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Lupu VV, Sasaran MO, Jechel E, Starcea IM, Ioniuc I, Mocanu A, Rosu ST, Munteanu V, Nedelcu AH, Danielescu C, Salaru DL, Knieling A, Lupu A. Celiac disease - a pluripathological model in pediatric practice. Front Immunol 2024; 15:1390755. [PMID: 38715620 PMCID: PMC11074362 DOI: 10.3389/fimmu.2024.1390755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/03/2024] [Indexed: 05/23/2024] Open
Abstract
Being defined as an autoimmune, chronic pathology, frequently encountered in any age group, but especially in pediatrics, celiac disease (also called gluten enteropathy), is gaining more and more ground in terms of diagnosis, but also interest in research. The data from the literature of the last decades attest the chameleonic way of its presentation, there may be both classic onset symptoms and atypical symptoms. Given the impact played by celiac disease, especially in the optimal growth and development of children, the current narrative review aims to highlight the atypical presentation methods, intended to guide the clinician towards the inclusion of the pathology in the differential diagnosis scheme. To these we add the summary presentation of the general data and therapeutic lines regarding the underlying condition and the existing comorbidities. In order to place the related information up to date, we performed a literature review of the recent articles published in international databases. We bring forward the current theories and approaches regarding both classic celiac disease and its atypical manifestations. Among these we note mainly constitutional, skin or mucous, bone, neuro-psychic, renal, reproductive injuries, but also disorders of biological constants and association with multiple autoimmunities. Knowing and correlating them with celiac disease is the key to optimal management of patients, thus reducing the subsequent burden of the disease.
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Affiliation(s)
- Vasile Valeriu Lupu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Maria Oana Sasaran
- Faculty of Medicine, “George Emil Palade” University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania
| | - Elena Jechel
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | | | - Ileana Ioniuc
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Adriana Mocanu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Solange Tamara Rosu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Valentin Munteanu
- Faculty of Medical Bioengineering, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Alin Horatiu Nedelcu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Ciprian Danielescu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Delia Lidia Salaru
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Anton Knieling
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Ancuta Lupu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
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Kamilova AT, Azizova GK, Poddighe D, Umarnazarova ZE, Abdullaeva DA, Geller SI, Azimova ND. Celiac Disease in Uzbek Children: Insights into Disease Prevalence and Clinical Characteristics in Symptomatic Pediatric Patients. Diagnostics (Basel) 2023; 13:3066. [PMID: 37835809 PMCID: PMC10572208 DOI: 10.3390/diagnostics13193066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/05/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND A few studies on pediatric Celiac Disease (CD) are available from Central Asia. Recent immunogenetic research has highlighted that the HLA-DQ2/8 genetic predisposition to CD as well as the dietary intake of gluten in this geographical area, are comparable to other regions of the world where CD prevalence is known to be 1% or higher. METHODS This is a prospective and cross-sectional study investigating the prevalence and clinical characteristics of CD in symptomatic children referred to the pediatric gastroenterology department of a tertiary hospital in Uzbekistan from 1 September 2021, until 31 July 2022. In addition to collecting the relevant information related to clinical manifestations and laboratory analyses from the clinical files, a specific survey was also administered to patients' guardians. Serological, histopathological, and immunogenetic parameters specific to CD, fecal zonulin, and pancreatic elastases were assessed in CD patients. RESULTS The study population consisted of 206 children. Overall, almost all of them (n = 192; 93.2%) were referred because of gastrointestinal manifestations, which were associated with extra-gastrointestinal manifestations in most cases (n = 153; 74.3%); a minority (n = 14; 6.8%) was mainly referred due short stature and/or growth failure only. Among all of these study participants, CD was diagnosed in 11 children (5.3%). Notably, although diarrhea was similarly reported in CD and non-CD patients, watery diarrhea (type 7 according to the Bristol stool scale) was much more frequently and significantly observed in the former group. All of these CD patients showed anti-tTG IgA 10 times higher than the upper normal limit, except one child with lower serum levels of total IgA; however, all of them received a diagnostic confirmation by histopathological analysis due to the lack of EMA testing in the country. Notably, most CD children (82%) showed a Marsh III histological grading. Around half patients (54.5%) showed zonulin values above the reference range, whereas none showed insufficient levels of pancreatic elastase. However, no correlation or association between zonulin and clinical, laboratory, histopathological, and immunogenetic parameters was found. CONCLUSIONS This study may further suggest a relevant prevalence of CD in Uzbek children, based on this partial picture emerging from symptomatic patients only. Additionally, we highlighted the prevalence of typical CD forms with watery diarrhea, which should strongly support a full diagnostic work-up for CD in the local clinical setting. The high levels of anti-tTG IgA and high Marsh grade might also lead us to speculate a significant diagnostic delay despite the classical clinical expression of CD.
