Hypercoagulability in celiac disease--an update

[Beyond hypercoagulability in celiac disease]

In celiac disease (CD) there is a state of hypercoagulability and multiple factors have been found that may be involved. Cases of association of CD and antiphospholipid síndrome (APS) have been described and several observational studies have found an increase in antiphospolipid antibodies (AAF) in patients with CD, so both entities may be interrelated, increasing the risk of thrombotic events. A descriptive case of a patient who is simultaneusly diagnosed with CD and APS is presented.

Combined Central Retinal Artery Occlusion (CRAO) and Central Retinal Vein Occlusion (CRVO) in a Celiac Disease Patient: A Case Report

Celiac disease (CD) is a digestive disorder caused by an abnormal immune reaction to gluten, leading to severe malabsorption syndrome. Central retinal vein occlusion (CRVO) was reported in a couple of cases worldwide in patients with this disease entity. Herein, we are reporting a rare case of combined central retinal vein and artery occlusion in a young female celiac disease patient presented with a counting finger vision at six feet and improved to 20/60 vision after conservative management.

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.

Celiac Disease and Cardiovascular Risk: A Retrospective Case-Control Study

Background: The association of celiac disease (CD) with premature atherosclerosis, including increased carotid artery intima-media thickness and cardiovascular disease (CVD), is controversial. The aim of this study was to investigate this relationship. Methods: Clinical records of patients from Northern Sardinia referred to the Gastroenterology section of the Department of Medicine, University of Sassari, Italy, were analyzed. Unadjusted and adjusted odds ratios (ORs) for CVD with their 95% confidence intervals (CIs) were calculated according to established risk factors, including age, sex, diabetes, dyslipidemia, overweight/obesity, blood hypertension, and cigarette smoking, as well as a possible risk factor such as H. pylori infection. Results: In a total of 8495 patients (mean age 52.1 ± 17.3 years; 64.7% females), 2504 reported a diagnosis of CVD and 632 of CD. Logistic regression analysis showed a significantly reduced risk of CVD among patients with CD (OR 0.30, 95% CI 0.22–0.41). Moreover, the long duration of the gluten-free diet (GFD) was able to lower the risk of CVD in celiac patients. Finally, CD significantly decreased the frequency of carotid plaques (11.8% vs. 40.1%, p < 0.001). Conclusions. Our retrospective study demonstrated that CD reduces the risk of CVD in general and more specifically of carotid lesions after adjusting for potential confounders, especially in those on GFD for a long time.

Body composition in pediatric celiac disease and metabolic syndrome component risk-an observational study

BACKGROUND

Celiac disease (CD) in children and adolescents has been linked with increased susceptibility for cardiometabolic disease in adulthood. We explored the interaction between body composition and metabolic syndrome (MetS) components in pediatric CD.

METHODS

We conducted a retrospective observational study of patients with CD followed at our Pediatric Endocrine and Gastroenterology Units between 1/2018-1/2022. Data on sociodemographic, clinical, laboratory, and body composition parameters (bioelectrical impedance analysis, BIA) were collected.

RESULTS

Forty-four patients with MetS components and 67 patients without them were enrolled. The cohort's mean age at BIA assessment was 11.5 ± 3.6 years. Individuals with MetS components were older (P = 0.045), had higher BMI z-scores (P < 0.001), higher total and truncal fat percentage levels (P < 0.001), lower muscle-to-fat ratio z-scores (P = 0.018), higher sarcopenic indices (P = 0.05), higher systolic blood pressure percentiles (P = 0.001), higher triglycerides levels (P = 0.009), and higher triglycerides/HDL-c ratios (P < 0.001) than those without MetS components. A sex- and age-adjusted model revealed that the diagnosis of MetS components was positively associated with fat percentage (odds ratio = 1.087, confidence interval [1.010-1.171], P = 0.027), but not with BMI z-scores (P = 0.138).

CONCLUSIONS

We found that fat percentage but not weight status is associated with risk for MetS components in individuals with childhood-onset CD. Preventive interventions should target an improvement in body composition.

