Celiac Disease Presenting as Profound Diarrhea and Weight Loss - A Celiac Crisis

Uncovering the role of TREM-1 in celiac disease: In silico insights into the recognition of gluten-derived peptides and inflammatory mechanisms

BACKGROUND

Celiac disease (CD) is a chronic enteropathy characterized by a permanent intolerance to gluten. While CD has been associated with heightened T cell responses and the involvement of distinct innate immunity components, the role of the triggering receptor expressed on myeloid cells (TREM) family in this disease remains unclear. Thus, as TREM-1 has already been implicated in other inflammatory bowel diseases, and given its role in the amplification of inflammation, we hypothesized that it might play a role in the pathophysiology of CD.

METHODS AND RESULTS

the STRING tool was used to predict protein-protein interaction networks between TREM-1 and CD signaling pathways. Then, molecular docking and molecular dynamics simulations were conducted to explore potential interactions between TREM-1 and different peptides derived from alpha-gliadin (25-mer, 33-mer and p31-43). Finally, we used transcriptomic data, available from public repositories, to assess TREM1 gene expression, and genes involved in its signaling pathway, in CD patients. Our results found an association between TREM-1 and CD markers, with STRING analysis, and the in silico simulations suggesting that the receptor might recognize the alpha-gliadin peptides, with the TREM-1/p31-43 interaction as the most likely interaction to occur biologically. Furthermore, TREM1 and its signaling pathway were increased in patients with active CD, while in those in clinical remission, the expression levels were similar to healthy controls.

CONCLUSIONS

collectively, our findings suggest that TREM-1 might recognize alpha-gliadin derived peptides, and TREM-1's activation may contribute to the intestinal inflammation observed in CD.

Analyzing the landscape of coeliac crisis in adult and paediatric populations: A systematic review and meta-analysis

BACKGROUND

Coeliac crisis (CC) is a rare, potentially life-threatening manifestation of coeliac disease (CD).

AIMS

To comprehensively explore the clinical aspects, management strategies, and outcomes related to CC in both adult and paediatric populations.

METHODS

We conducted a comprehensive literature search to identify studies eligible for inclusion up to 28 December 2024. The study protocol was registered in PROSPERO (CRD42024510682).

RESULTS

A total of 46 included articles and 195 patients were analyzed. The median age of presentation was 18 years (range: 8 months to 83 years), predominantly affecting the paediatric population. An overwhelming majority (180 patients, 92.8 %) had CC as their first presentation, whereas the others were previously diagnosed CD cases with poor adherence to gluten-free diet (GFD). Clinically, patients presented with diarrhoea (88.2 %), abdominal pain (72.8 %), vomiting (56.4 %), confusion and lethargy (11.3 %). Electrolyte derangements in the form of hypokalemia (89.7 %) and hyponatremia (64.1 %), along with metabolic acidosis (79.5 %) and hypoalbuminemia (76.9 %), reflected the severity of malabsorption. Treatment with GFD caused clinical improvement in 186 (95.4 %) patients and mostly favourable long-term outcomes.

CONCLUSION

CC is a poorly understood, life-threatening complication of CD. Given its similarity with infectious conditions, clinicians require a high index of suspicion for recognizing CC to diagnose early and provide proper management.

Meta-Analysis and Systematic Review of HLA DQ2/DQ8 in Adults with Celiac Disease

Although people with human leukocyte antigens (HLA) DQ2 and/or DQ8 are more likely to develop celiac disease (CD), the condition cannot be fully explained by this genetic predisposition alone. Multiple, as yet unidentified, factors contribute to the genesis of CD, including genetics, the environment, and the immune system. In order to provide insight into a prospective possibility and an expanded screening technique, we aim to undertake a comprehensive and meta-analytical study of the assessment and distribution of HLA class II (HLA-DQ2/DQ8) in adult CD patients. A systematic review was conducted using an electronic search of databases (PubMed, Google Scholar, Embase, and Direct Science) from January 2004 to February 2022. DQ2/DQ2 homozygotes have the highest risk of developing CD. DQ2/DQ8 typing is an effective test to exclude CD from the differential diagnosis of a patient with CD symptoms. Although other non-HLA genes have been associated with CD, they are rarely considered at diagnosis because they account for only a small proportion of the heritability of CD. This finding, together with the information gathered previously, may be useful in considering widely available and economically feasible screening options for celiac disease in young people.

