patients, anti-reticulin R1 (ARA-R1) and anti-endomysium (AEA) antibodies are more reliable markers than anti-gliadin (AGA) antibodies. Recent studies have reported an increased prevalence of CD in children with IDDM. In our experience intestinal biopsy confirmed a diagnosis of CD in 6 out of 172 diabetic patients, with a prevalence of 3.5%. Only occasionally does CD precede the onset of IDDM; more often CD is diagnosed shortly or sometimes years after the onset of diabetes. Typical gastrointestinal complaints of CD (such as diarrhoea, abdominal distension) are rare in IDDM patients, while atypical isolated signs or symptoms of CD are more common, in particular sideropenic anemia, short stature, delayed puberty, epilepsy, hypertransaminasemia, dyspeptic symptoms, herpetiform dermatitis, and recurrent aphthous stomatitis. It is recommended that all diabetic children, even those asymptomatic, should be screened yearly for CD, using a combination of AGA plus ARA-R1 and AEA.

Celiac disease and alopecia areata: report of a new association

Celiac disease is frequently associated with other autoimmune disorders but has never been reported in association with alopecia areata. In a routine clinical practice, 3 patients with such an association were observed. In one of the patients, celiac disease was diagnosed after the occurrence of malabsorption symptoms. In the youngest patient, a 14-year-old boy, gluten-free diet resulted in complete regrowth of scalp and body hair. A prospective screening program for celiac disease using antigliadin and antiendomysial antibodies was therefore set up in 256 consecutive outpatients with alopecia areata. Three patients, all completely asymptomatic for intestinal diseases, were found to be positive and underwent biopsy. Histological analysis showed a flat intestinal mucosa consistent with the diagnosis of celiac disease. The results show that alopecia areata may constitute the only clinical manifestation of celiac disease and that the association between these two conditions is a real one because the observed frequency of association is much greater than can be expected by chance. It is suggested that antigliadin and antiendomysial antibodies should be included in the work-up of patients with alopecia areata.

Coeliac disease in childhood

Coeliac disease usually presents in infancy or early childhood with diarrhoea, vomiting and interference with weight gain and growth. Withdrawal of dietary gluten is followed by resolution of the symptoms and signs and restoration of normal weight gain and growth; the characteristic subtotal villous atrophy of the jejunal mucosa also recovers. Later re-introduction of dietary gluten will lead to a return of the jejunal mucosal abnormality in the majority and to clinical relapse in many but not all. The severity and timing of both are variable and 5% of children initially considered on clinical, biopsy and gluten response evidence to have coeliac disease appear to develop permanent tolerance to gluten, although mucosal relapse may occur years after the re-introduction of dietary gluten in a minority, emphasizing the need for long-term follow-up. Although a diagnostic and subsequent follow-up jejunal biopsy are necessary to confirm the diagnosis, anti-gliadin IgA and IgG, anti-reticulum and anti-endomysium antibodies are now almost totally reliable in identifying children who have coeliac disease and are valuable in monitoring the adequacy of gluten withdrawal. Dietary compliance is frequently poor and regular supervision by a paediatric dietitian is needed; indeed, lifelong supervision to ensure gluten withdrawal is essential to reduce the chance of developing later gastrointestinal malignancy.

The occurrence of polyglandular autoimmune syndrome type III associated with coeliac disease in patients with sarcoidosis

OBJECTIVES

To study whether an association between polyglandular autoimmune (PGA) syndrome type III [including autoimmune thyroid disease (ATD) and insulin-dependent diabetes mellitus (IDDM)], coeliac disease and sarcoidosis, exists.

DESIGN

In patients with documented sarcoidosis, the presence of the disease constellation of ATD, IDDM and coeliac disease was examined.

SETTING

The patients were recruited at the Department of Pulmonary Medicine, and the study was conducted at the Department of Endocrinology, Lund University Clinics, General Hospital, Malmö, Sweden.

SUBJECTS

Of all patients (n = 89) with documented sarcoidosis attending the Department of Pulmonary Medicine between January 1980 and December 1991, 78 patients (44 males, 34 females: median age at the time of the study 48 years, range 22-81 years: median observation time since the diagnosis of sarcoidosis 120 months, range 1-468 months) were examined in the present study.

RESULTS

Amongst the 78 patients with documented sarcoidosis, one female patient was found with PGA syndrome type III, coeliac disease and sarcoidosis.

CONCLUSIONS

This present patient further indicates the existence of an association between polyglandular autoimmune (PGA) syndrome type III, coeliac disease and sarcoidosis. To determine whether this disease constellation might constitute a new syndrome, further studies on larger groups of patients with sarcoidosis are demanded.