IMPACT

The literature on cardiometabolic risk in pediatric patients with celiac disease (CD) is sparse. Our analysis revealed that at least one metabolic syndrome (MetS) component was present in two out of every five children and adolescents with CD. An increase in fat percentage but not in body mass index z-scores predicted the presence of MetS components in our cohort. These findings suggest that the weight status of children and adolescents with CD does not mirror their risk for MetS components. Body composition analysis should be considered as an integral part of the clinical evaluation in young patients with CD.

Gastrointestinal System: COVID-19 and Potential Mechanisms Associated with Coagulopathy

SARS-CoV-2 is a novel coronavirus that expanded worldwide, generating a pandemic of acute respiratory syndrome called "coronavirus disease 2019" (COVID-19), which resulted in a global health crisis. The spectrum of COVID-19 manifestations ranges from none or mild symptoms to severe respiratory failure associated with systemic manifestations, mostly gastrointestinal symptoms. Hypercoagulability is an important feature of COVID-19 disease, which can potentially influence patients' prognosis. Therefore, gastroenterologists should focus on subjects with concomitant hypercoagulable gastrointestinal disorders as they may display a higher risk of thrombotic complications during SARS-CoV-2 infection. The aim of this review is to summarize the available evidence regarding the interplay of the prothrombotic pathogenetic mechanisms of both COVID-19 and hypercoagulable digestive diseases and the possible clinical implications. We summarized the potential interplay of prothrombotic mechanisms of both COVID-19 and hypercoagulable digestive diseases in the graphical abstract.

An Uncommon Case of Celiac Disease and Deep Cerebral Venous Sinus Thrombosis

Celiac disease is an enteropathy characterized by malabsorption related with gluten intolerance and immune-mediated pathogenesis. It may manifest with gastrointestinal features like diarrhea, abdominal pain, weight loss, and anemia. Besides, it can manifest with various extraintestinal features like ataxia, neuropathy, stroke, or sometimes venous sinus thrombosis. Being of autoimmune origin, relation with systemic lupus erythematosus has also been reported. Herein, we present a rare case of a young patient with celiac disease who presented with fever, headache, and altered sensorium and was found to have meningitis with deep cerebral venous sinus thrombosis.

Celiac Disease and Thrombotic Events: Systematic Review of Published Cases

Extraintestinal manifestations of celiac disease (CD) should be considered, even in patients without typical intestinal symptoms. The aim of our study is to examine the literature regarding the occurrence of thrombotic events in CD, and to synthesize the data from case reports and case series. A systematic review of the literature was conducted by searching the Pub-Med/MEDLINE database, from the date of database inception to January 2022, to identify published cases and case series on this topic, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 55 cases were included in the study. The majority of patients were previously healthy individuals, with no comorbidities. In less than one-third of the cases (30.91%), the diagnosis of CD was established before the onset of thrombosis, while in the remaining cases (34.54%), thrombosis preceded the diagnosis or was diagnosed concomitantly with CD. The most common sites for thrombosis occurrence were hepatic veins (30.91%), while thrombosis of cerebral blood vessels, deep venous thrombosis of lower extremities, and pulmonary thromboembolism were less frequent. Thrombosis was most commonly isolated to one site only (78.18%). In 69.09% of cases (n = 38), some form of anticoagulation, along with a gluten-free diet, was initiated.

Outcomes of Acute Coronary Syndrome in Hospitalized Patients with Celiac Disease, a United States Nationwide Experience

