Celiac Disease and Thrombotic Events: Systematic Review of Published Cases

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.

Splanchnic Vein Thrombosis in Myelofibrosis-An Underappreciated Hallmark of Disease Phenotype

Splanchnic vein thrombosis (SVT) encompasses thrombosis in the vessels of the splanchnic basin and has a relatively rare occurrence with a reported frequency in the general population of 1-2%. An episode of seemingly unprovoked SVT almost always triggers a diagnostic work-up for a Philadelphia chromosome-negative myeloproliferative neoplasm (MPN), since atypical site thrombosis is a hallmark of MPN-associated thrombophilia. Primary myelofibrosis (PMF) is a rare MPN with an estimated incidence between 0.1 and 1/100,000 per year. Although prothrombotic tendency in PMF is not envisioned as a subject of specific therapeutic management, unlike other MPNs, such as polycythemia vera (PV) and essential thrombocythemia (ET), thrombotic risk and SVT prevalence in PMF may be comparably high. Additionally, unlike PV and ET, SVT development in PMF may depend more on procoagulant mechanisms involving endothelium than on blood cell activation. Emerging results from registry data also suggest that PMF patients with SVT may exhibit lower risk and better prognosis, thus highlighting the need for better thrombotic risk stratification and identifying a subset of patients with potential benefit from antithrombotic prophylaxis. This review highlights specific epidemiological, pathogenetic, and clinical features pertinent to SVT in myelofibrosis.

Prevalence of Coagulopathy in Patients with Celiac Disease: A Single-Center Retrospective Case-Control Study

Introduction: Despite being one of the most frequent chronic digestive diseases worldwide, with a prevalence of 1%, celiac disease (CD) remains severely underdiagnosed. Among the instruments used to improve its diagnostic rate, hematologic parameters have been proposed as screening tests to select patients with an increased probability of having CD. Assessment of coagulation is included in routine check-ups, and CD has been reported to be associated with coagulopathy. We aimed to assess if subtle changes in coagulation tests could be used in clinical practice to prompt testing for CD. Methods: We retrospectively recruited all patients with clinical suspicion for CD during a study period of 7 years (between 2015 and 2022), who were tested using IgA tissue transglutaminase (tTG) serology and serum total IgA (IgG tTG in case of IgA deficiency) and who underwent upper gastrointestinal endoscopy with multiple biopsy sampling of the duodenal bulb and distal duodenum. We stratified patients into three groups: newly diagnosed CD, gluten-free diet-treated CD, and non-CD controls. Results: Altogether, there were 133 CD patients (71 newly diagnosed, 62 GFD-treated) and 57 non-CD controls. Mean age and gender distribution were similar among the three groups: 43.3 years for newly diagnosed CD, 41.6 years for non-CD controls, and 44 years for GFD-treated CD patients, with a male gender distribution of 21.1%, 28%, and 24.1%, respectively. Among the included newly diagnosed CD patients, 14% had a prolonged INR. The mean INR was slightly higher in newly diagnosed CD patients, compared to GFD-treated CD patients and non-CD controls: 1.12 ± 0.30, 1.02 ± 0.83, and 1.00 ± 0.08, respectively (p = 0.009). Consequently, prothrombin activity was slightly lower in newly diagnosed CD patients, compared to GFD-treated CD and non-CD controls: 94.9 ± 19.3%, 102.3 ± 12.8%, and 101.9 ± 15.15, respectively. Interestingly, after GFD, the mean INR and prothrombin activity of CD individuals reached a value similar to that of non-CD controls. Conclusions: Subtle changes in INR, defined as a value within the normal range, but closer to the upper limit, could be an indicator of probability for CD.

More Than Three Years for Normalisation of Routine Laboratory Values after Gluten Withdrawal in Paediatric Coeliac Patients

The assessment of the nutritional and inflammatory status of paediatric patients with coeliac disease is an interesting approach to early diagnosis and functional follow-up. Most authors agree that the normalisation of symptoms takes about one year. The aim of the study was to evaluate the clinical manifestation and normalisation of routine analytics in Spanish children diagnosed with celiac disease.

METHODS

We performed a retrospective case-control study in Spanish paediatric patients, including 21 celiac patients and 20 healthy controls. The 21 patients selected in the case-control study were followed for 5 years after starting a gluten-free diet (GFD). All patients had type 3 villous atrophy according to the Marsh-Oberhuber classification. A total of 39 blood samples were taken before the start of the GFD, and 109 were taken after. Twenty control sera from healthy donors were used for comparison.

RESULTS

We found that patients had a subclinical but statistically significant increase in blood calcium, transaminases, and white blood cells, and a decrease in serum iron, at the time of diagnosis. Our study also shows that analytical values normalise within five years on a gluten-free diet.