The coexistence of systemic lupus erythematosus with other autoimmune diseases: the kaleidoscope of autoimmunity

Patients with systemic lupus erythematosis (SLE) often manifest features of other autoimmune diseases. In this review, we provide a detailed compendium of features of SLE that overlap with other conditions. This compendium is important because a critical feature in our understanding of autoimmunity has been the clustering of coexisting/different autoimmune diseases both within an affected patient and within a pedigree. Indeed, autoimmune disorders share a variety of similar clinical and serological defects. For example, all autoimmune disorders are associated with the elaboration of autoantibodies and/or the production of self-reactive mononuclear cell populations; many have high levels of immune complexes and defects in cell-mediated immunity. Several diseases share similar genetic backgrounds, as reflected by study of loci within the major histocompatibility complex. In part the coassociation is due to common genetic tendencies with different environmental precipitating agents (trigger mechanisms). It is likely that many factors can modulate the immune system to autoimmunity in the presence of an appropriate genetic background, eg, drugs, viral infections, UV irradiation, and toxins, ie, toxic oil syndrome and L-tryptophan-induced eosinophilic myalgia. The coexistence of SLE with other autoimmune diseases is an excellent venue to understand these events, and we believe that the presence of other autoimmune diseases in patients with SLE can be called the kaleidoscope of autoimmunity.

Erythema elevatum diutinum associated with celiac disease: response to a gluten-free diet

An 11-year-old girl with a history of insulin-dependent diabetes mellitus had erythema elevatum diutinum (EED) associated with a celiac disease related to a possible kidney disease. Dapsone did not improve the skin manifestations. However, the lesions disappeared after a gluten-free diet was begun. To our knowledge, this report describes the first case of EED in a patient with celiac disease.

The occurrence of IgA-nephropathy in patients with diabetes mellitus may not be coincidental: a report of five cases

We describe five patients with IgA-nephropathy complicating diabetes mellitus. In four cases, diabetic glomerulosclerosis was present at the same time. One patient suffered from dermatitis herpetiformis. The observation of the present five cases together with the notion of an increased prevalence in diabetes mellitus of celiac disease and dermatitis herpetiformis suggests that the occurrence of IgA-nephropathy in diabetic patients is not mere coincidence.

Gliadin antibodies identify gluten-sensitive oral ulceration in the absence of villous atrophy

This study demonstrates gluten-sensitive recurrent oral ulceration (ROU) in the absence of gastrointestinal abnormalities which is associated with a humoral response to wheat protein. Ten patients with severe ROU were investigated; all had normal small intestinal biopsies. Four patients had raised levels of antibodies to alpha gliadin, a wheat protein fraction; in three of these four, the ulceration remitted on treatment with a gluten-free diet (G.F.D.) and relapsed on gluten challenge. None of the remaining six patients had raised alpha gliadin antibody (AGA) levels and none responded to G.F.D. Thus raised AGA levels can be used to identify patients with ROU who are likely to respond to a GFD.

Bilateral papillitis with anti-neutrophil cytoplasmic antibodies associated with coeliac disease

A 39 year old woman with untreated coeliac disease presented with some of its complications and bilateral papillitis. She was found to have antineutrophil cytoplasmic antibodies (ANCA) in high titres. Following institution of gluten-free diet the complications resolved. The papillitis, however, persisted and needed a course of prednisolone to resolve, and a fall in the ANCA titres was noted. We believe that this is the first report of an association of coeliac disease and ANCA.

Susceptibility to tuberculosis in patients with coeliac disease

An increased prevalence of past tuberculosis is reported in an adult coeliac population. Of 76 adult coeliac disease patients, 6 had had a history of tuberculosis. This compared with the finding of no cases in a population of 81 patients with non-inflammatory bowel diseases, (p = 0.023), which was matched for age, sex, smoking, ethnic origin and social class. The 'expected' number of cases of tuberculosis amongst ACD patients has also been calculated based on local annual notification rates; this was 2.9. Radiological evidence of past tuberculosis was found in 13 (17%) ACD patients, compared with 4 (5%) control patients (p less than 0.05). It is postulated that the increased prevalence of past tuberculosis in ACD patients is the result of depressed cell mediated immunity and/or malnutrition.

Selective vitamin B12 malabsorption in adult coeliac disease. Report on three cases with associated autoimmune diseases

Three cases of adult coeliac disease with severe vitamin B12 deficiency not accompanied by folate or iron depletion are presented. Two of the patients had the extremely rare combination of coeliac disease and lack of intrinsic factor and autoimmune thrombocytopenic purpura. A close association between coeliac disease and autoimmunity is indicated by the development of autoimmune thyroiditis in the third patient. Vitamin B12 malabsorption caused by coeliac disease is emphasized as a pathogenetic mechanism of megaloblastic anaemia.