Background: Cardiovascular disease remains the leading cause of death in the United States. Coronary artery disease alone accounted for approximately 13% of deaths in the US in 2016. Some studies have suggested an increased prevalence of coronary artery disease (CAD) in chronic inflammatory conditions, such as celiac disease (CD). Chronic subclinical systemic inflammation, decreased absorption of cardio-protective nutrients and drugs have all been postulated as the driving mechanisms for this increased risk of CAD. Methods: We reviewed a Nationwide Inpatient Sample from 2007 to 2017, using Acute Coronary syndrome as a principal diagnosis with CD as the secondary diagnosis, utilizing validated ICD-9-CM and ICD-10 codes. We examined the annual trends in the number of cases and hospitalization charges yearly and used survey regression to calculate adjusted odds ratios (aOR) for hospital mortality and other outcomes. Results: We identified a total of 8,036,307 ACS hospitalizations from 2007 to 2017, of which 5917 (0.07%) had a diagnosis for CD. The proportion of patients with CD in ACS hospitalizations increased from 0.015% in 2007 to 0.076% in 2017. These patients were significantly older (70.3 vs. 67.4 years, p < 0.02), more likely female (51.9% vs. 39.5%, p < 0.01), and more likely to be white (93.8% vs. 76.6%; p < 0.01) than ACS patients without CD. After adjusting for age, gender, race, Charlson Comorbidity index and hospital level characteristics, ACS hospitalizations for CD patients had a lower odds ratio for hospital mortality (aOR = 0.39; 95% CI = 0.23–0.67; p < 0.01). Additionally, length of stay in this patient population was shorter (4.53 vs. 4.84 days, p < 0.01) but the mean hospitalization charges were higher (USD 64,058 vs. USD 60,223, p < 0.01). Conclusion: We found that the number of ACS-related admissions in CD patients has risen more than five-fold between 2007 and 2017. However, the odds of in-hospital mortality in these patients is not higher than patients without CD. The results of our study demonstrate that although the systemic inflammation related to CD is associated with an increasing prevalence of ACS hospitalizations, on the contrary, the mortality rate is significantly higher in patients without celiac disease.

Alpha-enolase involvement in intestinal and extraintestinal manifestations of celiac disease

Celiac disease is a life-long intestinal autoimmune disease, characterized by the gluten intolerance and chronic enteric inflammation. Traditionally presented by intestinal manifestations, however, a shift toward extra intestinal presentation is taking place. One of the affected organs is the nervous systems presented by neuropsychiatric manifestations, hence the mechanism and pathways are not clear. The presence of neuronal and alpha-enolases and their corresponding antibodies were noticed in the mucosa and serum of celiac disease patients, as well as in other various autoimmune diseases with psycho-neurological manifestations. The aims of the present review are to screen the literature on different isoforms of enolase, mainly alpha enolase, and their specific antibodies and to suggest their potential pathophysiological mechanisms relaying the enolases to intestinal or extraintestinal celiac disease manifestations. The shared aspects between the enolases and celiac disease and the cross-talks between alpha-enolase and tissue transglutaminase suggest new potential pathophysiological mechanisms that might drive celiac disease evolvement.

Diet-Dependent and Diet-Independent Hemorheological Alterations in Celiac Disease: A Case-Control Study

Hemorheology is the study of the flow properties of the blood and its elements, which, together with natural anticoagulants, are important determinants of cardiovascular events. This study aimed to assess hemorheological and natural anticoagulant profiles of patients with celiac disease (CeD) comprehensively.

Cerebral venous thrombosis as a rare thromboembolic complication of celiac disease: a case report

BACKGROUND

Celiac disease is a digestive inflammatory syndrome with several complications. It is associated with coagulation and platelets abnormalities leading to thromboembolic events. Cerebral venous thrombosis is an exceptional localization of thrombosis in celiac disease and could be life-threatening.

CASE SUMMARY

A 17-year-old female patient with history of celiac disease and not following a gluten-free diet, checked in to the emergency department for a sudden, 2-week-old, and deteriorating, onset of intense headache and muscle weakness. The cerebral computed tomography-scan showed bilateral fronto-parietal hypodensity with micro-bleeds. We investigated using a cerebral magnetic resonance imaging that revealed superior longitudinal sinus thrombosis and right transverse and sigmoid sinuses thrombosis, along with right haematoma and ischaemic areas. The patient was prescribed anticoagulation therapy. Follow-ups over a 2-year period confirmed a favourable outcome and a complete regression of symptoms.

DISCUSSION

Evolution of celiac disease could be associated with several complications. Eighty-five percent of patients is potentially exposed to thromboembolic events due to the hypercoagulability state of the disease and different coagulation and fibrinolysis abnormalities (e.g. hyperhomocysteinaemia, protein C and S deficiencies, vitamin K and B deficiencies). Cerebral venous thrombosis is a rare thromboembolic localization. Anticoagulation is efficient in most cases though endovascular treatment might be required.

