Coeliac disease and autoimmune thyroid disease

Impact of celiac disease in Behçet's syndrome patients: a study based on the database of Türkiye

Background/aim

Our primary aim was to investigate the effects of concomitant celiac disease (CD) on the clinical characteristics of Behçet's syndrome (BS) patients.

Materials and method

The study was a retrospective, nationwide, multicenter study. Turkish Ministry of Health National Electronic Database (e-Nabız) is used under Health Ministry's supervision to extract the subject's data.

Statistical analysis

Statistical analyses were made by the Statistical Package for Social Sciences (SPSS) software version 20 (IBM Corp., Armonk, New York). Continuous variables were presented by mean ± standard derivation (SD) or median (min-max) according to normality and compared by student-t test. A binary logistic regression analysis was performed to further investigating the relation between having a concomitant CD with each BD manifestation and comorbidity, frequencies of which were detected to be significantly different in the student-test.

Results

A total of 84,241 patients diagnosed with BS were analyzed, and CD was identified in 175 (0.21 %) patients. The group with CD had a mean age of 41.30 ± 13.69 which was significantly younger. the prevalence of females was significantly higher (71.4%). The mean age of first admission for BS was also significantly younger in the group with CD (36.64 ± 13.28). BS patients with CD had a significantly higher prevalence of inflammatory bowel disease (27.2% vs. 7.3%, p < 0.001). When comorbid conditions were investigated depression (35.4% vs. 23.3%, p < 0.001), migraine (7.4 % vs. 2.6%, p < 0.001), fibromyalgia (10.9% vs. 4.5%, p < 0.001) and osteoporosis (12.6% vs. 6.6%, p = 0.001) were significantly more frequent in BS patients with CD.

Conclusion

Our results suggest coexistence of CD in BS patients is related to female dominance and probably to an earlier disease onset. Several CD-related comorbidities as well as inflammatory bowel disease were more frequent in the CD group which implied an increased overall disease burden.

Causal influence of celiac disease on the risk of sarcoidosis: A Mendelian randomization study

Observational research shows a link between celiac disease (CeD) and sarcoidosis, but the causal link between CeD and sarcoidosis is still unknown. A two-sample Mendelian randomization (MR) study was conducted to ascertain the causal connection between the 2 disorders. In our two-sample MR analysis, we identified independent genetic variants associated with CeD using publicly accessible GWAS data from people of European ancestry. Summary data for sarcoidosis were obtained from the FinnGen Consortium, the UK-Biobank, and a large GWAS dataset. To assess the association between CeD and sarcoidosis, our MR analysis used inverse variance weighted (IVW) as the primary method, incorporating the MR-Egger, weighted median (WM), and MR-PRESSO (outliers test) as a complementary method. In order to ensure that the findings were reliable, several sensitivity analyses were performed. Our study indicated that CeD had a significant causal relationship with sarcoidosis (IVW odds ratio (OR) = 1.13, 95% confidence interval (CI): 1.07-1.20, P = 5.58E-05; WM OR = 1.12, 95% CI: 1.03-1.23, P = 1.03E-02; MR-Egger OR = 1.07, 95% CI: 0.96-1.19, P = 2.20E-01). Additionally, we obtain the same results in the duplicated datasets as well, which makes our results even more reliable. The results of this investigation did not reveal any evidence of horizontal pleiotropy or heterogeneity. Our MR analysis showed a causal effect between CeD and an elevated risk of sarcoidosis. Further study is still needed to confirm the findings and look into the processes underlying these relationships.

Cardiomyopathy in Celiac Disease: A Systematic Review

(1) Background: Cardiomyopathy in celiac disease or celiac cardiomyopathy (CCM) is a serious and potentially life-threatening disease that can occur in both adults and children. However, data supporting the causal relationship between celiac disease (CD) and cardiomyopathy (CMP) are still inconsistent. The aim of this study was to review and synthesize data from the literature on this topic and potentially reveal a more evidence-based causal relationship. (2) Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to search Medline, Embase, and Scopus databases from database inception until September 2023. A total of 1187 original articles were identified. (3) Results: We identified 28 CCM patients (19 adult and 9 pediatric) with a mean age of 27.4 ± 18.01 years. Adult patients with CCM were predominantly male (84.2%) while pediatric patients were predominantly female (75%). The most common comorbidities associated with CCM were anemia (75%) and pulmonary hemosiderosis (20%). In 35% of patients, CCM occurred before the diagnosis of CD, while in 48% of patients, CCM and CD were diagnosed at the same time. Diagnosis of CD preceded diagnosis of CCM in only 18% of patients. Diagnosis of CCM is often delayed with an average, from the onset of symptoms to diagnosis, of 16 months. All patients were treated with a gluten-free diet in addition to guideline-directed medical therapy. At 11-month follow-up, cardiovascular improvement was seen in 60.7% of patients. Pediatric mortality was 33.3%, while adult mortality was 5.3%. (4) Conclusions: Clinicians should be aware of the possible association between CD and CMP, and we recommend CD work-up in all patients with CMP who have concomitant anemia. While we identified only 28 cases in the literature, many cases might go unreported due to a lack of awareness regarding CCM. A high degree of clinical suspicion and a prompt diagnosis of CCM are essential to minimizing the risks of morbidity and mortality, as the combination of a gluten-free diet and guideline-directed medical therapy can improve clinical outcomes.

Metabolic Disorders and Psoriasis: Exploring the Role of Nutritional Interventions

(1) Background: Psoriasis is a chronic autoimmune disease with a close relationship with metabolic diseases such as obesity, diabetes, and dyslipidemia. The aim of this review was to identify the relationship between psoriasis, metabolic diseases, and dietetic therapies. According to recent findings, there is a strong association between psoriasis and obesity as well as vitamin D and micronutrient deficiencies. (2) Methods: This review was conducted via PubMed, aiming to search for studies involving psoriasis linked with metabolic disorders or with nutritional treatments. (3) Results: Our review shows that a healthy lifestyle can positively influence the course of the disease. The maintaining of a proper body weight together with physical activity and good nutritional choices are associated with an improvement in psoriasis severity. A Mediterranean diet rich in fiber, vitamins, and polyphenols may indeed be a strategy for controlling psoriasis symptoms. The effectiveness of this diet lies not only in its anti-inflammatory power, but also in its ability to favorably influence the intestinal microbiota and counteract dysbiosis, which is a risk factor for many autoimmune diseases. (4) Conclusions: In synergy with standard therapy, the adoption of an appropriate diet can be recommended to improve the clinical expression of psoriasis and reduce the incidence of comorbidities.

Type 3 autoimmune polyglandular syndrome (APS-3) or type 3 multiple autoimmune syndrome (MAS-3): an expanding galaxy

BACKGROUND

The number of recognised distinct autoimmune diseases (AIDs) has progressively increased over the years with more than 100 being reported today. The natural history of AIDs is characterized by progression from latent and subclinical to clinical stages and is associated with the presence of the specific circulating autoantibodies. Once presented, AIDs are generally chronic conditions. AIDs have the tendency to cluster and co-occur in a single patient. Autoimmune thyroid diseases (AITD) are the most prevalent of AIDs in the world population, and about one-third of the AITD patients also present with a non-thyroid AID during their life-span. Furthermore, patient with non-thyroid AIDs often presents with a form of AITD as a concurrent condition. Many of the clusters of AIDs are well characterized as distinctive syndromes, while some are infrequent and only described in case reports.

PURPOSE

In this review, we describe the wide spectrum of the combinations and the intricate relationships between AITD and the other AIDs, excluding Addison's disease. These combinations are collectively termed type 3 Autoimmune Polyglandular Syndrome (APS-3), also called type 3 Multiple Autoimmune Syndrome (MAS-3), and represent the most frequent APS in the world populations.

CONCLUSIONS

Numerous associations of AITD with various AIDs could be viewed as if the other AIDs were gravitating like satellites around AITD located in the center of a progressively expanding galaxy of autoimmunity.

