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Patt YS, Lahat A, David P, Patt C, Eyade R, Sharif K. Unraveling the Immunopathological Landscape of Celiac Disease: A Comprehensive Review. Int J Mol Sci 2023; 24:15482. [PMID: 37895160 PMCID: PMC10607730 DOI: 10.3390/ijms242015482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 10/20/2023] [Accepted: 10/21/2023] [Indexed: 10/29/2023] Open
Abstract
Celiac disease (CD) presents a complex interplay of both innate and adaptive immune responses that drive a variety of pathological manifestations. Recent studies highlight the role of immune-mediated pathogenesis, pinpointing the involvement of antibodies against tissue transglutaminases (TG2, TG3, TG6), specific HLA molecules (DQ2/8), and the regulatory role of interleukin-15, among other cellular and molecular pathways. These aspects illuminate the systemic nature of CD, reflecting its wide-reaching impact that extends beyond gastrointestinal symptoms to affect other physiological systems and giving rise to a range of pathological landscapes, including refractory CD (RCD) and, in severe cases, enteropathy-associated T cell lymphoma. The existing primary therapeutic strategy, a gluten-free diet (GFD), poses significant challenges, such as low adherence rates, necessitating alternative treatments. Emerging therapies target various stages of the disease pathology, from preventing immunogenic gluten peptide absorption to enhancing intestinal epithelial integrity and modulating the immune response, heralding potential breakthroughs in CD management. As the understanding of CD deepens, novel therapeutic avenues are emerging, paving the way for more effective and sophisticated treatment strategies with the aim of enhancing the quality of life of CD patients. This review aims to delineate the immunopathology of CD and exploring its implications on other systems, its complications and the development of novel treatments.
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Affiliation(s)
- Yonatan Shneor Patt
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
| | - Adi Lahat
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Paula David
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
| | - Chen Patt
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- The Adelson School of Medicine, Ariel University, Ariel 40700, Israel
| | - Rowand Eyade
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
| | - Kassem Sharif
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan 52621, Israel
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Valvano M, Fabiani S, Monaco S, Calabrò M, Mancusi A, Frassino S, Rolandi C, Mosca M, Faenza S, Sgamma E, Cesaro N, Latella G. Old and New Adjunctive Therapies in Celiac Disease and Refractory Celiac Disease: A Review. Int J Mol Sci 2023; 24:12800. [PMID: 37628981 PMCID: PMC10454405 DOI: 10.3390/ijms241612800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/13/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
Celiac disease (CD) is a chronic enteropathy caused by the ingestion of gluten in a genetically susceptible individual. Currently, a gluten-free diet (GFD) is the only recommended treatment. However, unintentional gluten ingestion or a persistent villous atrophy with malabsorption (regardless of a strict GFD) as in the case of Refractory Celiac Disease (RCD) represents a major issue. In this review, we have analysed and discussed data from both randomized controlled trials and observational studies concerning adjunctive therapies as well as novel therapies for the treatment of CD and RCD. The literature search was carried out through Medline and Scopus. In total, 2268 articles have been identified and 49 were included in this review (36 studies resulting from the search strategy and 13 from other sources). Today, GFD remains the only effective treatment, although steroids, mesalamine, and more recently biological therapies have found space in the complex management of RCD. Currently, studies evaluating the effectiveness of novel therapies are still limited and preliminary results have been controversial.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Giovanni Latella
- Gastroenterology Unit, Division of Gastroenterology, Hepatology and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (M.V.); (S.F.); (S.M.); (M.C.); (A.M.); (S.F.); (C.R.); (M.M.); (S.F.); (E.S.); (N.C.)