Thromboembolic complications and cardiovascular events associated with celiac disease

Celiac disease (CD) is a chronic intestinal immune-mediated disease occurring in genetically susceptible individuals who are exposed to gluten. Although it primarily affects the small intestine, CD has been associated with a wide spectrum of extraintestinal manifestations, including thromboembolism and cardiovascular events. The risk of ischemic stroke, myocardial infarction, and thromboembolism, such as deep vein thrombosis and pulmonary embolism, is higher in patients with CD, while there is accumulating evidence that gluten-free diet in CD patients decreases the risk of these complications. The pathogenetic mechanism of increasing hypercoagulability in CD is multifactorial and involves hyperhomocysteinemia due to malabsorption of vitamins B12, B6, and folic acid; endothelial dysfunction; acceleration of atherosclerosis; chronic inflammation; thrombocytosis; and thrombophilia. Therefore, in cases of thromboembolic complications and cardiovascular disease of obscure etiology, clinicians' awareness of possible celiac disease is warranted.

Ocular manifestations in celiac disease: an overview

PURPOSE

To review and highlight the ocular manifestations associated with celiac disease (CD) and presentation of their pathogenetic mechanisms.

METHODS

A thorough review of the literature was performed using PubMed to identify articles about serrated polyposis syndrome. The search was performed using the search string: ("celiac disease" OR "coeliac disease") AND ("ocular manifestations" OR "eye" OR "orbitopathy" OR "uveitis" OR "neuro-ophthalmic manifestations"). Only articles in English were reviewed.

RESULTS

Several ocular symptoms and disorders have been associated with CD and are a result of defective intestinal absorption and immunological mechanisms. These include nyctalopia, dry eye, cataract, thyroid-associated orbitopathy, uveitis, central retinal vein occlusion and neuro-ophthalmic manifestations. In addition, CD-related ocular disease may represent the first manifestation of CD.

CONCLUSION

CD may hold accountable for the development of ocular diseases of obscure etiology.

Prevalence of celiac disease in primary care: the need for its own code

BACKGROUND

Celiac disease (CD) is an autoimmune chronic enteropathy of the small intestine caused by exposure to gluten in genetically predisposed individuals. CD is not easy to diagnose due to its unspecific symptomatology, especially in adults, a diagnosed/undiagnosed ratio of 1:7 is estimated. CD does not have its own code in the International Classification of Primary Care (ICPC) but it is coded under code D99 "Disease digestive system, other", which hinders diagnosis, intervention and research. The aim of this study is to investigate the prevalence of CD in Aragón, Spain, using the information available from Primary Care, as well as to discuss the difficulties involved in determining prevalence of CD from data collected at this level of medical intervention.

METHODS

We designed an epidemiological cross-sectional study and analysed 26,964 electronic clinical records from the Aragonese Health Service under code ICPC D99 collected up to December 31st, 2016. The clinical records were classified by their editable field "descriptor" according to their probability of being related to CD. Analyses of gender, age, age at diagnosis, province and health sector were carried out.

RESULTS

We found 4534 clinical records under 293 different descriptors with a high probability of referring to CD. Prevalence in Aragón was estimated to be 0.35% ranging from 0.24 to 0.81% with important differences among health sectors.

CONCLUSIONS

The prevalence of 0.35% is a long way from the generally accepted 1% but within the usually considered ratio 1:7 of diagnosed:undiagnosed cases. Differences among sectors should be carefully analysed. Lacking its own ICPC code, diagnosis of CD in Primary Care Services is not included in a single category, but it is distributed under several descriptors, which makes it difficult to offer any firm diagnosis for treatment and hinders research. Finally, the high prevalence of CD justifies its own ICPC code and the need to withdraw CD from the generic D99 code "Disease digestive system other".