Selective Silencing of Disease-Associated B Lymphocytes from Hashimoto's Thyroiditis Patients by Chimeric Protein Molecules

Hashimoto's thyroiditis is one of the most common endocrine disorders, affecting up to 20% of the adult population. No treatment or prevention exists except hormonal substitution for hypothyroidism. We hypothesize that it may be possible to selectively suppress anti-thyroglobulin (Tg) IgG antibody-producing B lymphocytes from HT patients by a chimeric protein molecule containing a monoclonal antibody specific for the human inhibitory receptor CR1, coupled to peptide epitopes derived from Tg protein. We expect that this treatment will down-regulate B-cell autoreactivity by delivering a strong inhibitory signal. Three peptides-two epitope-predicted ones derived from Tg and another irrelevant peptide-were synthesized and then coupled with monoclonal anti-human CR1 antibody to construct three chimeric molecules. The binding to CD35 on human B cells and the effects of the chimeric constructs on PBMC and TMC from patients with HT were tested using flow cytometry, ELISpot assay, and immunoenzyme methods. We found that after the chemical conjugation, all chimeras retained their receptor-binding capacity, and the Tg epitopes could be recognized by anti-Tg autoantibodies in the patients' sera. This treatment downregulated B-cell autoreactivity and cell proliferation, inhibited Tg-specific B-cell differentiation to plasmablasts and promoted apoptosis to the targeted cells. The treatment of PBMCs from HT patients with Tg-epitope-carrying chimeric molecules affects the activity of Tg-specific autoreactive B lymphocytes, delivering to them a strong suppressive signal.

Recurrent heart failure in a child with underlying dilated cardiomyopathy associated with celiac disease: An unusual presentation

Many previous studies have shown that certain cardiovascular conditions (including myocarditis, arrhythmias, and cardiomyopathy) are more prevalent in individuals with celiac disease compared to individuals without the disease. Association of celiac disease with dilated cardiomyopathy (DCMP) is a rare occurrence and a few cases have been reported and even fewer in children. Here, we report an interesting case of a 10-year-old male child who presented to the pediatric emergency in a life-threatening condition with congestive cardiac failure manifested by dyspnea, hepatomegaly, pedal edema, and raised JVP with underlying severe anemia. The diagnosis of DCMP associated with celiac disease was made. The child was advised for strict gluten-free diet and hematinics, and ivabradine was started for managing DCMP. Early diagnosis with screening tests may prevent serious complications and also are essential to prevent progression of the disease.

Artificial Intelligence Analysis of Celiac Disease Using an Autoimmune Discovery Transcriptomic Panel Highlighted Pathogenic Genes including BTLA

Celiac disease is a common immune-related inflammatory disease of the small intestine caused by gluten in genetically predisposed individuals. This research is a proof-of-concept exercise focused on using Artificial Intelligence (AI) and an autoimmune discovery gene panel to predict and model celiac disease. Conventional bioinformatics, gene set enrichment analysis (GSEA), and several machine learning and neural network techniques were used on a publicly available dataset (GSE164883). Machine learning and deep learning included C5, logistic regression, Bayesian network, discriminant analysis, KNN algorithm, LSVM, random trees, SVM, Tree-AS, XGBoost linear, XGBoost tree, CHAID, Quest, C&R tree, random forest, and neural network (multilayer perceptron). As a result, the gene panel predicted celiac disease with high accuracy (95-100%). Several pathogenic genes were identified, some of the immune checkpoint and immuno-oncology pathways. They included CASP3, CD86, CTLA4, FASLG, GZMB, IFNG, IL15RA, ITGAX, LAG3, MMP3, MUC1, MYD88, PRDM1, RGS1, etc. Among them, B and T lymphocyte associated (BTLA, CD272) was highlighted and validated at the protein level by immunohistochemistry in an independent series of cases. Celiac disease was characterized by high BTLA, expressed by inflammatory cells of the lamina propria. In conclusion, artificial intelligence predicted celiac disease using an autoimmune discovery gene panel.

Association between idiopathic pulmonary hemosiderosis and celiac disease in pediatric patients: A scoping review of the literature over the past 50 years

INTRODUCTION

Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of diffuse alveolar hemorrhage, the mechanism of which is currently unknown. Nearly one-third of pediatric patients with IPH test positive for Celiac disease (CD) serology. Several hypothetical mechanisms have been proposed to unify the coexistence of these two entities, also referred to as Lane-Hamilton syndrome (LHS).

METHOD

This manuscript is a scoping review of the medical literature. Medline, Embase, and PubMed Central databases were searched between 1971 and 2021 with appropriate search words to identify all cases of pediatric LHS.

RESULTS

A total of 20 manuscripts with 23 pediatric patients with LHS were identified. The mean age was 11 years, and 13/23 (56.5%) of the children were boys. Hemoptysis was present in 57% of patients during diagnosis. Bronchoscopy with bronchoalveolar lavage demonstrating hemosiderin laden macrophages was the primary mode of diagnostic confirmation. Only three patients underwent lung biopsy. Any significant GI symptom was reported in a minority of patients (22%). Iron deficiency anemia on presentation was described in 83% of children. The majority of patients were malnourished. Serology for CD was positive in all patients, as was the histopathologic analysis of the small bowel biopsy. No patients had any other autoantibody positivity. The introduction of gluten free diet (GFD) was associated with a positive response in 20/23 patients.

CONCLUSION

All pediatric patients with IPH should undergo screening for CD. Low serum ferritin in patients with IPH could be suggestive of coexisting CD. Strict GFD should be tried as the initial therapy.

IgA Deficiency Is Not Systematically Ruled Out in Patients Undergoing Celiac Disease Testing

BACKGROUND

Guidelines for celiac disease (CD) testing recommend total serum IgA determination alongside anti-transglutaminase IgA antibodies. It is not well known if lack of serum IgA determination is a common finding in clinical practice.

AIM

To determine the prevalence of lack of serum IgA determination among patients screened for celiac disease.

MATERIALS AND METHODS

We identified all subjects who underwent serum anti-transglutaminase IgA and/or other CD-related antibodies determination at a single teaching hospital in Buenos Aires from October 2019 to February 2020. Medical records were reviewed to select adult patients who were tested for celiac disease. The primary outcome was the proportion of patients with inadequate testing for celiac disease due to lack of serum IgA determination. We retrieved the following variables from each patient's record: age, gender, body mass index, symptoms present at screening, first-grade family history of CD, history of type-1 diabetes mellitus, autoimmune hypothyroidism, Down's syndrome.

RESULTS

Overall, 1122 patients were included for analysis. Lack of serum IgA determination prevalence was 20.49%. Among patients who did have serum IgA determination, the prevalence of IgA deficiency was 5.16%. The following variables were independently associated with a significantly increased odds of serum IgA determination: diarrhea [OR 1.55 (1.01-2.34)] and abdominal pain [OR 2.28 (1.44-3.63)]; higher body mass index [OR 0.91 (0.85-0.98)], osteoporosis [OR 0.49 (0.28-0.89)], hypothyroidism [OR 0.18 (0.07-0.45)], arthralgia/arthritis [OR 0.47 (0.27-0.85)], or testing by endocrinologist [OR 0.46 (0.23-0.91)] and gynecologist [OR 0.14 (0.06-0.31)] were inversely associated.

CONCLUSION

IgA deficiency is not systematically ruled out in a relatively high proportion of patients undergoing serological screening of celiac disease.

Serologic Testing for Celiac Disease in Graves' Hyperthyroidism: Should We Act Early?

BACKGROUND

The general practice is to screen patients with autoimmune thyroid disease for celiac disease (CD); however, optimal timing for CD screening for patients with Graves'Disease (GD) has not been identified yet. The aim of the study was to show whether positive celiac antibodies persist after euthyroidism is achieved.