CONCLUSIONS

The use of a combination of subclinical changes, including low iron, high calcium, elevated leukocytes, lymphocytes, and ALT levels in blood samples, together with a low growth percentile, is pertinent in detecting coeliac disease. This set of parameters could help in the diagnosis of patients without clinical symptoms. We can also show that the levels of Fe, Ca, transaminases, and leucocytes remain subclinically altered after 3 years, despite the gluten-free diet.

Deep Vein Thrombosis Revealing A "Silent" Coeliac Disease

Introduction

We present a clinical case of a 45-year-old man with recurrent deep vein thrombosis (DVT) and multiple hospital admissions due to severe infectious conditions. A newfound hypoalbuminemia raised the suspicion of a protein-losing condition, with an upper endoscopy revealing lesions at the D2 level compatible with coeliac sprue and HLA typing positive for both DQ-2 and DQ-8.

Methods

A gluten free diet was started and apixaban was suspended.

Results

No new complications were reported.

Discussion

Multiple mechanisms are believed to be behind the association between DVT and coeliac disease. However, to this date, no consensus exists regarding the ideal duration of anticoagulation.

LEARNING POINTS

Coeliac disease should always be considered a systemic disease.Thromboembolism is a possible extraintestinal manifestation of coeliac disease.Coeliac disease should be considered as a possible cause of thromboembolism even in the absence of gastrointestinal symptoms, which it can precede by several years.

Molecular Mechanisms Underlying Vascular Liver Diseases: Focus on Thrombosis

Vascular liver disorders (VLDs) comprise a wide spectrum of clinical-pathological entities that primarily affect the hepatic vascular system of both cirrhotic and non-cirrhotic patients. VLDs more frequently involve the portal and the hepatic veins, as well as liver sinusoids, resulting in an imbalance of liver homeostasis with serious consequences, such as the development of portal hypertension and liver fibrosis. Surprisingly, many VLDs are characterized by a prothrombotic phenotype. The molecular mechanisms that cause thrombosis in VLD are only partially explained by the alteration in the Virchow's triad (hypercoagulability, blood stasis, and endothelial damage) and nowadays their pathogenesis is incompletely described and understood. Studies about this topic have been hampered by the low incidence of VLDs in the general population and by the absence of suitable animal models. Recently, the role of coagulation imbalance in liver disease has been postulated as one of the main mechanisms linked to fibrogenesis, so a novel interest in vascular alterations of the liver has been renewed. This review provides a detailed analysis of the current knowledge of molecular mechanisms of VLD. We also focus on the promising role of anticoagulation as a strategy to prevent liver complications and to improve the outcome of these patients.

Nutritional Status and Metabolism in Celiac Disease: Narrative Review

This review summarizes findings from studies assessing the nutritional status of patients with celiac disease (CD). Malnutrition, including over- and undernutrition, may be present in CD, both at diagnosis and while under treatment. Underweight and growth retardation in children, which mostly reflect malabsorption as a consequence of intestinal inflammation, are not a rule. Clinical presentations of CD can vary widely, and each manifestation has its own characteristics. Evaluating various nutritional parameters can be beneficial for CD patients and may improve health outcomes by facilitating an accurate definition of dietary needs and the development of a balanced diet that not only focuses on eliminating gluten but also provides adequate nutrients, alters metabolism, and reduces the risk of other disorders developing. The cornerstone of CD therapy is a gluten-free diet (GFD), which improves nutritional status, but even on a GFD, features of malnutrition may be present. Additionally, overweight and obesity may occur in patients on a GFD, with typical metabolic consequences.

Stroke in Young Adults

Stroke in young adults is associated with significant morbidity, and its prevalence is rising in the United States. This is partly attributed to a rise in the prevalence of traditional risk factors including hypertension, hypercholesterolemia, obesity, diabetes mellitus, smoking and heart disease. In addition, there are non-modifiable risk factors comprising migraine, pregnancy and postpartum state, illicit drug use, oral contraceptives and hypercoagulable state. The mechanisms causing stroke in young adults are unique and include cervical dissection, cardioembolic phenomenon, vasculitis and vasculopathy, connective tissue disease, patent foramen ovale and cerebral venous thrombosis. The diagnosis of stroke in the young population can be challenging given its myriad clinical presentations. In this document, we provide an overview of the epidemiology of stroke in young adults, explore mechanisms that may explain increasing rates of stroke in this population, and provide a critical updated overview of the existing literature on the management and prevention of stroke in young adults.