Hematologic Manifestations in Celiac Disease-A Practical Review

Celiac disease (CD) is a systemic autoimmune disease driven by gluten-ingestion in genetically predisposed individuals. Although it primarily affects the small bowel, CD can also involve other organs and manifest as an extraintestinal disease. Among the extraintestinal features of CD, hematologic ones are rather frequent and consist of anemia, thrombocytosis (thrombocytopenia also, but rare), thrombotic or hemorrhagic events, IgA deficiency, hyposplenism, and lymphoma. These hematologic alterations can be the sole manifestation of the disease and should prompt for CD testing in a suggestive clinical scenario. Recognition of these atypical, extraintestinal presentations, including hematologic ones, could represent a great opportunity to increase the diagnostic rate of CD, which is currently one of the most underdiagnosed chronic digestive disorders worldwide. In this review, we summarize recent evidence regarding the hematological manifestations of CD, with focus on practical recommendations for clinicians.

Hematologic Manifestations in Celiac Disease-A Practical Review

Celiac disease (CD) is a systemic autoimmune disease driven by gluten-ingestion in genetically predisposed individuals. Although it primarily affects the small bowel, CD can also involve other organs and manifest as an extraintestinal disease. Among the extraintestinal features of CD, hematologic ones are rather frequent and consist of anemia, thrombocytosis (thrombocytopenia also, but rare), thrombotic or hemorrhagic events, IgA deficiency, hyposplenism, and lymphoma. These hematologic alterations can be the sole manifestation of the disease and should prompt for CD testing in a suggestive clinical scenario. Recognition of these atypical, extraintestinal presentations, including hematologic ones, could represent a great opportunity to increase the diagnostic rate of CD, which is currently one of the most underdiagnosed chronic digestive disorders worldwide. In this review, we summarize recent evidence regarding the hematological manifestations of CD, with focus on practical recommendations for clinicians.

Haemorheological and haemostatic alterations in coeliac disease and inflammatory bowel disease in comparison with non-coeliac, non-IBD subjects (HERMES): a case-control study protocol

INTRODUCTION

Haemorheological and haemostatic changes predispose to the development of arterial and venous thrombotic events; however, limited information is available on the status of these changes in coeliac disease (CeD) and inflammatory bowel disease (IBD). In this study, we aim to describe the haemorheological and haemostatic profiles of CeD and IBD patients in a Hungarian cohort of patients to investigate whether any alterations contribute to elevated thrombotic risk.

METHODS AND ANALYSIS

This is a case-control study involving newly diagnosed and followed CeD and IBD patients with age-matched and sex-matched non-CeD, non-IBD subjects with an allocation ratio of 1:1:1.After informed consent is obtained, a detailed medical history will be collected, including venous and arterial thrombotic risk factors and medications. Symptoms in CeD patients will be assessed with the Gastrointestinal Symptoms Rating Scale, and disease activity in IBD patients will be determined by disease-specific scores. Dietary adherence will be assessed among CeD patients with a thorough interview together with a measurement of self-reported adherence, dietary knowledge and urine analysis (detection of gluten immunogenic peptides). In addition to routine laboratory parameters, haemorheological (ie, erythrocyte deformability and aggregation, viscosity of whole blood and plasma) and haemostatic parameters (eg, protein C, protein S and antithrombin) with immunological indicators (ie, coeliac-specific serology and antiphospholipid antibodies) will be measured from venous blood for every participant.Primary and secondary outcomes will be haemorheological and haemostatic parameters, respectively. Univariate and multivariate statistics will be used to compare CeD and IBD patients to control subjects. Subgroup analysis will be performed by disease type in IBD, (Crohn's disease and ulcerose colitis), dietary adherence in CeD, and disease activity in IBD and CeD.

ETHICS AND DISSEMINATION

The study was approved by the Regional and Local Research Ethics Committee, University of Pécs (Ref. No. 6917). Findings will be disseminated at research conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN49677481.

Elevated serum antiphospholipid antibodies in adults with celiac disease

BACKGROUND AND AIMS

An increased incidence of thrombosis is suggested in celiac disease. We explored serum levels of antiphospholipid antibodies in untreated and treated adult celiac disease patients.