MATERIALS AND METHODS

Serum samples were collected from 35 patients with GD (23 female and 12 male) who applied to the endocrine outpatient clinic. Patients and healthy controls were screened for CD with IgG and IgA antigliadin antibodies (IgG - AGA and IgA - AGA), IgA endomysial antibody (IgA-EMA) and IgA tissue transglutaminase antibody (IgA anti-tTG). These antibodies were reevaluated when patients were euthyroid under antithyroid therapy. Small intestine biopsy was offered to the patients who remained antibody positive after being euthyroid.

RESULTS

Screening 35 patients with GD revealed positive results for IgA-AGA (n = 6/35, 17%), IgG-AGA (n = 9/35, 26%), IgA-EmA (n = 2/35, 6%) and IgA-tTG (n = 2/35, 6%). No patient had multiple antibodies positive. Selective IgA deficiency was not detected in patients and controls. When patients were euthyroid, baseline positive IgA-AGA, IgG-AGA, and IgA-EmA became negative, while positive anti-tTG persisted in two patients. Endoscopic duodenal biopsy showed a normal villi/crypts ratio in these patients. None of the controls had positive antibodies.

CONCLUSION

Due to possibility of false seropositivity of celiac antibodies in patients with Graves' thyrotoxicosis, one should defer testing for CD until euthyroidism has been achieved.

The Role of Exposomes in the Pathophysiology of Autoimmune Diseases I: Toxic Chemicals and Food

Autoimmune diseases affect 5–9% of the world’s population. It is now known that genetics play a relatively small part in the pathophysiology of autoimmune disorders in general, and that environmental factors have a greater role. In this review, we examine the role of the exposome, an individual’s lifetime exposure to external and internal factors, in the pathophysiology of autoimmune diseases. The most common of these environmental factors are toxic chemicals, food/diet, and infections. Toxic chemicals are in our food, drink, common products, the air, and even the land we walk on. Toxic chemicals can directly damage self-tissue and cause the release of autoantigens, or can bind to human tissue antigens and form neoantigens, which can provoke autoimmune response leading to autoimmunity. Other types of autoimmune responses can also be induced by toxic chemicals through various effects at the cellular and biochemical levels. The food we eat every day commonly has colorants, preservatives, or packaging-related chemical contamination. The food itself may be antigenic for susceptible individuals. The most common mechanism for food-related autoimmunity is molecular mimicry, in which the food’s molecular structure bears a similarity with the structure of one or more self-tissues. The solution is to detect the trigger, remove it from the environment or diet, then repair the damage to the individual’s body and health.

Type 1 diabetes, thyroid, gastric and adrenal humoral autoantibodies are present altogether in almost one third of adult celiac patients at diagnosis, with a higher frequency than children and adolescent celiac patients

Background: No data are available on the frequency of organ-specific humoral autoimmunity at diagnosis of adult celiac disease (CD).Aim: To evaluate the humoral immunoreactivities specific of type 1 diabetes (T1D), thyroid (THD), atrophic-gastritis (AG) and Addison's (AD) diseases in 92 adult CD patients at diagnosis and 237 adult healthy subjects (CTRL).Methods: T1D, THD and AD specific autoantibodies were analyzed by radioimmunoprecipitation assays. AG autoantibodies were detected by enzyme-linked immunosorbent assay.Results: Of 92 CD patients, 31.5% were positive for at least one of the organ-specific autoantibodies investigated (p < .0001 vs CTRL). Thyroid, diabetes, gastric and adrenal-autoantibodies, that increase with age at diagnosis, were detected in 12.0%, 10.9%, 10.9%, 2.2% of CD patients, respectively. Gastric- and diabetes- rather than thyroid- and adrenal-autoimmunity seem to be specifically related to presence of CD.Conclusions: One third of adult CD patients at diagnosis is target of at least one organ-specific autoantibody. A systematic organ-specific autoantibody screening in these patients might be of value to promptly identify, prevent or treat the relative diseases.

Hyposplenism, Hashimoto's Autoimmune Thyroiditis and Overlap Syndrome (Celiac Disease and Autoimmune Hepatitis Type 1)

Hyposplenism is associated with autoimmune diseases, inflammatory bowel disease, severe celiac disease, autoimmune thyroiditis, untreated HIV infection and chronic graft-versus-host disease. The aim of this study was to review the existing data on hyposplenism associated with celiac disease and Hashimoto's autoimmune thyroiditis. Our research was based on a clinical case concerning a 41-year-old female who presented with asthenia, fatigue, dyspepsia and chronic diarrhea. The medical history revealed autoimmune Hashimoto's thyroiditis, type 2 diabetes, fatty liver disease, chronic gastritis and thrombocytosis. Multiple investigations showed hyposplenism and complex autoimmune dysfunction with positive serum markers for celiac disease and type 1 autoimmune hepatitis along with minor symptomatology. The intestinal symptomatology of celiac disease is often hid by hypothyroidism-associated autoimmune thyroiditis. Asymptomatic or minimally symptomatic celiac disease associated with Hashimoto's autoimmune thyroiditis is diagnosed by biomarkers. Hyposplenism in celiac disease can occur regardless of the disease stage, latent or symptomatic.

Testing for IgA anti-tissue transglutaminase in routine clinical practice: Requesting behaviour in relation to prevalence of positive results

OBJECTIVE

Due to the high awareness of coeliac disease and improvement of serological tests, the number of requested laboratory tests has increased substantially over the years. In the current study we have evaluated the requesting behaviour of distinct clinical disciplines in relation to the prevalence of positive results and in the context of existing guidelines.

METHODS

Data were retrospectively extracted from the laboratory information system over a time-span of 5 years in a tertiary hospital and compared with the situation in a secondary hospital.

RESULTS

Data reveal that for initial testing (n=18,183) the percentage positive results for IgA anti-TTG is <2%. Paediatricians have a slightly higher percentage of seropositive results (2.4-4.0%). Early confirmation (<2 months) of positive results by IgA anti-endomysium antibodies in an independent sample is only performed in a minority of paediatric patients. The majority of positive patients, however, have follow-up measurements (<14 months) in order to examine compliance to a gluten-free diet. Interestingly, initial requests for paediatric patients reveal an equal distribution between boys and girls, while in adult patients there is a two times preponderance of requests in female patients, similar to the female/male ratio in patients with positive results, being either paediatric or adult patients.

CONCLUSION

Although laboratory testing for coeliac disease may be primarily used to exclude the disease, it is evident that the percentage positive results for IgA anti-TTG is extremely low. This may indicate that the clinical manifestations that warrant testing, should be further specified in order to increase the pre-test probability. As the specific serology is important to bypass a biopsy in the diagnosis of coeliac disease according to the paediatric guideline, the confirmation in an independent sample needs to get more attention.

Endocrine complications of celiac disease: a case report and review of the literature

PURPOSE

The purpose of this article is to review recent literature regarding endocrine disorders related to celiac disease (CD).

METHODS

We describe a case report and review existing literature on the endocrine manifestations of CD.

RESULTS

CD is an autoimmune disorder characterized by intestinal inflammation in response to gluten. CD can cause a wide range of extra-intestinal complications, including endocrine manifestations. Metabolic bone disease including osteoporosis and osteopenia, vitamin D deficiency, secondary hyperparathyroidism and less frequently osteomalacia can be seen. In CD, fracture risk is increased by 30-40%, while risk for hip fracture is approximately doubled. The risk for other endocrine disorders, particularly autoimmune endocrinopathies, is also increased in those with CD compared to the general population. Epidemiologic data indicate the risk for hypothyroidism is 3-4 times higher among those with CD, while risk of type 1 diabetes is greater than double. Risk for primary adrenal insufficiency is a striking 11-fold higher in those with versus without CD, though the absolute risk is low. Fertility is reduced in women with CD before diagnosis by 37% while male fertility in the absence of hypogonadism does not appear to be affected. Other endocrine conditions including hyperthyroidism, ovarian failure, androgen insensitivity, impaired growth and growth hormone deficiency and autoimmune polyendocrine syndromes have also been associated with CD.

