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Fernández-Bañares F, Crespo L, Planella M, Farrais S, Izquierdo S, López-Palacios N, Roy G, Vidal J, Núñez C. Improving the Diagnosis of Dermatitis Herpetiformis Using the Intraepithelial Lymphogram. Nutrients 2024; 16:232. [PMID: 38257124 PMCID: PMC10819692 DOI: 10.3390/nu16020232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Dermatitis herpetiformis is a cutaneous manifestation of celiac disease. Phenotyping of intraepithelial lymphocytes in the small bowel mucosa can strengthen the diagnosis of celiac disease when it is not clear-cut. We aim to evaluate the usefulness of the intraepithelial lymphogram to confirm dermatitis herpetiformis in equivocal cases. We performed a retrospective multicenter study on patients diagnosed with dermatitis herpetiformis and collected data from the intraepithelial lymphogram assessed by flow cytometry. A total of 36 patients were analyzed in relation to the severity of intestinal damage (18 had non-atrophic mucosa) at baseline (N = 28) and/or after the adoption of a gluten-free diet (median follow-up of three years, N = 16). We observed that patients with atrophy more often had positive celiac serology (p = 0.019), celiac clinical symptoms (p = 0.018), and iron-deficiency anemia (p = 0.018), but the severity of skin damage was similar in both groups (p = 0.79). At baseline, increased TCRγδ+ cells were present in 94% of patients with atrophy and 67% with non-atrophic lesions (p = 0.13). After a gluten-free diet, increased TCRγδ+ cells persisted in 100% and 63% of cases, respectively (p = 0.21). We concluded that increased TCRγδ+ cells may be helpful in confirming the diagnosis of dermatitis herpetiformis in equivocal cases, even in patients who were started on a gluten-free diet.
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Affiliation(s)
- Fernando Fernández-Bañares
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrasa, Spain;
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Laura Crespo
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
| | - Montserrat Planella
- Department of Gastroenterology, Hospital Arnau Vilanova, 25198 Lleida, Spain;
| | - Sergio Farrais
- Department of Gastroenterology, Hospital Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - Sandra Izquierdo
- Department of Gastroenterology, Hospital Clínico Universitario, 47003 Valladolid, Spain;
| | - Natalia López-Palacios
- Department of Gastroenterology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, 28040 Madrid, Spain;
| | - Garbiñe Roy
- Department of Immunology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, 28034 Madrid, Spain;
| | - Judith Vidal
- Section of Flow Cytometry, CATLAB, 08232 Viladecavalls, Spain;
| | - Concepción Núñez
- Laboratorio de Investigación en Genética de Enfermedades Complejas, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, 28040 Madrid, Spain
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), 28029 Madrid, Spain
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Abstract
GOALS To validate cut-off values of CD3 T-cell receptor gamma-delta chain (TCRγδ) intraepithelial lymphocyte (IEL) in the (differential) diagnosis of celiac disease (CD). BACKGROUND CD is characterized by an increase in gamma-delta IEL (CD3TCRγδ IEL). STUDY Percentages were determined by flow cytometric analysis of IELs from small bowel biopsies in 213 CD and 13 potential CD (PCD) patients and in total 112 controls. A cut-off value for percentages of CD3TCRγδ IEL to differentiate active CD and controls was obtained from a receiver operating characteristic curve and implemented in controls and PCD patients. RESULTS Percentage of CD3TCRγδ IEL was significantly increased in the majority of CD patients, irrespective of the presence of villous atrophy. A cut-off value of 14% for CD3TCRγδ IEL resulted in 66.3% sensitivity and 96.6% specificity for CD diagnosis (area under the curve, 88.6%). CONCLUSIONS A percentage of ≥14% CD3TCRγδ IEL has a high specificity for CD diagnosis and can be of diagnostic help in cases where diagnosis is not straightforward.
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Verbeek WHM, Schreurs MWJ, Visser OJ, von Blomberg BME, Al-Toma A, Mulder CJJ. Novel approaches in the management of refractory celiac disease. Expert Rev Clin Immunol 2014; 4:205-19. [PMID: 20477051 DOI: 10.1586/1744666x.4.2.205] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Wieke H M Verbeek
- VU University Medical Center, Department of Gastroenterology and Hepatology, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.