Association between villous atrophy in rheumatoid arthritis and a rheumatoid factor and gliadin-specific IgG

93 patients with rheumatoid arthritis (RA) were examined for histological or other evidence of gut abnormalities. 44 had raised levels of IgG to gliadin, and of these 38 (86%) were also positive for IgA rheumatoid factor (RF). 24 patients (15 with raised levels of IgA RF and wheat protein IgG [AB+] and 9 with normal levels of both antibodies [AB-]) underwent jejunal biopsy. 6 of the AB+ and 1 of the AB- patients had villous atrophy. The AB+ group had lower villous surface/volume ratio and small intestinal lactase concentrations than did the AB- group or age-matched controls. There was no significant difference between the two groups of RA patients in disease severity or treatment regimen. The findings suggest that the gut may play a more important part in the immunopathogenesis of some cases of RA than in others, and that the former may be identified by raised levels of IgA RF and wheat protein IgG.

The immunology of coeliac disease

Coeliac disease is defined as that disorder in which there is an abnormality of the small intestinal mucosa manifested by contact with the gluten of wheat and certain other cereal grains. In the immunological theory of the pathogenesis of coeliac disease, gluten, or a component, is viewed as the antigen responsible for the immune response. The search for the gluten component responsible for 'toxicity' and, by implication, antigenicity, is described. The antigen may be presented differently to the immune system by an abnormal cell membrane, either of the enterocyte, lymphocyte or macrophage. Alternatively, increased amounts of antigen may be absorbed due to increased membrane binding or permeability, either of which could be genetically determined. As a further possibility, coeliac disease may occur because the patients are immunologically hyperresponsive and this too appears to be genetically determined. The perturbations which occur in the mucosal immune system and the systemic immune system are described. It is conceivable that the major complications described (intestinal ulceration, malignancy and splenic atrophy) result from immunological disturbances. The incidence of childhood coeliac disease is declining, which may be due to altered exposure to, or increased protection from, the antigen in infancy, or to changes in environmental factors. The immunological mystery of coeliac disease continues to excite interest and fascination, and has certainly been a stimulus to our deeper understanding of gastrointestinal immunology.

Coeliac proctitis

An increased association of ulcerative colitis and coeliac disease has been reported, as have the results of several small-bowel biopsy studies in ulcerative colitis. Forty-two patients from a population of 438 patients with coeliac disease had rectal biopsies. Fourteen of these showed inflammation of various degrees of severity, including three compatible with a diagnosis of ulcerative colitis. The presenting complaint in 34 of these patients was diarrhoea or steatorrhoea. Twenty-seven patients had coeliac disease diagnosed at the same time or after their rectal biopsy. The other 15 were previously diagnosed coeliacs. Twelve of the 14 patients with abnormal rectal biopsy specimens were known to have subtotal/total villous atrophy at the time of rectal biopsy. Proctitis as seen in these coeliac patients had no unique features to differentiate it from proctitis caused by other disorders. The diarrhoea/steatorrhoea stopped in all patients on commencement of a gluten-free diet, except in those with ulcerative colitis. Proctitis is common in patients with coeliac disease presenting with diarrhoea/steatorrhoea. This study supports the finding of an increased association of coeliac disease and ulcerative colitis and is, to our knowledge, the first rectal biopsy study of a coeliac population.

Avidity of antigliadin IgA and IgG antibodies in gluten-sensitive enteropathy and dermatitis herpetiformis

Antigliadin antibodies (AGA) of IgG and IgA class were assayed with a modified enzymeimmunoassay in serum samples of 18 patients with gluten-sensitive enteropathy and 30 patients with dermatitis herpetiformis. No difference between antibody amount or avidity of the two groups of patients was observed. Avidity and total amount of AGA were also compared in 15 patients with a recent diagnosis of dermatitis herpetiformis and in 15 patients with a disease history of several years without a proper gluten-free diet. No difference in IgG antibodies was found but the amount of high avidity IgA antibodies was significantly higher in patients with several years' experience of dermatitis herpetiformis than in those with a recent diagnosis. The results indicate that in dermatitis herpetiformis, maturation of IgA response occurs. Further, clinically, maturation of anti-gliadin IgA response during the disease can increase the sensitivity of the patient against diet-derived gliadin.

Sarcoidosis and coeliac disease: an association?

An association between sarcoidosis and coeliac disease is suggested by the occurrence of both diseases in 5 patients. In 3 cases the gastrointestinal symptoms of coeliac disease preceded those of sarcoidosis and in the other 2 patients symptoms of both diseases appeared at the same time.