CONCLUSIONS

CD is associated with a wide range of endocrine manifestations.

DOES GRAVES' DISEASE AFFECT ESOPHAGEAL MOTILITY?

CONTEXT

The gastrointestinal tract is one of the most affected systems in hyperthyroidism. Although thyrotoxicosis is thought to be associated with gastrointestinal dysmotility, there are limited studies focused on motility disorders in hyperthyroidism.

OBJECTIVES

We aimed to investigate the manometric measurements to determine if esophageal motility is affected in Graves' disease.

MATERIALS AND METHODS

Thirty patients with Graves' disease (18 female and 12 male) and 30, age and sex matched, healthy controls (22 female and 8 male) were recruited to the study between 2015 and 2016. Esophageal manometry was performed using MMS (Medical Measurement Systems bv. The Netherlands) Solar GI - Air Charged Intelligent Gastrointestinal Conventional Manometry.

RESULTS

The mean lower esophageal sphincter pressure (LESP) was 16.9 ± 5.3 mmHg in hyperthyroid patients and 20.1 ± 8.8 mmHg in the control group and there was no significant difference (p>0.05). It was observed that the duration of contraction was 3.9 ± 0.7 s in healthy subjects and, significantly shorter 3.2 ± 0.5 s in hyperthyroid patients (p<0.001). Duration of contraction was negatively correlated with TSH receptor Ab titer in patients (p=0.006, r= -0.48). Also, it was observed that the duration of relaxation was negatively correlated with fT4 levels in the patient group (p<0.05, r= -0.46).

CONCLUSION

In this study, we observed that esophageal motility can be affected via shortened duration of contraction in Graves' disease. The gastrointestinal symptoms due to possible motility dysfunctions should be considered in the evaluation of hyperthyroid patients.

Celiac Disease and Glandular Autoimmunity

Celiac disease is a small intestinal inflammatory disease with autoimmune features that is triggered and maintained by the ingestion of the storage proteins (gluten) of wheat, barley, and rye. Prevalence of celiac disease is increased in patients with mono- and/or polyglandular autoimmunity and their relatives. We have reviewed the current and pertinent literature that addresses the close association between celiac disease and endocrine autoimmunity. The close relationship between celiac disease and glandular autoimmunity can be largely explained by sharing of a common genetic background. Further, between 10 and 30% of patients with celiac disease are thyroid and/or type 1 diabetes antibody positive, while around 5–7% of patients with autoimmune thyroid disease, type 1 diabetes, and/or polyglandular autoimmunity are IgA anti-tissue transglutaminase antibody positive. While a gluten free diet does not reverse glandular autoimmunity, its early institution may delay or even prevent its first manifestation. In conclusion, this brief review highlighting the close association between celiac disease and both monoglandular and polyglandular autoimmunity, aims to underline the need for prospective studies to establish whether an early diagnosis of celiac disease and a prompt gluten-free diet may positively impact the evolution and manifestation of glandular autoimmunity.

Cutaneous and Mucosal Manifestations Associated with Celiac Disease

Celiac disease (CD) is an immune-mediated, gluten-induced enteropathy that affects predisposed individuals of all ages. Many patients with CD do not report gastrointestinal symptoms making it difficult to reach an early diagnosis. On the other hand, CD is related to a wide spectrum of extra-intestinal manifestations, with dermatitis herpetiformis (DH) being the best characterized. These associated conditions may be the clue to reaching the diagnosis of CD. Over the last few years, there have been multiple reports of the association between CD and several cutaneous manifestations that may improve with a gluten-free diet (GFD). The presence of some of these skin diseases, even in the absence of gastrointestinal symptoms, should give rise to an appropriate screening method for CD. The aim of this paper is to describe the different cutaneous manifestations that have been associated with CD and the possible mechanisms involved.

Delay in Diagnosis of Celiac Disease in Patients Without Gastrointestinal Complaints

PURPOSE

The purpose of our study is to investigate the delay in diagnosis of patients with biopsy-proven celiac disease in those who present with gastrointestinal complaints vs nongastrointestinal complaints at our tertiary care center. Celiac disease is an autoimmune disorder that affects approximately 1% of the population worldwide. Celiac disease can have variable clinical presentations; it can be characterized by predominately gastrointestinal symptoms, or it may present without any gastrointestinal symptoms.

METHODS

We retrospectively reviewed the charts of 687 adult patients who carried the diagnosis of celiac disease. Patients included had biopsy-proven celiac disease and were categorized based on presence or absence of gastrointestinal symptoms prior to their diagnosis.

RESULTS

There were 101 patients with biopsy-proven celiac disease that met inclusion criteria. Fifty-two patients presented with gastrointestinal symptoms and 49 had nongastrointestinal complaints. Results from Mann-Whitney statistical analysis showed a median delay in diagnosis of 2.3 months for the gastrointestinal symptoms group and 42 months for the nongastrointestinal group (P <.001); 43.2% of patients with nongastrointestinal symptoms had abnormal thyroid-stimulating hormone, as opposed to 15.5% in the gastrointestinal symptom group (P = .004). Of patients with nongastrointestinal symptoms, 69.4% had anemia, compared with 11.5% of the gastrointestinal symptom group (P <.001). The majority of patients in the nongastrointestinal symptom group, 68%, were noted to have abnormal bone density scans, compared with 41% in the gastrointestinal symptom group. No sex differences were noted on chi-squared analysis between the 2 groups (P = .997).

CONCLUSIONS

Although there is growing awareness of celiac disease, the delay in diagnosis for patients without gastrointestinal symptoms remains prolonged, with an average delay of 3.5 years.

A novel data-driven workflow combining literature and electronic health records to estimate comorbidities burden for a specific disease: a case study on autoimmune comorbidities in patients with celiac disease

BACKGROUND

Data collected in EHRs have been widely used to identifying specific conditions; however there is still a need for methods to define comorbidities and sources to identify comorbidities burden. We propose an approach to assess comorbidities burden for a specific disease using the literature and EHR data sources in the case of autoimmune diseases in celiac disease (CD).

METHODS

We generated a restricted set of comorbidities using the literature (via the MeSH® co-occurrence file). We extracted the 15 most co-occurring autoimmune diseases of the CD. We used mappings of the comorbidities to EHR terminologies: ICD-10 (billing codes), ATC (drugs) and UMLS (clinical reports). Finally, we extracted the concepts from the different data sources. We evaluated our approach using the correlation between prevalence estimates in our cohort and co-occurrence ranking in the literature.

RESULTS

We retrieved the comorbidities for 741 patients with CD. 18.1% of patients had at least one of the 15 studied autoimmune disorders. Overall, 79.3% of the mapped concepts were detected only in text, 5.3% only in ICD codes and/or drugs prescriptions, and 15.4% could be found in both sources. Prevalence in our cohort were correlated with literature (Spearman's coefficient 0.789, p = 0.0005). The three most prevalent comorbidities were thyroiditis 12.6% (95% CI 10.1-14.9), type 1 diabetes 2.3% (95% CI 1.2-3.4) and dermatitis herpetiformis 2.0% (95% CI 1.0-3.0).

CONCLUSION

We introduced a process that leveraged the MeSH terminology to identify relevant autoimmune comorbidities of the CD and several data sources from EHRs to phenotype a large population of CD patients. We achieved prevalence estimates comparable to the literature.

THE RELATIONSHIP BETWEEN THYROID HORMONES, ANTITHYROID ANTIBODIES, ANTI-TISSUE TRANSGLUTAMINASE AND ANTI-GLIADIN ANTIBODIES IN PATIENTS WITH HASHIMOTO'S THYROIDITIS

BACKGROUND

Hashimoto's thyroiditis is in coexistence with many autoimmune disorders, especially celiac disease. There are a limited number of studies evaluating the prevalence of celiac-related antibodies in patients with Hashimoto's thyroiditis.