Celiac crisis in patients with celiac disease. Case report

Celiac crisis (CC) is a rare life-threatening course of celiac disease, observed mainly in children. In adults, CK can be the first manifestation of the disease and, very rarely, a relapse that occurs in patients who do not follow the gluten-free diet (AGD). Triggers can be stress, surgery, childbirth, etc. A clinical observation of CC developed in a 49-year-old patient with previously established latent celiac disease with subtotal villous atrophy, stage Marsh III C is presented. The patient did not comply with AHD. After severe angina, she developed anorexia, diarrhea, emaciation, coagulopathy, bilateral pulmonary embolism, infarction pneumonia, and enterogenic sepsis. As a result of intensive therapy with prednisolone, Fraxiparine, antibiotics, fresh frozen plasma and strict adherence to hypertension, remission of the disease was achieved.

Life-threatening onset of coeliac disease: a case report and literature review

BACKGROUND

Coeliac disease (CD) results from an immune-mediated reaction to gluten in genetically predisposed individuals. In rare cases CD may occur with acute features deferring the diagnosis and exposing these patients to possible life-threatening complications. Herein we present the case of a young woman with a coeliac crisis, that is, a sudden clinical onset characterised by severe electrolyte imbalance due to an unknown (previously unrecognised) CD.

METHODS

This is a case report and literature review revealing that coeliac crisis is under-reported, with a total of 48 adult cases so far published. The diagnosis in our case was established by histopathological analysis of multiple duodenal biopsies. The patient's serum was tested by enzyme-linked immunoassay to detect antitransglutaminase IgA antibodies.

RESULTS

In contrast to cases reported in the literature, with male gender predominance and a mean age of 50±17 years, our patient was a young female case of coeliac crisis. However, like in our patient, a higher incidence of coeliac crisis was associated with the human leucocyte antigen (HLA)-DQ2 haplotype, versus HLA-DQ8, and a severe (Marsh-Oberhüber 3c) duodenal mucosa atrophy. Notably, there is no clear correlation between the antitissue transglutaminase 2 IgA antibody titre and coeliac crisis onset/severity, as confirmed by our case report.

CONCLUSIONS

The present case highlights that CD may manifest quite abruptly with a severe malabsorption syndrome, that is, electrolyte abnormalities and hypoproteinaemia. Our case should alert physicians, in particular those in the emergency setting, that even a typically chronic disorder, such as CD, may show life-threatening complications requiring urgent management.

Celiac Disease in an Adult Presenting as Behavioral Disturbances

BACKGROUND Celiac disease is very common, with some estimates placing the prevalence at approximately 1: 300 worldwide. Typified by autoimmune degradation of the duodenal brush border due to reactivity with dietary gluten, causing malabsorption, it classically presents with both gastrointestinal and extra-intestinal symptoms. Gastrointestinal symptoms commonly include diarrhea, constipation, foul steatorrhea, flatulence, and bloating. With increased awareness and availability of testing, it is rare that a patient would present with celiac crisis, which is a syndrome of profuse diarrhea and severe metabolic/nutritional disturbances. In children, interestingly, celiac disease can present primarily as behavioral disturbance, such as increased aggression or anxiety, with milder or absent gastrointestinal symptoms. CASE REPORT A 25-year-old man with a history of schizophrenia and autism spectrum disorder presented for behavioral disturbance after breaking into a neighbor's house to eat food. He also reported several months of diarrhea and fecal incontinence and was noted to have severe malnutrition on exam, despite dramatic food intake. Tissue transglutaminase IgA antibody (TTG) and gliadin IgA were highly suggestive of celiac disease, which was confirmed by biopsy. He was started on a lactose-free and gluten-free diet, and required a short course of total parenteral nutrition (TPN) for nutritional resuscitation. He improved rapidly with this intervention, and returned to nutritional and behavioral baseline. CONCLUSIONS We report a unique case in which an adult with psychiatric comorbidities presented with predominantly behavioral disturbances, a more common presentation in children with the disorder. These patients may present in an atypical fashion, and the clinician should have a high index of suspicion.