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Olivencia Palomar P, Cano Ruiz A, Martín Scapa MA, León Prieto F, Roy Ariño G, Redondo Verge C. [Adult celiac disease and intraepithelial lymphocytes. New options for diagnosis?]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 31:555-9. [PMID: 19091242 DOI: 10.1157/13128293] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Permanent changes have been found in intraepithelial lymphocyte (IEL) subsets in patients with celiac disease. OBJECTIVE The main aim of this study was to demonstrate the utility of determining CD3()/CD7(+) and T cell receptor (TCR) gamma-delta IEL subsets by flow cytometry as a diagnostic marker of adult celiac disease. PATIENTS AND METHODS We performed a prospective study in a sample of 128 adult patients (70 with celiac disease and 58 controls). In all patients, distal duodenal biopsy was performed and IEL subsets were determined by flow cytometry. RESULTS Patients with celiac disease showed an increase in gamma-delta IEL subsets and a decrease in CD3(-)/CD7(+) IEL subsets in comparison with the control group, independently of diet. CONCLUSIONS The results indicate that IEL subset determination by flow cytometry could be useful to confirm diagnosis of celiac disease. IEL subsets should be investigated in diseases other than celiac disease, as well as in patients with potential or latent celiac disease.
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Camarero C, Eiras P, Asensio A, Leon F, Olivares F, Escobar H, Roy G. Intraepithelial lymphocytes and coeliac disease: permanent changes in CD3−/CD7+ and T cell receptor γβ subsets studied by flow cytometry. Acta Paediatr 2007. [DOI: 10.1111/j.1651-2227.2000.tb01330.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Holtmeier W, Pfänder M, Zollner TM, Kaufmann R, Caspary WF. Distinct TCR delta repertoires are present in the cutaneous lesions and inflamed duodenum of patients with dermatitis herpetiformis. Exp Dermatol 2002; 11:527-31. [PMID: 12473060 DOI: 10.1034/j.1600-0625.2002.110605.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Intraepithelial gammadelta T cells are increased in the inflamed small bowel and are also found in increased numbers in cutaneous lesions from patients with dermatitis herpetiformis (DH). Thus, these cells might play an important role in the pathogenesis of the disease. We investigated the T-cell receptor (TCR) delta repertoire in involved and non-involved skin and compared it with the TCR delta repertoire of the inflamed duodenum and peripheral blood of the same patients. An identical TCR delta repertoire in the small bowel and in the cutaneous lesions would suggest a migration of antigen-specific gammadelta T cells from the intestine to the skin which cross-react with cutaneous antigens. T-cell receptor DV1-DV3 transcripts were amplified by reverse transcriptase (RT)-PCR and analyzed by complementarity determining region 3 (CDR3) size spectratyping and nucleotide sequencing. Our results indicate that the cutaneous TCR delta repertoires were oligoclonal and identical dominant gammadelta T-cell clones were present in the involved and non-involved skin. Furthermore, the TCR delta repertoire of the skin was distinct from that in the small bowel. The peripheral blood exhibited a restricted TCR delta repertoire, which differed from that in the intestine and skin. Thus, cutaneous gammadelta T cells are not specifically expanded within the involved skin and are unlikely to be derived from the inflamed duodenum.
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MESH Headings
- Amino Acid Sequence/genetics
- Base Sequence/genetics
- Complementarity Determining Regions
- Dermatitis Herpetiformis/complications
- Dermatitis Herpetiformis/metabolism
- Duodenum/metabolism
- Enteritis/etiology
- Enteritis/metabolism
- Humans
- Middle Aged
- Molecular Sequence Data
- Receptors, Antigen, T-Cell, gamma-delta/blood
- Receptors, Antigen, T-Cell, gamma-delta/genetics
- Receptors, Antigen, T-Cell, gamma-delta/immunology
- Receptors, Antigen, T-Cell, gamma-delta/metabolism
- Skin/metabolism
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Affiliation(s)
- Wolfgang Holtmeier
- Department of Medicine II, Division of Gastroenterology, University of Frankfurt, Frankfurt am Main, Germany. W.Holtmeier.em.uni-frankfurt.de
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Iltanen S, Holm K, Ashorn M, Ruuska T, Laippala P, Mäki M. Changing jejunal gamma delta T cell receptor (TCR)-bearing intraepithelial lymphocyte density in coeliac disease. Clin Exp Immunol 1999; 117:51-5. [PMID: 10403915 PMCID: PMC1905475 DOI: 10.1046/j.1365-2249.1999.00948.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/1999] [Indexed: 12/11/2022] Open
Abstract
The function of jejunal intraepithelial gamma delta+ T cells is obscure, but they are commonly implicated as playing a role in inflammatory and autoimmune conditions. In coeliac disease (CoD), there are controversial reports as to gluten dependency of these cells. We have now studied the small bowel mucosal intraepithelial T cell densities, and the ratios of gamma delta+ to CD3+ T cells and gamma delta+ to alpha beta+ T cells during early disease development and on a gluten-free diet. Nine children initially excluded for CoD were followed up and rebiopsy after 0.8-4.5 years showed mucosal deterioration. Further, 21 biopsy specimens from newly diagnosed CoD patients were studied, together with 20 specimens taken from children on a gluten-free diet. During CoD development the density of gamma delta+ and alpha beta+ T cells as well as the ratios of gamma delta+ to CD3+ T cells and gamma delta+ to alpha beta+ T cells increased. In the latent stage of CoD when the small bowel mucosal architecture was still normal, two children had clearly normal densities of gamma delta+ (< 2.5 cells/100 epithelial cells) and alpha beta+ (< 25.0 cells/100 epithelial cells) T cells, and low ratios as well. In patients with newly diagnosed CoD the densities decreased significantly on a long-term gluten-free diet. We conclude that the density of intraepithelial gamma delta+ T cells as well as alphabeta+ T cells in CoD is gluten-dependent. CoD can develop in a child ingesting normal amounts of gluten and having normal jejunal mucosal morphology on biopsy and a normal density of gamma delta+ T cells.