OBJECTIVE

This study aimed to further investigate the prevalence of undiagnosed celiac disease in patients with Hashimoto's thyroiditis and the relationship between these two autoimmune disorders in these patients.

SUBJECTS AND METHODS

This study was performed on 82 women aged 20-50 years including 40 patients with Hashimoto's thyroiditis and 42 healthy age-matched individuals. Anthropometric assessments were performed and biochemical parameters including thyroid hormones (TSH, T3 and T4), antithyroid antibodies, anti-tissue transglutaminase and anti-gliadin antibodies were measured by enzyme linked immunosorbent assay (ELISA).

RESULTS

The prevalence of IgG and IgA anti-tissue transglutaminase antibodies and IgA anti-gliadin antibody was higher in Hashimoto's thyroiditis patients compared with control group (15% vs. 7%, 22.5% vs. 17% and 15% vs. 12% respectively). In ordinal regression model, serum IgG anti-tissue transglutaminase and IgA anti-gliadin antibodies were significant predictors of antithyroid antibodies in patients with Hashimoto's thyroiditis (P < 0.05). A significant relationship between serum TSH and IgG anti-gliadin antibody were also found (P = 0.003).

CONCLUSION

To our findings, a high prevalence of anti-tissue transglutaminase and IgA anti-gliadin antibodies and their positive relationship with antithyroid antibodies in patients with Hashimoto's thyroiditis were reported. These findings further warrant the need for interventions to reduce the prevalence of these antibodies in Hashimoto's thyroiditis for preventing the occurrence of celiac disease in these patients.

Psoriasis and Risk of Celiac Disease: A Systematic Review and Meta-analysis

Background and Objectives:

The possible association between psoriasis and celiac disease (CD) has long been observed, but epidemiologic studies attempting to characterize this association have yielded inconclusive results. This meta-analysis was conducted with the aims to summarize all available data.

Methods:

We conducted a systematic review and meta-analysis of observational studies that reported relative risk, hazard ratio, odds ratio (OR), or standardized incidence ratio with 95% confidence interval (CI) comparing the risk of CD in patients with psoriasis versus participants without psoriasis. Pooled risk ratio and 95% CI were calculated using random-effect, generic inverse-variance methods of DerSimonian and Laird.

Results:

Four retrospective cohort studies with 12,912 cases of psoriasis and 24,739 comparators were included in this meta-analysis. The pooled analysis demonstrated a significantly higher risk of CD among patients with psoriasis compared with participants without psoriasis with the pooled OR of 3.09 (95% CI, 1.92–4.97).

Limitations:

Most primary studies reported unadjusted estimated effect, raising a concern over confounders.

Conclusions:

Our meta-analysis demonstrated an approximately 3-fold increased risk of CD among patients with psoriasis.

Celiac disease and the risk of kidney diseases: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Previous epidemiologic studies attempting to demonstrate the risk of kidney diseases among patients with celiac disease (CD) have yielded inconsistent results. This meta-analysis was conducted with the aims to summarize all available evidence.

METHODS

A literature search was performed using MEDLINE and EMBASE from inception to May 2016. Studies that provided relative risks, odd ratios, or hazard ratios examining the risk of kidney diseases among patients with CD versus individuals without CD were included. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.

RESULTS

Eight studies met our eligibility criteria and were included in our analysis. A pooled RR of overall kidney diseases in patients with CD was 2.01 (95% CI, 1.44-2.81, I²=76%). The pooled RR of end-stage renal disease in patients with CD was 2.57 (95% CI, 2.03-3.24). Subgroup analyses showed that significant risks were increased for diabetic nephropathy (pooled RR of 1.49, 95% CI, 1.09-2.02) and IgA nephropathy (pooled RR of 2.62, 95% CI, 1.27-5.42) in patients with CD.

CONCLUSIONS

Our study demonstrates a significantly increased risk of kidney diseases among patients with CD. These findings may influence clinical management and primary prevention of kidney diseases in patients with CD.

Endocrine manifestations in celiac disease

Celiac disease (CD) is an autoimmune small intestinal mucosal disorder that often presents with diarrhea, malabsorption and weight loss. Often, one or more associated endocrine disorders may be associated with CD. For this review, methods involved an extensive review of published English-language materials. In children and adolescents, prospective studies have demonstrated a significant relationship to insulin-dependent or type 1 diabetes, whereas in adults, autoimmune forms of thyroid disease, particularly hypothyroidism, may commonly co-exist. In some with CD, multiple glandular endocrinopathies may also occur and complicate the initial presentation of the intestinal disease. In others presenting with an apparent isolated endocrine disorder, serological screening for underlying subclinical CD may prove to be positive, particularly if type 1 diabetes, autoimmune thyroid or other autoimmune endocrine diseases, such as Addison’s disease are first detected. A number of reports have also recorded hypoparathyroidism or hypopituitarism or ovarian failure in CD and these may be improved with a strict gluten-free diet.

Celiac Disease and Risk of Autoimmune Disorders: A Population-Based Matched Birth Cohort Study

OBJECTIVES

To estimate the relative risk of developing type 1 diabetes mellitus (T1DM) and autoimmune thyroid disease in children with celiac disease (CD).

STUDY DESIGN

A matched cohort design with linkage of administrative data was adopted. A total of 1215 cases of CD and 6075 references matched by sex and year of birth born in Friuli Venezia Giulia Region (Italy) between 1989 and 2011 were included. Cox regression models were used to estimate hazard ratios (HRs) for autoimmune diseases in patients with CD compared with references, stratified by sex and age at diagnosis.

RESULTS

Individuals with CD had an increased risk of subsequent hypothyroidism (HR 4.64 [95% CI 2.88-7.46]) and T1DM (HR 2.50 [95% CI 0.94-6.66]), the latter not statistically significant. Risk of hypothyroidism was higher in males (HR 20.00; 95% CI 5.64-70.87) than females (HR 3.21; 95% CI 1.85-5.57) (P value <.01). No differences were observed between males and females risks for diabetes or age at CD diagnosis. The small number of hyperthyroidism cases identified precluded any statistical analysis.

CONCLUSIONS

Children and youth with CD are at increased risk of developing autoimmune hypothyroidism and to some extent T1DM. This suggests the need for surveillance of children with CD in order to timely detect the onset of such comorbidities.

Support for patients with celiac disease: A literature review

BACKGROUND

Celiac disease (CD) is a lifelong disorder. Patients are at increased risk of complications and comorbidity.

OBJECTIVES

We conducted a review of the literature on patient support and information in CD and aim to issue recommendations about patient information with regards to CD.

DATA SOURCE

We searched PubMed for English-language articles published between 1900 and June 2014, containing terms related to costs, economics of CD, or education and CD.

STUDY SELECTION

Papers deemed relevant by any of the participating authors were included in the study.

DATA SYNTHESIS

No quantitative synthesis of data was performed. Instead we formulated a consensus view of the information that should be offered to all patients with CD.

RESULTS

There are few randomized clinical trials examining the effect of patient support in CD. Patients and their families receive information from many sources. It is important that health care personnel guide the patient through the plethora of facts and comments on the Internet. An understanding of CD is likely to improve dietary adherence. Patients should be educated about current knowledge about risk factors for CD, as well as the increased risk of complications. Patients should also be advised to avoid other health hazards, such as smoking. Many patients are eager to learn about future non-dietary treatments of CD. This review also comments on novel therapies but it is important to stress that no such treatment is available at present.

CONCLUSION

Based on mostly observational data, we suggest that patient support and information should be an integral part of the management of CD, and is likely to affect the outcome of CD.