Nutritional management of celiac crisis in an elderly adult: A case report of the rare presentation of celiac disease in a 75-y-old woman

In adults, a very uncommon presentation of celiac disease (CD) is a celiac crisis, a life-threatening and severe form of the disease having a dramatic onset with diarrhea and metabolic acidosis with electrolyte and fluid imbalance. Treatment of celiac crisis requires a gluten-free diet; however, the risk for refeeding syndrome (RFS) should be considered in patients showing marked malabsorption symptoms and important unintentional weight loss. Therefore, to avoid metabolic and potentially fatal complications of re-nutrition, nutritional management is crucial for a safe recovery after a celiac crisis. This review reports the rare onset of celiac crisis in a 75-y-old woman presenting with severe malnutrition resulting in >40% weight loss in 3 mo, after a period of severe diarrhea and vomiting. She arrived at the hospital showing electrolyte imbalance, hypoalbuminemia, lower limb edema, multiple bowel movements (>10/d) with steatorrhea, sarcopenia with profound asthenia, hyporexia due to intolerance to any food, and vomiting after meals. After being diagnosed with CD, the first approach was a gluten-free diet, which demonstrated only small and slow improvements of gastrointestinal symptoms. Therefore, a second approach was parenteral nutrition (PN) support that dramatically helped the patient's recovery. Here we describe the nutritional management during the inpatient stay for clinical stabilization and the following outpatient visits during and after the support with PN, until the patient's complete recovery to a regular follow-up.

Coeliac crisis mimicking nephrotic syndrome in a post-partum patient

BACKGROUND

Coeliac crisis is a life-threatening presentation of coeliac disease. Severe diarrhoea, weight loss, electrolyte imbalances and malnutrition are prominent features. Although mainly a disease of childhood, it can on the rare occasion be diagnosed in adults.

CASE PRESENTATION

A 25-year-old female with severe generalised oedema, lower extremity weakness, hypokalemia and profound hypoalbuminemia was referred with an initial diagnosis of nephrotic syndrome. Three months previously she had given birth to a healthy child following an uneventful pregnancy. She did not have proteinuria. She had a history of diarrhoea with gluten-containing food since childhood but lacked a formal diagnosis of coeliac disease. A duodenal biopsy confirmed the suspected diagnosis. Coeliac crisis was diagnosed with life-threatening multisystem involvement. Introduction of a gluten-free diet abolished all disease symptoms and ameliorated laboratory parameters at six months' follow-up.

CONCLUSION

Coeliac crisis is a rare, yet dangerous presentation of coeliac disease in adults. As this case suggests, it can present with generalised oedema and hypoalbuminemia mimicking nephrotic syndrome. Rapid diagnosis is the key to successful treatment.