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Affiliation(s)
- Altinoy T. Kamilova
- Gastroenterology Department, Pediatric Republican Specialized Scientific-Practical Medical Center of the Ministry of Health of Republic of Uzbekistan, Tashkent 100179, Uzbekistan; (A.T.K.); (G.K.A.); (Z.E.U.); (D.A.A.); (S.I.G.); (N.D.A.)
| | - Gulnoza K. Azizova
- Gastroenterology Department, Pediatric Republican Specialized Scientific-Practical Medical Center of the Ministry of Health of Republic of Uzbekistan, Tashkent 100179, Uzbekistan; (A.T.K.); (G.K.A.); (Z.E.U.); (D.A.A.); (S.I.G.); (N.D.A.)
| | - Dimitri Poddighe
- School of Medicine, Nazarbayev University, Astana 010000, Kazakhstan
- Department of Pediatrics, National Research Center for Maternal and Child Health, University Medical Center, Astana 010000, Kazakhstan
| | - Zulkhumar E. Umarnazarova
- Gastroenterology Department, Pediatric Republican Specialized Scientific-Practical Medical Center of the Ministry of Health of Republic of Uzbekistan, Tashkent 100179, Uzbekistan; (A.T.K.); (G.K.A.); (Z.E.U.); (D.A.A.); (S.I.G.); (N.D.A.)
| | - Dilrabo A. Abdullaeva
- Gastroenterology Department, Pediatric Republican Specialized Scientific-Practical Medical Center of the Ministry of Health of Republic of Uzbekistan, Tashkent 100179, Uzbekistan; (A.T.K.); (G.K.A.); (Z.E.U.); (D.A.A.); (S.I.G.); (N.D.A.)
| | - Svetlana I. Geller
- Gastroenterology Department, Pediatric Republican Specialized Scientific-Practical Medical Center of the Ministry of Health of Republic of Uzbekistan, Tashkent 100179, Uzbekistan; (A.T.K.); (G.K.A.); (Z.E.U.); (D.A.A.); (S.I.G.); (N.D.A.)
| | - Noiba D. Azimova
- Gastroenterology Department, Pediatric Republican Specialized Scientific-Practical Medical Center of the Ministry of Health of Republic of Uzbekistan, Tashkent 100179, Uzbekistan; (A.T.K.); (G.K.A.); (Z.E.U.); (D.A.A.); (S.I.G.); (N.D.A.)
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Correlation of Anti-Tissue Transglutaminase Antibodies With the Mucosal Changes and IgA Status of Children With Celiac Disease. J Pediatr Gastroenterol Nutr 2022; 75:743-748. [PMID: 36123770 DOI: 10.1097/mpg.0000000000003620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The objective of this study was to assess the association between serological markers and changes of the intestinal mucosa in children with celiac disease (CD). METHODS Clinical data from CD patients under 15 years old were collected from the participating centers in an on-line multicenter nationwide observational Spanish registry called REPAC-2 (2011-2017). Correlation between anti-tissue transglutaminase antibodies (t-TGA) levels and other variables, including mucosal damage and clinical findings (symptoms, age, and gender), was assessed. RESULTS A total of 2955 of 4838 patients had t-TGA and a small bowel biopsy (SBB) performed for CD diagnosis. A total of 1931 (66.2%) patients with normal IgA values had a Marsh 3b-c lesion and 1892 (64.9%) had t-TGA Immunoglobulin A (IgA) ≥ 10 times upper limit of normal (ULN). There is a statistically significant association between t-TGA IgA levels and the degree of mucosal damage ( P < 0.001), the higher the t-TGA IgA levels the more severe the mucosal damage. Those patients who reported symptoms had more severe mucosal damage ( P = 0.001). On the contrary, there was a negative association between age and changes of the intestinal mucosa ( P < 0.001). No association was found with gender. Regarding the IgA-deficient patients, 47.4% (18 cases) had t-TGA Immunoglobulin A (IgA) ≥ 10 times ULN and a Marsh 3b-c lesion was observed in 68.4% (26 patients). No statistical relation was found between t-TGA IgG levels and the changes of the intestinal mucosa, neither a relation with age, gender, or symptoms. CONCLUSIONS There is a positive correlation between t-TGA IgA levels and the severity of changes of the intestinal mucosa. Such correlation was not found in IgA-deficient patients who had positive t-TGA IgG serology. The results in this group of patients support the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition recommendations about the need of performing a SBB in IgA-deficient individuals despite high t-TGA IgG levels.