Prevalence and clinical features of celiac disease in patients with autoimmune thyroiditis: cross-sectional study

CONTEXT AND OBJECTIVE

Celiac disease is an autoimmune disorder with an average prevalence of 1% in Europe and the United States. Because of strong European ancestry in southern Brazil, this study aimed to evaluate the seroprevalence of celiac disease among autoimmune thyroiditis patients.

DESIGN AND SETTING

Cross-sectional study in a public university hospital.

METHODS

This cross-sectional prevalence study included autoimmune thyroiditis patients who were tested for anti-endomysial and anti-transglutaminase antibodies between August 2010 and July 2011.

RESULTS

Fifty-three patients with autoimmune thyroiditis were included; 92.5% were women, with mean age of 49.0 ± 13.5 years. Five patients (9.3%) were serologically positive for celiac disease: three of them (5.6%) were reactive for anti-endomysial antibodies and two (3.7%) for anti-transglutaminase. None of them exhibited anemia and one presented diarrhea. Endoscopy was performed on two patients: one with normal histology and the other with lymphocytic infiltrate and villous atrophy.

CONCLUSION

The prevalence of celiac disease among patients with autoimmune thyroid disease was 9.3%; one patient complained of diarrhea and none presented anemia. Among at-risk populations, like autoimmune thyroiditis patients, the presence of diarrhea or anemia should not be used as a criterion for indicating celiac disease investigation. This must be done for all autoimmune thyroiditis patients because of its high prevalence.

Prevalence and clinical features of celiac disease in patients with autoimmune thyroiditis: cross-sectional study

CONTEXT AND OBJECTIVE

Celiac disease is an autoimmune disorder with an average prevalence of 1% in Europe and the United States. Because of strong European ancestry in southern Brazil, this study aimed to evaluate the seroprevalence of celiac disease among autoimmune thyroiditis patients.

DESIGN AND SETTING

Cross-sectional study in a public university hospital.

METHODS

This cross-sectional prevalence study included autoimmune thyroiditis patients who were tested for anti-endomysial and anti-transglutaminase antibodies between August 2010 and July 2011.

RESULTS

Fifty-three patients with autoimmune thyroiditis were included; 92.5% were women, with mean age of 49.0 ± 13.5 years. Five patients (9.3%) were serologically positive for celiac disease: three of them (5.6%) were reactive for anti-endomysial antibodies and two (3.7%) for anti-transglutaminase. None of them exhibited anemia and one presented diarrhea. Endoscopy was performed on two patients: one with normal histology and the other with lymphocytic infiltrate and villous atrophy.

CONCLUSION

The prevalence of celiac disease among patients with autoimmune thyroid disease was 9.3%; one patient complained of diarrhea and none presented anemia. Among at-risk populations, like autoimmune thyroiditis patients, the presence of diarrhea or anemia should not be used as a criterion for indicating celiac disease investigation. This must be done for all autoimmune thyroiditis patients because of its high prevalence.

Esophagus motility in overt hypothyroidism

PURPOSE

Gastrointestinal tract is one of the most affected systems in hypothyroidism. Despite decreased esophageal emptying, prolonged esophageal and gastric transit time have been indicated in previous reports, the mechanism of thyroid hormones activity and antibodies on the esophagus motility is not yet fully understood. This study was conducted to evaluate the esophagus motility by manometry in hypothyroid patients.

METHODS

The study enrolled with 28 overt, newly diagnosed hypothyroid patients and 29 age- and sex-matched healthy controls. Twenty-one females and 7 males with overt hypothyroidism and 22 females and 7 males with healthy control subjects were recruited to study. Esophageal manometry was performed using MMS (Medical Measurement Systems bv. The Netherlands) Solar GI-Air-Charged Intelligent Gastrointestinal Conventional Manometry.

RESULTS

The lower esophageal sphincter pressure (LESP) was 19.5 ± 6.5 mmHg in hypothyroid patients and 17.48 ± 4.65 mmHg in controls, and there was no significant difference (p = 0.18). Percentage of relaxation was 61.5 and 80.9 %, and it was significantly lower in hypothyroid patients than controls (p < 0.001). Additionally, duration of relaxation was found 3.85 ± 2.3 and 5.5 ± 2.28 s in patients and controls, respectively (p = 0.009). In patient group, LESP was positively correlated with fT3 (p = 0.033), and the duration of the contraction was negatively correlated with fT4 (p = 0.044).

CONCLUSION

In this study, we observed that hypothyroid state can affect esophagus motility via shortened duration of relaxation and reduced percentage of relaxation even if in patients without any gastrointestinal symptoms. Further studies are needed to clarify the effect of thyroid hormones on esophagus motility.

Prevalence of thyroid autoimmunity in children with celiac disease compared to healthy 12-year olds

Objectives. Studies have suggested a correlation between untreated celiac disease and risk for other autoimmune diseases. We investigated the prevalence of thyroid autoimmunity in 12-year-old children (i) with symptomatic celiac disease diagnosed and treated with a gluten-free diet, (ii) with screening-detected untreated celiac disease, and (iii) without celiac disease. Methods. Blood samples from 12632 children were collected. All celiac disease cases, previously diagnosed and newly screening-detected, were identified. Per case, 4 referents were matched. Blood samples were analyzed for autoantibodies against thyroid peroxidase (TPOAb). The cut-off value for TPO positivity was set to 100 U/mL. Results. Altogether, 335 celiac disease cases were found. In the entire celiac disease group, 7.2% (24/335) had elevated titers of TPOAb compared to 2.8% (48/1695) of the referents. Among the previously diagnosed celiac disease cases, 7.5% (7/93, OR 2.8, 95% CI 1.2-6.4) was TPOAb positive and among screening-detected cases, 7.0% (17/242, OR 2.6, 95% CI 1.5-4.6) was TPOAb positive. Conclusion. Children with celiac disease showed a higher prevalence of thyroid autoimmunity. We could not confirm the hypothesis that untreated celiac disease is associated with increased risk of developing thyroid autoimmunity. Early initiation of celiac disease treatment might not lower the risk for other autoimmune diseases.

Does gluten intake influence the development of celiac disease-associated complications?

Celiac disease (CD) is regarded as the most common autoimmune enteropathy in western countries. Epidemiological studies indicate that approximately 1:100 individuals may present with histologically proven CD. CD develops in genetically predisposed subjects after gluten ingestion. It usually subsides after gluten is withdrawn from their diet. Gluten is the only known environmental factor that affects the progression/regression of the intestinal villous atrophy, which is the hallmark of this disease. CD generally follows a benign course after gluten elimination. However, it is also associated with the development of other autoimmune disorders or of intestinal malignancies. The issue of whether such complications, sometimes of significant clinical and prognostic impact, are or are not the result of ongoing gluten ingestion, is an important one that has been investigated over the recent years with conflicting results. In terms of practical implications, the presence of a positive correlation between gluten intake and the development of severe complications would lead to the need for early diagnosis and mass screening. The lack of such correlation would instead suggest a less aggressive diagnostic strategy. This review aims at critically summarizing the evidence supporting either hypothesis.

Risk of thyroid cancer in a nationwide cohort of patients with biopsy-verified celiac disease

BACKGROUND

In earlier studies based on selected populations, the relative risk for thyroid cancer in celiac disease has varied between 0.6 and 22.5. We aimed to test this relationship in a population-based setting.

METHODS

We collected small intestinal biopsy report data performed in 1969-2008 from all 28 Swedish pathology departments. 29,074 individuals with celiac disease (villous atrophy; Marsh histopathology stage III) were matched for sex, age, calendar year, and county to 144,440 reference individuals from the Swedish general population. Through Cox regression, we then estimated hazard ratios (HRs) and confidence intervals (CIs) for any thyroid cancer and papillary thyroid cancer (defined according to relevant pathology codes in the Swedish Cancer Register) in patients with celiac disease.