Severe Coagulopathy as a Rare Feature of Celiac Crisis in a Patient Previously Diagnosed with Celiac Disease

BACKGROUND Celiac crisis is an uncommon but critical complication of celiac disease (CD) manifesting with copious diarrhea, dehydration, and severe metabolic imbalances. Celiac crisis occurring in individuals who have been formerly diagnosed with CD and displaying severe coagulopathy is tremendously rare. CASE REPORT We report a case of a 76-year-old male, previously diagnosed with CD and non-compliant with gluten free diet, who presented with severe coagulopathy manifesting as gastrointestinal bleeding in addition to other features of celiac crisis, including severe diarrhea, dehydration, metabolic acidosis, electrolyte disturbances, and renal dysfunction. Esophagogastroduodenoscopy revealed flattened mucosa and mucosal nodularity in the duodenum. Duodenal biopsies exhibited active chronic inflammation with intraepithelial lymphocytosis and subtotal villous blunting. The patient was diagnosed with celiac crisis and treatment with vitamin K, parenteral nutrition, and steroids was commenced. After initial clinical improvement, a gluten-free diet was implemented with complete resolution of symptoms. CONCLUSIONS Though celiac crisis typically presents in patients with undiagnosed CD, it should be considered in patients who have been previously diagnosed CD but who are non-compliant with gluten free diet. Severe coagulopathy, though extremely rare, can be a feature of celiac crisis and should be consider when encountered in a patient with history of steatorrhea and gastrointestinal bleeding.

Celiac crisis, a rare occurrence in adult celiac disease: A systematic review

BACKGROUND

Celiac crisis (CC), a potentially life-threatening condition, is one of the rare clinical presentations of celiac disease (CD). Several cases have been documented in the literature, mostly in children.

AIM

To perform a review of CC cases reported in adult CD patients.

METHODS

A systematic search of the literature was conducted in two databases, PubMed/MEDLINE and EMBASE, using the term "celiac crisis" and its variant "coeliac crisis", from January 1970 onwards. Altogether, 29 articles reporting 42 biopsy-proven cases were found in the search. Here, we summarized the demographic, clinical characteristics, laboratory and diagnostic work-ups, and therapeutic management in these patients.

RESULTS

Among the 42 CD cases, the median age was 50 years (range 23-83), with a 2:1 female to male ratio. The majority of patients (88.1%) developed CC prior to CD diagnosis, while the remaining were previously diagnosed CD cases reporting low adherence to a gluten-free diet (GFD). Clinically, patients presented with severe diarrhea (all cases), weight loss (about two thirds) and, in particular situations, with neurologic (6 cases) or cardiovascular (1 case) manifestations or bleeding diathesis (4 cases). One in four patients had a precipitating factor that could have triggered the CC (e.g. trauma, surgery, infections). Laboratory workup of patients revealed a severe malabsorptive state with metabolic acidosis, dehydration, hypoalbuminemia and anemia. The evolution of GFD was favorable in all cases except one, in whom death was reported due to refeeding syndrome.

CONCLUSION

Celiac crisis is a rare but severe and potentially fatal clinical feature of CD. A high index of suspicion is needed to recognize this clinical entity and to deliver proper therapy consisting of supportive care and, subsequently, GFD.

Celiac Crisis: an unusual presentation of gluten-sensitive enteropathy

Celiac disease (CD)—also known as gluten-sensitive enteropathy—is a chronic, genetically predisposing and autoimmune entity with a wide range of clinical manifestations triggered by gluten ingestion, which affects 1% of the general population. Currently, up to 60% of the diagnosis of CD is in adults due to the atypical course of the disease. The severe acute onset of CD—also called celiac crisis—is very uncommon and is still not well documented in adults. We report the case of a 58-year-old man who presented a 45-day history of subtle-onset diarrhea followed by malabsorption syndrome with progressive weight loss, anasarca, and electrolyte disturbances. The diagnostic work-up included an upper digestive endoscopy, which showed scalloping of the duodenal mucosa with pathological features confirmed on biopsies. Specific antibodies were positive, and a satisfactory clinical response was obtained once a gluten-free diet was started. Celiac crisis is a rare initial presentation of CD characterized by severe diarrhea, dehydration, weight loss, hypoproteinemia, and metabolic and electrolyte disturbances. Although rare, it should be considered in patients with apparently unexplained chronic diarrhea.