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Elli L, Soru P, Roncoroni L, Rossi FG, Ferla V, Baldini L, Nandi N, Scaramella L, Scricciolo A, Rimondi A, Fusco N, Croci GA, Gianelli U, Cro L, Barbieri M, Lombardo V, Costantino A, Vaira V, Ferrero S, Tontini GE, Barigelletti G, Fabiano S, Doneda L, Vecchi M. Clinical features of type 1 and 2 refractory celiac disease: Results from a large cohort over a decade. Dig Liver Dis 2023; 55:235-242. [PMID: 36096991 DOI: 10.1016/j.dld.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Refractory celiac disease (RCeD) is a rare complication of celiac disease (CeD) with a severe prognosis. We describe a cohort of patients with RCeD, their clinical and histological features at diagnosis, after therapy and at lymphoma onset, and the rate and causes of death over a 17-year follow-up. METHODS We retrospectively enrolled RCeD-I and RCeD-II patients attending our center between January 2002 and October 2019. Medical data were collected at diagnosis and during monitoring. Response to therapy, changes in RCeD molecular markers, number of hospitalizations, discharge diagnosis, and cause and date of death were evaluated. The control cohort consisted of 1015 responsive CeD patients. RESULTS Compared with RCeD-I, RCeD-II more frequently exhibits diarrhea (83 vs 64%), anemia (61 vs 50%), hypoalbuminemia (70 vs 21%), parenteral nutrition need (48 vs 7%), ulcerative jejuno-ileitis (7 vs 39%), and extended small intestinal atrophy (62 vs 21%). One RCeD-I and six RCeD-II patients developed lymphoma. Ten RCeD-II patients died, four from lymphoma progression. Among RCeD-II patients, atrophy extension was the only parameter correlated with hypoalbuminemia and mortality. CONCLUSIONS Clinical severity, response to therapy, and mortality differ between RCeD-I and RCeD-II. Atrophy extension, evaluated at capsule endoscopy, was associated with disease severity and mortality.
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Affiliation(s)
- Luca Elli
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20122, Italy; Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy.
| | - Pietro Soru
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20122, Italy; Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Leda Roncoroni
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan 20133, Italy
| | - Francesca Gaia Rossi
- Division of Hematology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Valeria Ferla
- Division of Hematology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Luca Baldini
- Division of Hematology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan 20122, Italy
| | - Nicoletta Nandi
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20122, Italy; Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Lucia Scaramella
- Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Alice Scricciolo
- Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Alessandro Rimondi
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20122, Italy; Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Nicola Fusco
- Biobank for Translational Medicine Unit (B4MED), Division of Pathology, IEO European Institute of Oncology, University of Milan, Via Ripamonti 435, 20132 Milan, Italy
| | - Giorgio Alberto Croci
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20122, Italy; Division of Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Umberto Gianelli
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20122, Italy; Division of Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Lilla Cro
- Servizio di Citofluorimetria, Laboratorio Centrale, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marzia Barbieri
- Servizio di Citofluorimetria, Laboratorio Centrale, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Vincenza Lombardo
- Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Andrea Costantino
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20122, Italy; Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Valentina Vaira
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20122, Italy; Division of Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Stefano Ferrero
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan 20133, Italy; Division of Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Gian Eugenio Tontini
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20122, Italy; Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
| | - Giulio Barigelletti
- Cancer Registry Unit, Fondazione IRCCS Istituto Nazionale dei Tumori Milano, Milan Italy
| | - Sabrina Fabiano
- Cancer Registry Unit, Fondazione IRCCS Istituto Nazionale dei Tumori Milano, Milan Italy
| | - Luisa Doneda
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan 20133, Italy
| | - Maurizio Vecchi
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20122, Italy; Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
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Branchi F, Wiese JJ, Heldt C, Manna S, Dony V, Loddenkemper C, Bojarski C, Siegmund B, Schneider T, Daum S, Hummel M, Moos V, Schumann M. The combination of clinical parameters and immunophenotyping of intraepithelial lymphocytes allows to assess disease severity in refractory celiac disease. Dig Liver Dis 2022; 54:1649-1656. [PMID: 35850920 DOI: 10.1016/j.dld.2022.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 06/03/2022] [Accepted: 06/21/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Flow cytometry of intestinal lymphocytes is discussed to be a stronger predictor of enteropathy-associated T-cell lymphoma development in refractory celiac disease than T-cell clonality analysis. AIMS To investigate possible associations between clinical characteristics of refractory celiac disease patients and aberrant intraepithelial lymphocytes and to evaluate the accuracy of immunophenotyping for the identification of high-risk refractory celiac disease. METHODS Flow cytometry of isolated lymphocytes from duodenal biopsies of controls and celiac disease patients was performed and results were compared to clinical data. RESULTS Flow cytometry analysis was performed on 42 controls, 37 non-complicated celiac disease and 30 refractory celiac disease cases with or without T-cell receptor clonality. Elevated aberrant intraepithelial lymphocyte counts were significantly associated with severe malabsorption. A 15% cut-off (aberrant lymphocytes among all lymphocytes) had the best discriminatory ability to identify high-risk patients. However, this technique failed to identify some high-risk cases (sensitivity 63%, specificity 100%). The severity of malabsorption was added to the criteria for high-risk refractory celiac disease, improving the correct patients' allocation (sensitivity 100%, specificity 96%). CONCLUSION Immunophenotyping of aberrant intraepithelial lymphocytes is a good predictor for high-risk refractory celiac disease. Furthermore, adding the evaluation of malabsorption to the diagnostic assessment of refractory celiac disease optimizes accuracy.