RESULTS

During follow-up, any thyroid cancer developed in seven patients with celiac disease (expected=12) and papillary thyroid cancer developed in five patients (expected=7). Celiac disease was not associated with an increased risk of any thyroid cancer (HR 0.6 [CI 0.3-1.3]) or of papillary thyroid cancer (HR 0.7 [CI 0.3-1.8]). All cases of thyroid cancer in celiac disease occurred in female patients. Risk estimates were similar before and after the year 2000 and independent of age at celiac diagnosis (≤24 years vs. ≥25 years).

CONCLUSIONS

We conclude that, in the Swedish population, there is no increased risk of thyroid cancer in patients with celiac disease. This differs from what has been reported in smaller studies in Italy and the United States.

Cardiomyopathy associated with celiac disease in childhood

Celiac disease is predominantly a disease of the small intestine characterized by chronic malabsorption in genetically susceptible individuals who ingest grains containing gluten, such as wheat, barley, and rye. Although previously believed to be uncommon, celiac disease may be present in up to 1% of the adult and children population. Celiac disease is associated frequently with iron-deficiency anemia, dermatitis herpetiformis, selective IgA deficiency, thyroid disorders, diabetes mellitus, and various connective tissue disorders but is rarely associated with cardiomyopathy.

An update on celiac disease histopathology and the road ahead

CONTEXT

Celiac disease (CD) is a common immune-mediated disorder that occurs in genetically predisposed individuals (carriers of HLA-DQ2 and DQ8 haplotypes) on consumption of wheat (gluten). It is characterized by inflammation of the small-intestinal mucosa and myriad gastrointestinal and systemic manifestations. Celiac disease is common in the general population (prevalence, 0.5%-1%). Currently, small-bowel biopsy is considered the gold standard for diagnosing CD. However, the role of serologic testing in the diagnosis of CD has evolved, from being a supportive test to supplanting intestinal biopsies in certain patient populations.

OBJECTIVE

To summarize key aspects of histopathologic assessment, discuss the benefit of standardized pathology reports, impact of the site and number of small-bowel biopsy samples on diagnosis, and recommendations regarding serologic testing.

DATA SOURCES

Literature review of publications on CD and experience with histopathologic review of biopsies at the Department of Pathology and Cell Biology, Columbia University Medical Center, New York-Presbyterian Hospital, New York.

CONCLUSIONS

Intraepithelial lymphocytosis in the context of villous atrophy is considered a characteristic histologic finding of CD; however, it is a rather nonspecific finding. A growing list of publications has also indicated that the detection of intraepithelial lymphocytosis in the absence of villous atrophy has rather low specificity for CD. Therefore, communication between pathologists and gastroenterologists is paramount, as is knowledge regarding the pertinent clinical and laboratory data, in distinguishing between CD and other disorders with similar histopathologic and clinical manifestations.

Immunological comorbity in coeliac disease: associations, risk factors and clinical implications

PURPOSE

Coeliac disease is frequently associated with other immunomediated diseases. Our aim was to identify immunological comorbidities and possible risk factors for their development in coeliac patients.

METHODS

We recruited a cohort of 1,015 coeliac patients followed from 0 to 46 years in a single tertiary referral centre. Data were collected from the yearly scheduled clinical and serological evaluations. Possible risk factors such as demographic parameters, type of symptomatic presentation, gluten exposure, gluten-free diet compliance and family history were all evaluated. Subjects (848,606) from the regional health registry were investigated as controls.

RESULTS

The prevalence of immunomediated diseases was higher in patients with coeliac disease compared to the registry population (23 % vs 0.4 %, p < 0.001). Diagnosis during paediatric age represented a risk factor for the presence of at least an immunomediated disease (hazard ratio = 1.62, 95 % confidence interval 1.15-2.29, p = 0.0061). Type of presentation and dietetic compliance did not represent risk factors. Long-standing gluten exposure reduced the risk of developing immunomediated diseases in coeliac subjects (hazard ratio for 1 year longer exposure 0.23, 95 % confidence interval 0.16-0.33, p < 0.0001). A familiar background characterized by the presence of immunological disorders was not a risk factor, although 419 (13 %) first degree relatives of coeliac patients out of 3,195 had an immunomediated disease.

CONCLUSIONS

Our study suggests the need to investigate coeliac patients for other associated immunomediated diseases, independently of sex, gluten exposure and compliance to therapy; also subjects diagnosed in paediatric age should be carefully screened during follow up.

Frequency of celiac disease in patients with hypothyroidism

Background. Celiac disease (CD) is closely associated with other autoimmune endocrine disorders, particularly autoimmune thyroid disease. The aim of this study was to find the frequency of celiac disease in patients with hypothyroidism in Guilan province, north of Iran. Methods. A total of 454 consecutive patients with hypothyroidism underwent celiac serological tests antiGliadin antibodies (AGA), antitissue transglutaminase antibodies (IgA-tTG) and antiendomysial antibodies (EMA-IgA). Small intestinal biopsy was performed when any of celiac serological tests was positive. Results. Eleven (2.4%) patients were positive for celiac serology, and two patients with documented villous atrophy were diagnosed with classic CD (0.4%; 95%). Two patients with classic CD had Hashimoto's thyroiditis (HT) (0.6%; 95%). Six (54.5%) of 11 were suffering from overt hypothyroidism and 45.5% from subclinical hypothyroidism. Six (54.5%) had HT, and 45.5% had nonautoimmune hypothyroidism. Conclusions. In this study, prevalence of CD was lower than other studies. Most of the patients with CD were suffering from HT, but there was no significant statistical relation between CD and HT.

Celiac disease and hypothyroidism

BACKGROUND

Celiac disease is more common in patients with hypothyroidism. Malabsorption of levothyroxine has not been studied in this population. We sought to determine if levothyroxine dosing was influenced by the presence and treatment of celiac disease.

METHODS

This retrospective study was conducted at an academic medical center. Cases had hypothyroidism and celiac disease. Controls had hypothyroidism alone and were selected randomly through the endocrinology clinic records. Celiac disease was defined as representative pathology with positive serology. Age, sex, height, weight, body mass index, creatinine, and medical comorbidity were assessed for cases and controls. The levothyroxine dose and weight-based levothyroxine dose necessary to maintain a euthyroid state was evaluated for controls, and before and after celiac disease therapy for cases.

RESULTS

Celiac disease was identified in 152 patients, and 22 patients had concomitant hypothyroidism (14.5%). Seven cases met inclusion criteria. Overall, 200 control patients were identified. The mean celiac disease pretreatment levothyroxine dose and weight-based levothyroxine dose needed to maintain a euthyroid state were higher in cases than in controls (154 μg vs 106 μg, P=.007, and 2.6 μg/kg vs 1.3 μg/kg, P <.001). Doses decreased significantly after treatment of celiac disease (154 μg vs 111 μg, P=.03; and 2.64 μg/kg vs 1.89 μg/kg, P=.04). All cases required at least 125 μg of levothyroxine initially to maintain a euthyroid state.

CONCLUSIONS

Levothyroxine malabsorption likely occurs with hypothyroidism and untreated celiac disease. Absorption may improve after celiac disease treatment. Screening for celiac disease in patients with hypothyroidism requiring elevated levothyroxine doses warrants further investigation.

Value of gluten patch test in diagnosis of celiac disease

OBJECTIVE

Celiac disease is an intestinal disorder identified by mucus inflammation, villous atrophy and crypt hyperplasia. This disorder can be controlled by elimination of gluten from daily diet. Patients with celiac disease are at greater risk of gastrointestinal malignancy and non-Hodgkin lymphoma than are the general population. This study tries to present the value of gluten patch test for diagnosis of celiac disease.

METHODS

In this investigation, the study population was divided into case and control groups. The case group consisted of patients with celiac disease. The control group were patients involved in celiac disease but suffering from other gastrointestinal disorders. Both gluten patch and placebo patch were attached to the skin between the scapulas. The results were read twice: 48 hours and 96 hours after the patch was applied. Patients who showed irritation reactions were withdrawn from this study. The results were analysed by SPSS software, Spearman's test, chi square, and Mann-Whitney tests.