Monitoring the Coagulation Profile of COVID-19 Patients Using Standard and ClotPro® Hemostasis Tests

Background and Objectives: Coagulation disorders during COVID-19 infection are associated with a poorer prognosis and higher disease severity because thrombosis and inflammation are two processes that interfere with each other. A very important issue for clinicians is timely and adequate hemostasis and inflammation monitoring to prevent and treat potentially lethal consequences. The aim of this study was to identify specific hemostatic parameters that are associated with a higher risk of intrahospital mortality. Materials and Methods: This study was approved by the Ethics Committee of the Clinical Center Nis in Serbia. One hundred and forty-two patients presented with COVID-19 ARDS and were admitted to the ICU in the Clinic for Anesthesiology at the Clinical Center Nis from 14 April 2020 to 25 May 2020. Upon admission, blood was collected for biochemical and coagulation testing. The data obtained were analyzed using the Statistical Package for Social Sciences (SPSS v. 25, Chicago, IL, USA). Results: Among all the parameters assessed, older age; increased levels of fibrinogen, INR, D-dimer, and presepsin; and higher results in the platelet aggregation tests (aggregation induced by adenosine diphosphate based on the ADP test (AU/min), aggregation induced by arachidonic acid based on the ASPI test (AU/min), and aggregation induced by thrombin based on the TRAP test (AU/min)) and some assays of the viscoelastic test (clot amplitude after 5 min in the extrinsic coagulation pathway based on the A5 EX-test (mm), clot amplitude after 10 min in the extrinsic coagulation pathway based on the A10 EX-test (mm), clot amplitude after 5 min regarding functional fibrinogen based on the A5 FIB-test (mm), clot amplitude after 10 min regarding functional fibrinogen based on the A10 FIB-test (mm), and maximum clot firmness based on the MCF FIB-test (mm)); and lower values of viscoelastic clotting time in the extrinsic coagulation pathway based on the CT EX-test (s) were significantly correlated with mortality. In the multivariate analysis, D-dimer levels above 860 ng/mL, higher TRAP test value bins, and values above the normal reference range of the A10 FIB test were found to be independent predictors of mortality. Conclusions: Sophisticated hemostasis parameters can contribute to early risk assessment, which has initially been performed only on the basis of patients' clinical status. Hypercoagulability is the main coagulation disorder in COVID-19 infection.

Diagnostic and Therapeutic Challenges of Concurrent Intracranial Hemorrhage and Cerebral Venous Thrombosis in a Patient With Acute Lymphoblastic Leukemia: A Case Report and Literature Review

Cerebral venous sinus thrombosis (CVST) is a cerebrovascular condition due to the thrombosis of cerebral venous sinuses, leading to intracranial hemorrhage, increased intracranial pressure, focal deficit, seizure, toxic edema, encephalopathy, and death. The diagnosis and therapeutic approach of CVST remain challenging because of its highly nonspecific clinical presentation including headaches, seizures, focal neurologic deficits, and altered mental status, etc. Anticoagulation is the mainstay of CVST treatment and should be started as soon as the diagnosis is confirmed. Here, we present the case of a 34-year-old male construction worker who presented to the emergency department with a complaint of right chest wall pain and swelling. He was admitted to the hospital following a diagnosis of anterior chest wall abscess and mediastinitis. During hospitalization, his complete blood count revealed pancytopenia with blast cells, and bone marrow biopsy revealed 78.5% lymphoid blasts by aspirate differential count and hypercellular marrow (100%) with decreased hematopoiesis. He developed concurrent CVST and intracranial hemorrhage while receiving CALGB10403 (vincristine, daunorubicin, pegaspargase, prednisone) with intrathecal cytarabine induction chemotherapy for acute lymphoblastic leukemia (ALL). The patient failed two standard chemotherapy for ALL and achieved remission while on third-line chemotherapy with an anti-CD19 monoclonal antibody, blinatumomab. Although this patient had an MRI scan of the brain with multiple follow-up non-contrast CT scans, it was CT angiography that revealed CVST. This showed the diagnostic challenge in CVST, with CT and MRI venography having excellent sensitivity in diagnosing CVST. Risk factors for CVST in our patient were ALL and its intensive induction chemotherapy with pegaspargase.

Severe Urine Retention and Deep Vein Thrombosis: A Case Report and Review of the Literature on an Unusual Association

Acute urine retention is the most common urologic emergency, and it usually presents with abdominal pain and an inability to pass urine. The distended bladder in urine retention can be enormously large, raising the intra-abdominal pressure and compressing the iliac veins draining the lower limbs and pelvis. Many cases have been reported to have deep vein thrombosis (DVT)-like features with urine retention that resolves with bladder decompression. In rare cases, urine retention can lead to DVT, particularly in young patients. We report a case of a young female patient with a huge distended bladder who devolved extensive venous thrombosis bilaterally. The report sheds light on this unusual complication of acute urine retention and reviews the existing literature on the topic.