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Affiliation(s)
- Federica Branchi
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany; Center for the Diagnosis and Prevention of Celiac Disease - Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122 Milan, Italy
| | - Jakob Johann Wiese
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Claudia Heldt
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Subhakankha Manna
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Violaine Dony
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Christoph Loddenkemper
- PathoTres Gemeinschaftspraxis für Pathologie und Neuropathologie, Teltowkanalstrasse 2, 12247 Berlin, Germany
| | - Christian Bojarski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Britta Siegmund
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Thomas Schneider
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Severin Daum
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Michael Hummel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institut für Pathologie, Molekularpathologie, Charitéplatz 1, 10117 Berlin, Germany
| | - Verena Moos
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Michael Schumann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany.
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Green PHR, Paski S, Ko CW, Rubio-Tapia A. AGA Clinical Practice Update on Management of Refractory Celiac Disease: Expert Review. Gastroenterology 2022; 163:1461-1469. [PMID: 36137844 DOI: 10.1053/j.gastro.2022.07.086] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/21/2022] [Accepted: 07/23/2022] [Indexed: 12/02/2022]
Abstract
DESCRIPTION The purpose of this expert review is to summarize the diagnosis and management of refractory celiac disease. It will review evaluation of patients with celiac disease who have persistent or recurrent symptoms, differential diagnosis, nutritional support, potential therapeutic options, and surveillance for complications of this condition. METHODS This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Since systematic reviews were not performed, these BPA statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: In patients believed to have celiac disease who have persistent or recurrent symptoms or signs, the initial diagnosis of celiac disease should be confirmed by review of prior diagnostic testing, including serologies, endoscopies, and histologic findings. BEST PRACTICE ADVICE 2: In patients with confirmed celiac disease with persistent or recurrent symptoms or signs (nonresponsive celiac disease), ongoing gluten ingestion should be excluded as a cause of these symptoms with serologic testing, dietitian review, and detection of immunogenic peptides in stool or urine. Esophagogastroduodenoscopy with small bowel biopsies should be performed to look for villous atrophy. If villous atrophy persists or the initial diagnosis of celiac disease was not confirmed, consider other causes of villous atrophy, including common variable immunodeficiency, autoimmune enteropathy, tropical sprue, and medication-induced enteropathy. BEST PRACTICE ADVICE 3: For patients with nonresponsive celiac disease, after exclusion of gluten ingestion, perform a systematic evaluation for other potential causes of symptoms, including functional bowel disorders, microscopic colitis, pancreatic insufficiency, inflammatory bowel disease, lactose or fructose intolerance, and small intestinal bacterial overgrowth. BEST PRACTICE ADVICE 4: Use flow cytometry, immunohistochemistry, and T-cell receptor rearrangement studies to distinguish between subtypes of refractory celiac disease and to exclude enteropathy-associated T-cell lymphoma. Type 1 refractory celiac disease is characterized by a normal intraepithelial lymphocyte population and type 2 is defined by the presence of an aberrant, clonal intraepithelial lymphocyte population. Consultation with an expert hematopathologist is necessary to interpret these studies. BEST PRACTICE ADVICE 5: Perform small bowel imaging with capsule endoscopy and computed tomography or magnetic resonance enterography to exclude enteropathy-associated T-cell lymphoma and ulcerative jejunoileitis at initial diagnosis of type 2 refractory celiac disease. BEST PRACTICE ADVICE 6: Complete a detailed nutritional assessment with investigation of micronutrient and macronutrient deficiencies