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Mansour HH, Mohsen NA, El-Shabrawi MHF, Awad SM, Abd El-Kareem D. Serologic, endoscopic and pathologic findings in pediatric celiac disease: A single center experience in a low/middle income country. World J Clin Pediatr 2022; 11:296-307. [DOI: 10.5409/wjcp.v11.i3.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Mansour HH, Mohsen NA, El-Shabrawi MHF, Awad SM, Abd El-Kareem D. Serologic, endoscopic and pathologic findings in pediatric celiac disease: A single center experience in a low/middle income country. World J Clin Pediatr 2022; 11:295-306. [PMID: 35663003 PMCID: PMC9134153 DOI: 10.5409/wjcp.v11.i3.295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/25/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Studies in Africa, Asia, and Latin America are needed to provide a comprehensive picture of the global incidence of celiac disease (CD).
AIM To describe the serology, endoscopic and histological findings in typical and atypical presentations of pediatric CD at a tertiary referral hospital in an African low/middle income country (LMIC).
METHODS This observational study was conducted on 199 patients with CD from 2010 to 2019. The patients were divided into typical and atypical groups according to the presenting symptoms including 120 and 79 patients respectively. Serology, upper gastrointestinal endoscopy with duodenal biopsy were performed for patients who had symptoms suggestive of CD. The severity of the intestinal damage was graded according to the histo-pathologic Marsh-Oberhuber classification.
RESULTS Chronic diarrhea was the main intestinal presentation in the typical group. Anemia was the most common extraintestinal symptom in both the typical and atypical group. Marsh-Oberhuber type 3b and 3c was significantly higher in the seropositive patients with a P value of 0.007. A significant correlation was observed between the histological grade of the biopsied duodenal mucosa and the clinical presentation (P < 0.001). Age was significantly higher in the atypical group (P value < 0.001).
CONCLUSION Although typical CD was observed in 120 patients in this study, the clinical variability of the condition was frequently observed. Age only was a significant predictor for the appearance of atypical CD. Therefore, CD presentations in LMIC are not different from industrialized countries.
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Affiliation(s)
- Hala H Mansour
- Department of Pediatrics, Faculty of Medicine Kasr Al Ainy, Cairo University, Cairo 12411, Egypt
| | - Nabil A Mohsen
- Department of Pediatrics, Faculty of Medicine Kasr Al Ainy, Cairo University, Cairo 12411, Egypt
| | - Mortada HF El-Shabrawi
- Department of Pediatrics, Faculty of Medicine Kasr Al Ainy, Cairo University, Cairo 12411, Egypt
| | - Somia M Awad
- Department of Pediatrics, Faculty of Medicine Kasr Al Ainy, Cairo University, Cairo 12411, Egypt
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Severity of Villous Atrophy at Diagnosis in Childhood Does Not Predict Long-term Outcomes in Celiac Disease. J Pediatr Gastroenterol Nutr 2020; 71:71-77. [PMID: 32097370 DOI: 10.1097/mpg.0000000000002675] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Current pediatric guidelines allow noninvasive diagnosis of celiac disease in selected children. We investigated in a large cohort study whether the severity of villous atrophy at diagnosis is associated with clinical characteristics or long-term health outcomes, thus having a prognostic significance. METHODS Comprehensive medical data on 906 children with celiac disease were analyzed. Long-term health outcomes of 503 adult patients diagnosed in childhood were moreover assessed with a specific study questionnaire and validated Gastrointestinal Symptom Rating Scale (GSRS) and Psychological General Well-Being (PGWB) questionnaires. Patients were classified into 3 groups according to the severity of villous atrophy at diagnosis, and all variables were compared. RESULTS Altogether 34% of the patients had partial, 40% subtotal, and 26% total villous atrophy. Children with milder lesions were diagnosed more recently (median year 2007 vs 2006 vs 2001, respectively, P < 0.001), more often by screening (30% vs 25% vs 17%, P < 0.001) and they suffered less often from anemia (16% vs 21% vs 32%, P < 0.001) and growth disturbances (22% vs 36% vs 54%, P < 0.001) and had lower transglutaminase-2 antibody levels (median 64 U/L vs 120 U/L vs 120 U/L, P < 0.001). There was no difference in other disease features.Altogether 212 adults diagnosed in childhood completed the questionnaires. Severity of villous atrophy at childhood diagnosis did not predict presence of complications or comorbidities, persistent symptoms, and self-perceived health, quality of life or adherence to a gluten-free diet in adulthood. CONCLUSION Presence of advanced villous atrophy at diagnosis is associated with more severe clinical characteristics but not with poorer long-term health and treatment outcomes.
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Fasano A, Leonard MM, Mitchell DM, Eng G. Case 1-2020: An 11-Year-Old Boy with Vomiting and Weight Loss. N Engl J Med 2020; 382:180-189. [PMID: 31914246 PMCID: PMC8176458 DOI: 10.1056/nejmcpc1913469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Alessio Fasano
- From the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Harvard Medical School - both in Boston
| | - Maureen M Leonard
- From the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Harvard Medical School - both in Boston
| | - Deborah M Mitchell
- From the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Harvard Medical School - both in Boston
| | - George Eng
- From the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Harvard Medical School - both in Boston
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