FINDINGS

The value obtained from the gluten patch test after 96 hours are as follows: specification at 95%, sensitivity at 8%, positive prediction value at 67%, and negative prediction value at 43%.

CONCLUSION

It can be concluded that the gluten patch test is not an efficient test for screening of celiac disease, however, it can be useful for diagnosis of celiac disease if employed and studied with clinical symptoms and serologic and biopsy tests. Furthermore, we should doubt our judgment if the result of gluten patch test for the patient with celiac disease is positive.

Clinical management of coeliac disease

OBJECTIVE

To describe the prevalence of Coeliac disease (CD) and its clinical management.

METHODS

Narrative review.

RESULTS

Coeliac disease (CD) is an immune-mediated disorder that primarily affects the gastrointestinal (GI) tract. Recent data suggest a prevalence of about 1% in most Western countries, a figure that likely represents an increase in the prevalence of CD. Risk groups include those who are members of families with individuals who have CD as well as those with Type I diabetes and a variety of autoimmune diseases. Whereas biopsy is the gold standard in diagnosis, serological tests are crucial in determining who should undergo endoscopy and biopsy. HLA testing should be used only to rule out CD. Currently, a gluten-free diet is the only available therapy.

CONCLUSION

In conclusion, CD is one of the most common immune-mediated disorders in the Western world. It should be considered in patients with a number of varying GI and non-GI symptoms, as well as in high-risk groups that include first-degree relatives.

Celiac disease: diagnostic criteria in progress

Until a few years ago, celiac disease (CD) was thought to be a rare food intolerance that was confined to childhood and characterized by severe malabsorption and flat intestinal mucosa. Currently, CD is regarded as an autoimmune disorder that is common in the general population (affecting 1 in 100 individuals), with possible onset at any age and with many possible presentations. The identification of CD is challenging because it can begin not only with diarrhea and weight loss but also with atypical gastrointestinal (constipation and recurrent abdominal pain) and extra-intestinal symptoms (anemia, raised transaminases, osteoporosis, recurrent miscarriages, aphthous stomatitis and associated autoimmune disorders), or it could be completely symptomless. Over the last 20 years, the diagnostic accuracy of serology for CD has progressively increased with the development of highly reliable tests, such as the detection of IgA tissue transglutaminase and antiendomysial and IgG antideamidated gliadin peptide antibodies. The routine use of antibody markers has allowed researchers to discover a very high number of 'borderline' cases, characterized by positive serology and mild intestinal lesions or normal small intestine architecture, which can be classified as potential CD. Therefore, it is evident that the 'old celiac disease' with flat mucosa is only a part of the spectrum of CD. It is possible that serology could identify CD in its early stages, before the appearance of severe intestinal damage. In cases with a positive serology but with mild or absent intestinal lesions, the detection of HLA-DQ2 and HLA-DQ8 can help reinforce or exclude the diagnosis of gluten sensitivity.

The thyroid and the gut

Thyroid disease is common, and its effects on the gastrointestinal system are protean, affecting most hollow organs. Hashimoto disease, the most common cause of hypothyroidism, may be associated with an esophageal motility disorder presenting as dysphagia or heartburn. Dyspepsia, nausea, or vomiting may be due to delayed gastric emptying. Abdominal discomfort, flatulence, and bloating occur in those with bacterial overgrowth and improve with antibiotics. Reduced acid production may be due to autoimmune gastritis or low gastrin levels. Constipation may result from diminished motility, leading to an ileus, megacolon, or rarely pseudoobstruction. Ascites in myxedema is characterized by a high protein concentration. Graves' disease accounts for 60% to 80% of thyrotoxicosis. Hyperthyroidism is accompanied by normal gastric emptying with low acid production, partly due to an autoimmune gastritis with hypergastrinemia. Transit time from mouth to cecum is accelerated, resulting in diarrhea. Steatorrhea is due to hyperphagia and stimulation of the adrenergic system. Diarrhea in medullary carcinoma of the thyroid (MCT) may be due to elevated calcitonin, prostaglandins, or 5-hydroxyindoleacetic acid. Ileal or colonic function may be abnormal. The esophagus may be compressed by benign processes, but more often by malignancies. MRI and CT scans are the best diagnostic modalities. The gastrointestinal manifestations of thyroid disease are generally due to reduced motility in hypothyroidism, increased motility in hyperthyroidism, autoimmune gastritis, or esophageal compression by a thyroid process. Symptoms usually resolve with treatment of the thyroid disease.

Association of celiac disease with cardiomyopathy and pulmonary hemosiderosis

Celiac disease is predominantly a disease of the small intestine characterized by chronic malabsorption in genetically susceptible individuals who ingest grains containing gluten, such as wheat, barley and rye. Although previously believed to be uncommon, celiac disease may be present in up to 1% of the general population. Celiac disease is frequently associated with many extraintestinal disorders, but rarely with cardiomyopathy. We describe a patient with celiac disease associated with cardiomyopathy and pulmonary hemosiderosis.

Celiac disease with a mixed pattern: a case report

INTRODUCTION

Celiac disease can be severe and associated with progressive malabsorption and death. A subset of patients may develop subepithelial collagen deposition, a condition referred to as collagenous sprue.

CASE PRESENTATION

We report a case of a 46-year-old female who was previously diagnosed as having seronegative arthritis and inflammatory bowel disease, and three years later after the initial diagnosis she was histologically confirmed to have celiac disease in association with collagenous sprue, another underlying malabsorptive disorder.

CONCLUSION

Although the precise relationship between celiac disease and collagenous sprue has been debated and remains controversial, it should be considered among the differential diagnoses of chronic diarrhea with progressive malabsorption.

Celiac sprue: a unique autoimmune disorder

Celiac sprue (CS) is a gluten-sensitive enteropathy with many autoimmune features. CS involves multiple organs through immune and nonimmune processes, and is frequently associated with other autoimmune disorders. This article reviews the co-occurrence of CS with autoimmune disorders of the cutaneous, nervous, endocrine, musculoskeletal, gastrointestinal and cardiovascular systems. The types of autoimmune disorders associated with CS and the prevalence of CS in other autoimmune disorders are also discussed. A brief review of the literature on the potential mechanisms behind these associations and the therapeutic effects of a gluten-free diet for autoimmune comorbidities in CS is also provided.

Prevalence of autoimmune thyroiditis in children with celiac disease and effect of gluten withdrawal

OBJECTIVE

To study the prevalence of autoimmune thyroiditis (AT) in Sardinian children with celiac disease (CD) and the effects of a gluten-free diet (GFD) on thyroid function.

STUDY DESIGN

Children with biopsy-proven CD (n = 324; female:male 2:1; mean age, 6.6 years) followed from 1 to 15 years, were retrospectively evaluated for AT at onset of CD and during GFD. Serum thyroid peroxidase and thyroglobulin antibodies (AbTPO, AbTG), thyroid-stimulating hormone (TSH), free thyroxine (FT4), free triiodothyronine (FT3), and thyroid ultrasonography were considered. Age-matched Sardinian schoolchildren (n = 8040), previously evaluated for antithyroid antibodies and thyroid function, were used as controls.

RESULTS

Thirty-four patients with CD (10.5%) developed AT (female:male 4,5:1; mean age, 10.5 years), 11 at onset of CD and 23 during GFD, with a higher prevalence than controls (P = 2.9(-13)). Twenty-eight patients were euthyroid and 6 hypothyroid. AbTPO and/or AbTG persisted elevated for 2 to 9 years despite the GFD in 9 of 11 patients with AT at onset of CD.

CONCLUSIONS

AT is strongly associated with CD in Sardinian children, has an age of onset of 10.5 years, and appears to be gluten-independent. In children with CD with AT, the female:male bias reported in adult AT is present before puberty.