Psychiatric and Neurological Manifestations of Celiac Disease in Adults

Celiac disease (CD), a chronic inflammatory disorder of the intestines, affects 0.7% to 1.4% of the world's population. CD causes diarrhea, abdominal discomfort, bloating, flatulence, and, in rare cases, constipation in the digestive tract. Since the identification of gluten as the disease-causing antigen, CD patients have been treated with a gluten-free diet, which is advantageous but has limitations for certain patient groups. CD is associated with mood disorders, such as manic-depressive disease, schizophrenia, and bipolar disorder, as well as other disorders such as depression and anxiety. The relationship between CD and psychological issues is not entirely understood. Here, we look at the most recent psychiatric data as they pertain to CD, as well as the relevant psychiatric manifestations that have been associated with this condition. Clinicians should examine mental health factors when a CD diagnosis is established. More research is needed to understand the pathophysiology of CD's psychiatric manifestations.

Cognitive Impairment in Celiac Disease Patients: Scoping Review Exploring Psychological Triggers in a Chronic Condition

Celiac disease (CD), also known as gluten-sensitive enteropathy, is an inflammatory autoimmune reaction triggered by ingestion of gluten in genetically predisposed subjects. Celiac disease is often associated with a wide range of disorders, caused by immune responses and by malabsorption with subsequent nutritional deficiencies. Prevalent neurologic manifestations are ataxia, epilepsy, cerebral calcification, cerebral white matter lesions, peripheral neuropathy and myopathy, but also cognitive impairment. The study aimed to identify emerging and urgent research domains in order to establish a CD-specific patient-tailored protocol that includes both psychological and neuropsychological evaluations. We performed a systematic search of MEDLINE, PubMed, SCOPUS, Web of Science and Cochrane library in November 2022. We conducted a descriptive analysis of the characteristics of the included literature. Based on the exclusion/inclusion criteria, a total of seven articles were included in the scoping review process. This review demonstrated the lack of research on CD-related cognitive impairment key features and tries to focus on both cognitive and psychological manifestations as well as their two-way interaction. We tried to establish the specific areas involved, in order to have a comprehensive view of this condition and trying to determine a correct way of assessing CD cognitive impairment and its correlations with psychological distress and personal coping skills to a chronic condition. Nevertheless, research on this topic is progressively increasing and future studies should address specific key points.

Lane-Hamilton Syndrome in an Adult With Down Syndrome: A Case Report

The Lane-Hamilton syndrome (LHS) is an extremely rare association between celiac disease (CD) and idiopathic pulmonary hemosiderosis (IPH), with only a few cases reported in the literature. The authors report a case of a 32-year-old man with Down syndrome who presented to the emergency department with a history of hemoptysis and chronic diarrhea. The complementary investigation revealed iron deficiency anemia and features suggestive of diffuse alveolar hemorrhage on computed tomography (CT) scan of the chest. After excluding all competing diagnosis, the IPH diagnosis was made. The biopsy of the small intestine confirmed CD and the diagnosis of LHS was established. A gluten-free diet and steroids were given to the patient with a very good clinical response. Since there is an established association between IPH and CD, if the diagnosis of IPH is made, it's recommended to screen for CD even in patients without gastrointestinal symptoms.

Clinical Characteristics, Risk Factors, and Outcomes of Acute Pulmonary Embolism in Asian Population

BACKGROUND

Acute pulmonary embolism (APE) is a common condition with increasing worldwide incidence. However, the clinical characteristics, risk factors, and clinical outcomes of APE in the Asian population especially in the Thai population are still limited. Therefore, the objective of this study was to identify the clinical characteristics, risk factors, and clinical outcomes of APE in the Asian population.

METHODS

A cross-sectional study was conducted on patients diagnosed with APE at Chiang Mai University Hospital, Thailand during 2011-2020.

RESULTS

During the study period, 696 patients confirmed the diagnosis of APE with a mean age of 57.7 ± 15.7 years and 41.1% males. APE was suspected in 468 of 696 patients (67.2%), while 228 patients (32.8%) had incidental PE. Active malignancy during treatment was found in 388 (55.7%). Dyspnea, cough, and chest pain were the most common presenting symptoms. Respiratory failure was found in 129 patients (18.6%). The thirty-day all-cause mortality rate was 19.1%. PE-related mortality was 5.6%. Most PE-related mortality was high-risk PE.

CONCLUSION

APE was not uncommon in the Asian population. Active cancer, especially lung cancer was the most common risk factors. High-risk and intermediate-high-risk PE were associated with high mortality. Risk stratification and prompt management are warranted to improve outcomes.