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Affiliation(s)
- S Iltanen
- Institute of Medical Technology, University of Tampere, Finland
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Kerttula TO, Holm K, Partanen J, Polvi A, Mäki M. Circulating T lymphocyte subsets in coeliac disease (CoD) patients and healthy family members. Clin Exp Immunol 1998; 111:536-40. [PMID: 9528895 PMCID: PMC1904878 DOI: 10.1046/j.1365-2249.1998.00539.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Increased proportions of circulating antigen-primed CD45RO+ TCR gammadelta cells have been found in untreated CoD patients. As certain immunological features are now found in both CoD and healthy persons carrying the HLA DQ2 heterodimer, we sought to establish whether healthy members of the families of CoD patients who are positive for HLA DQ2 and also have increased densities of TCR gammadelta intraepithelial lymphocytes (IEL) in their small bowel mucosa have elevated levels of circulating TCR gammadelta memory cells. Peripheral blood T cells were analysed by flow cytometry in 22 patients with CoD and 16 healthy family members. Untreated CoD patients had higher percentages of circulating CD45RO+ TCR gammadelta cells and CD45RO+ Vdelta1+ cells than healthy family members. On the other hand, the amount of circulating Vdelta1+ lymphocytes was lower in patients with CoD compared with healthy family members. In contrast, no differences were found between HLA DQ2+ and HLA DQ2- healthy family members in respect of circulating TCR gammadelta cell subsets. The change in circulating TCR gammadelta cell subsets found in patients with CoD is thus a consequence of an ongoing immunological process which diminishes on a gluten-free diet rather than a phenomenon directly caused by DQ2. These changes in peripheral blood are not found in healthy individuals who have the same HLA alleles DQA1*0501 and DQB1*0201 encoding the HLA DQ2 and who also have increased densities of TCR gammadelta IEL in their otherwise normal jejunal mucosa.
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Affiliation(s)
- T O Kerttula
- Department of Clinical Microbiology, Tampere University Hospital and Institute of Medical Technology, Finland
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Przemioslo RT, Kontakou M, Nobili V, Ciclitira PJ. Raised pro-inflammatory cytokines interleukin 6 and tumour necrosis factor alpha in coeliac disease mucosa detected by immunohistochemistry. Gut 1994; 35:1398-403. [PMID: 7959194 PMCID: PMC1375013 DOI: 10.1136/gut.35.10.1398] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The levels of two pro-inflammatory cytokines, interleukin 6 (IL-6) and tumour necrosis factor alpha (TNF-alpha), in coeliac disease were studied by immunohistochemistry. Jejunal biopsy specimens from patients with untreated disease, (n = 11), treated disease (n = 9), and normal controls, (n = 11) were stained to detect IL-6, TNF-alpha, CD45 (pan-leukocyte), and CD68 (macrophage surface antigen). Positive cells were identified in the epithelium (per 100 enterocytes) and in the lamina propria (per unit area). There was a significant increase in median IL-6 and TNF-alpha staining in both the lamina propria and the epithelium of untreated coeliac disease patients (lamina propria, 16.2 and 13.0 respectively; epithelium, 0.86 and 1.21, all p < 0.05) when compared with treated coeliac disease patients (lamina propria; 6.0 and 6.2, epithelium; 0.60 and 0.60) and controls (lamina propria; 6.5 and 7.5, epithelium; 0.58 and 0.60). A significant increase in the number of CD45 positive cells was found in the untreated coeliac disease lamina propria and epithelium (p < 0.05) but this was accompanied by a significant rise in CD68 positive cells in the lamina propria only (p < 0.05). Increased IL-6 and TNF-alpha in the lamina propria and epithelium of patients with untreated coeliac disease further supports their role in the immune pathogenesis of this disorder.
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Affiliation(s)
- R T Przemioslo
- Gastroenterology Unit UMDS, St Thomas's Hospital, London
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