METHODS

A cohort of 179 biopsy-proven celiac disease patients (89 untreated, 90 on long-term gluten-free diet) and 91 non-celiac controls underwent clinical examination, assessment of celiac serology and enzyme immunoassay testing for anticardiolipin IgG and IgM, prothrombin IgG, and phosphatidylserine-prothrombin IgG and IgM.

RESULTS

The level of antiphospholipid antibodies was higher in celiac disease patients compared with controls: anticardiolipin IgG 4.9 (0.7-33.8) vs 2.2 (0.4-9.6) U/ml, antiprothrombin IgG 2.9 (0.3-87.8) vs 2.1 (0.5-187.0) U/ml, antiphosphatidylserine-prothrombin IgG 6.9 (0.0-54.1) vs 2.3 (0.5-15.1) U/ml; p < 0.05 for all. Anticardiolipin IgG, antiprothrombin IgG and antiphosphatidylserine-prothrombin IgG were higher in treated compared with untreated patients. The phenotype of celiac disease at presentation (gastrointestinal symptoms, malabsorption or anemia, and extraintestinal symptoms or screen-detected disease) had no effect on the level of serum antiphospholipid antibodies.

CONCLUSION

The serum level of antiphospholipid antibodies is increased in adults with celiac disease. The higher level of antibodies in treated patients suggests that the increase is not gluten-dependent. The prothrombotic role of antiphospholipid antibodies in celiac disease warrants further studies.

Microbes and Viruses Are Bugging the Gut in Celiac Disease. Are They Friends or Foes?

The links between microorganisms/viruses and autoimmunity are complex and multidirectional. A huge number of studies demonstrated the triggering impact of microbes and viruses as the major environmental factors on the autoimmune and inflammatory diseases. However, growing evidences suggest that infectious agents can also play a protective role or even abrogate these processes. This protective crosstalk between microbes/viruses and us might represent a mutual beneficial equilibrium relationship between two cohabiting ecosystems. The protective pathways might involve post-translational modification of proteins, decreased intestinal permeability, Th1 to Th2 immune shift, induction of apoptosis, auto-aggressive cells relocation from the target organ, immunosuppressive extracellular vesicles and down regulation of auto-reactive cells by the microbial derived proteins. Our analysis demonstrates that the interaction of the microorganisms/viruses and celiac disease (CD) is always a set of multidirectional processes. A deeper inquiry into the CD interplay with Herpes viruses and Helicobacter pylori demonstrates that the role of these infections, suggested to be potential CD protectors, is not as controversial as for the other infectious agents. The outcome of these interactions might be due to a balance between these multidirectional processes.

Cardiovascular Risk Factors in Adolescents With Celiac Disease: A Cross-sectional Population-Based Study

BACKGROUND

Recent data have shown that adults with celiac disease (CD) may have a higher prevalence of risk factors for cardiovascular disease (CVD) compared with the general population. Thus, we aimed to investigate the association of CD with CVD risk factors at late adolescence in a cross-sectional population-based study.

METHODS

A total of 2,001,353 Jewish Israeli adolescents who underwent a general health examination at median age of 17.1 years from 1988 to 2015 were included. Covariate data included demographic measures, blood pressure (BP), resting heart rate, and risk factors associated with CVD.

RESULTS

Overall, 10,566 cases of CD were identified (0.53%). Multivariate analysis showed that mean diastolic BP was significantly lower in subjects with CD (men: 72.0±8.7 vs 70.4 ± 8.5, P < 0.0001; women: 70.0 ± 8.3 vs 69.0 ± 8.2, P < 0.0001), whereas systolic BP did not differ between groups. Resting heart rate was higher in CD cases (an absolute difference of 0.4 beats per minute, P < 0.0001). The proportions of overweight and obese subjects were significantly lower in CD cases. Noninsulin-dependent diabetes mellitus (relative risk [RR], 4.1; 95% confidence interval [CI] 2.8-5.7), hypercoagulability (RR, 2.6; 95% CI 1.5-4.5), and hyperlipidemia (RR, 1.9; 95% CI 1.2-3) were significantly more common in subjects with CD.

CONCLUSIONS

At the age of 17 years, the prevalence of risk factors for CVD is higher in subjects with CD compared with the general population. There is, however, neither increase in BP nor increase in overweight and obesity rates.

Fatal Streptococcus pneumoniae Sepsis in a Patient With Celiac Disease-Associated Hyposplenism

We present a 59-year-old male with poorly controlled celiac disease (CD) and fatal Streptococcus pneumoniae sepsis, describe the morphologic findings, and stress the need for monitoring splenic function and pneumococcal vaccination in these patients.

Risk of venous thromboembolism in neuromyelitis optica patients hospitalized for acute relapse

Background:

Neuromyelitis optica spectrum disorder (NMOSD) patients may be at increased risk of venous thromboembolism (VTE) not only due to ambulatory disability but also due to systemic autoimmune and inflammatory mechanisms altering the hemostatic balance.

Objective:

To compare the risk of VTE in NMOSD versus multiple sclerosis (MS) patients hospitalized for acute relapses.

Methods:

Hospital admissions for MS or NMOSD exacerbations were retrospectively identified. Demographics and medical history were recorded. The relationship between visit diagnosis and presence of VTE within 6 weeks of relapse onset was assessed by univariate logistic regression. A multivariate model evaluated the relationship between diagnosis, age, race, gender, body mass index (BMI), disease modifying therapy use, oral corticosteroid use, oral contraceptive use, smoking, length of stay (LOS), and ambulatory status on VTE risk.

Results:

A total of 30 NMOSD patients had 55 hospitalizations; 179 MS patients had 264 hospitalizations. Six NMOSD patients and one MS patient had VTE. NMOSD visits compared to MS visits had an odds ratio (OR) of VTE of 32.2 ( p = 0.002). NMOSD was more likely to be associated with VTE (OR = 17.4; p = 0.01) controlling for age, LOS, and ambulatory disability.

Conclusion:

NMOSD may be a risk factor for VTE. Larger prospective studies are required to confirm this risk and determine implications for prophylaxis.

Central Retinal Vein Occlusion Revealing Coeliac Disease

Introduction

Thrombosis has been widely reported in coeliac disease (CD) but central retinal vein occlusion (CRVO) is rarely described.

Case presentation

A 27-year-old woman presented with acute visual loss and was diagnosed with CRVO. Her protein S and protein C levels were low and CD was diagnosed on the basis of endoscopic, immunological and histological results. A gluten-free diet resulted in favourable evolution.

Conclusion

CD should be considered in young patients with thrombosis, especially if in an unusual location. Treatment is based on a gluten-free diet.

LEARNING POINTS

Assessment of Endothelial Dysfunction With Adhesion Molecules in Patients With Celiac Disease

OBJECTIVES

Celiac disease (CD) is a systemic immune disorder. We assessed serum levels of adhesion molecules as a marker of endothelial dysfunction in patients with CD at first diagnosis and in those on a gluten-free diet.

METHODS

Sixty-five patients with CD (mean age 6.74 ± 4.6 years) and 51 age- and sex-matched control patients participated in the present case-controlled, prospective clinical study. Serum levels of vascular adhesion molecule-1, intercellular adhesion molecule-1, endothelial selectin, vascular endothelial cadherin, high-sensitivity C-reactive protein, and homocysteine levels were measured.

RESULTS

Average soluble vascular adhesion molecule-1 (CD vs control group: 1320 ± 308 vs 1120 ± 406 ng/mL, P = 0.006), soluble intercellular adhesion molecule-1 (336 ± 99 vs 263 ± 67 ng/mL, P = 0.025), and soluble endothelial selectin (113.9 ± 70 vs 76.9 ± 32 ng/mL, P = 0.007) levels were significantly higher in cases of newly diagnosed CD than in the control group. Soluble vascular adhesion molecule-1 (1050 ± 190 ng/mL) and soluble endothelial selectin (68.7 ± 45 ng/mL) levels in patients with CD, who were fully compliant with a gluten-free diet, were significantly lower than that in those newly diagnosed as having CD (P = 0.003 and P = 0.0012, respectively).

CONCLUSIONS

These results show that serum adhesion molecule levels are higher in patients with CD. Some of the risks associated with endothelial dysfunction may be related to CD and these risks can be reduced with an appropriate and fully controlled diet.

Risk of venous thromboembolism in patients with celiac disease: A systematic review and meta-analysis

BACKGROUND AND AIM

Patients with celiac disease (CD) might be at an increased risk of developing venous thromboembolism (VTE) due to chronic inflammation and vitamin deficiency. However, epidemiologic studies attempting to investigate this risk have yielded inconsistent results. We conducted this meta-analysis with the aims to better characterize this possible association.

METHODS

We conducted a systematic review and meta-analysis of observational studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio comparing the risk of VTE in patients with CD versus participants without CD. Generic inverse variance method of DerSimonian and Laird was used to calculate the pooled risk ratio.

RESULTS

Out of 279 potentially relevant articles, four studies met the inclusion criteria and were included in the meta-analysis. We found a statistically significant increased risk of VTE among patients with CD with the pooled risk ratio of 1.25 (95% confidence interval, 1.02-1.53). The statistical heterogeneity was moderate with an I(2) of 69%.

CONCLUSIONS

A significantly increased risk of VTE among patients with CD was demonstrated in this meta-analysis. Further studies are required to clarify how this risk should be addressed in clinical practice.

Rheumatoid arthritis-celiac disease relationship: joints get that gut feeling

Rheumatoid arthritis (RA) and celiac disease (CD) belong to the autoimmune disease family. Despite being separate entities they share multiple aspects. Epidemiologically they share comparable incidence environmental influences, associated antibodies and a recent incidental surge. They differ in their HLA pre-dispositions and specific predictive and diagnostic biomarkers. At the clinical level, celiac disease exhibits extra-intestinal rheumatic manifestations and RA gastrointestinal ones. Small bowel pathology exists in rheumatic patients. A trend towards responsiveness to a gluten free diet has been observed, ameliorating celiac rheumatic manifestations, whereas dietary interventions for rheumatoid arthritis remain controversial. Pathophysiologically, both diseases are mediated by endogenous enzymes in the target organs. The infectious, dysbiotic and increased intestinal permeability theories, as drivers of the autoimmune cascade, apply to both diseases. Contrary to their specific HLA pre-disposition, the diseases share multiple non-HLA loci. Those genes are crucial for activation and regulation of adaptive and innate immunity. Recently, light was shed on the interaction between host genetics and microbiota composition in relation to CD and RA susceptibility, connecting bugs and us and autoimmunity. A better understanding of the above mentioned similarities in the gut-joint inter-relationship, may elucidate additional facets in the mosaic of autoimmunity, relating CD to RA.

Changes in intestinal tight junction permeability associated with industrial food additives explain the rising incidence of autoimmune disease

The incidence of autoimmune diseases is increasing along with the expansion of industrial food processing and food additive consumption. The intestinal epithelial barrier, with its intercellular tight junction, controls the equilibrium between tolerance and immunity to non-self-antigens. As a result, particular attention is being placed on the role of tight junction dysfunction in the pathogenesis of AD. Tight junction leakage is enhanced by many luminal components, commonly used industrial food additives being some of them. Glucose, salt, emulsifiers, organic solvents, gluten, microbial transglutaminase, and nanoparticles are extensively and increasingly used by the food industry, claim the manufacturers, to improve the qualities of food. However, all of the aforementioned additives increase intestinal permeability by breaching the integrity of tight junction paracellular transfer. In fact, tight junction dysfunction is common in multiple autoimmune diseases and the central part played by the tight junction in autoimmune diseases pathogenesis is extensively described. It is hypothesized that commonly used industrial food additives abrogate human epithelial barrier function, thus, increasing intestinal permeability through the opened tight junction, resulting in entry of foreign immunogenic antigens and activation of the autoimmune cascade. Future research on food additives exposure-intestinal permeability-autoimmunity interplay will enhance our knowledge of the common mechanisms associated with autoimmune progression.