in patients diagnosed with refractory celiac disease. Check albumin as an independent prognostic factor. BEST PRACTICE ADVICE 7: Correct deficiencies in macro- and micronutrients using oral supplements and/or enteral support. Consider parenteral nutrition for patients with severe malnutrition due to malabsorption. BEST PRACTICE ADVICE 8: Corticosteroids, most commonly open-capsule budesonide or, if unavailable, prednisone, are the medication of choice and should be used as first-line therapy in either type 1 or type 2 refractory celiac disease. BEST PRACTICE ADVICE 9: Patients with refractory celiac disease require regular follow-up by a multidisciplinary team, including gastroenterologists and dietitians, to assess clinical and histologic response to therapy. Identify local experts with expertise in celiac disease to assist with management. BEST PRACTICE ADVICE 10: Patients with refractory celiac disease without response to steroids may benefit from referral to a center with expertise for management or evaluation for inclusion in clinical trials.
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Affiliation(s)
| | - Shirley Paski
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Cynthia W Ko
- Department of Medicine, University of Washington, Seattle, Washington.
| | - Alberto Rubio-Tapia
- Celiac Disease Program, Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Felber J, Bläker H, Fischbach W, Koletzko S, Laaß M, Lachmann N, Lorenz P, Lynen P, Reese I, Scherf K, Schuppan D, Schumann M, Aust D, Baas S, Beisel S, de Laffolie J, Duba E, Holtmeier W, Lange L, Loddenkemper C, Moog G, Rath T, Roeb E, Rubin D, Stein J, Török H, Zopf Y. Aktualisierte S2k-Leitlinie Zöliakie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:790-856. [PMID: 35545109 DOI: 10.1055/a-1741-5946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Jörg Felber
- Medizinische Klinik II - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Hendrik Bläker
- Institut für Pathologie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | | | - Sibylle Koletzko
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU-Klinikum München, München, Deutschland.,Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, 10-719 Olsztyn, Polen
| | - Martin Laaß
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | - Nils Lachmann
- Institut für Transfusionsmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Pia Lorenz
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Petra Lynen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Imke Reese
- Ernährungsberatung und -therapie Allergologie, München, Deutschland
| | - Katharina Scherf
- Institute of Applied Biosciences Department of Bioactive and Functional Food Chemistry, Karlsruhe Institute of Technology (KIT), Karlsruhe, Deutschland
| | - Detlef Schuppan
- Institut für Translationale Immunologie, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland.,Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Michael Schumann
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
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7
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Ferretti F, Branchi F, Orlando S, Roncoroni L, Barigelletti G, Fabiano S, Vecchi M, Penagini R, Doneda L, Elli L. Effectiveness of Capsule Endoscopy and Double-Balloon Enteroscopy in Suspected Complicated Celiac Disease. Clin Gastroenterol Hepatol 2022; 20:941-949.e3. [PMID: 33189853 DOI: 10.1016/j.cgh.2020.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/31/2020] [Accepted: 11/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Complicated celiac disease (CCD) is a rare but severe condition with a poor prognosis. Guidelines recommend use of capsule endoscopy (CE) to explore the small bowel (SB), followed by a double-balloon enteroscopy (DBE) in selected cases with suspected CCD. Our study aimed to evaluate the diagnostic yield (DY) of CE and DBE in identifying and monitoring CCD. METHODS Consecutive suspected CCD patients were enrolled prospectively to undergo CE and/or DBE in the presence of: persistent symptoms despite a correct gluten-free diet (GFD), increased anti-transglutaminase antibodies titer, lack of adherence to the GFD, and CCD monitoring. The DY of CE and DBE were calculated. The incidence of neoplastic complications and mortality were assessed. RESULTS In total, 130 patients (97 women; age, 49 ± 16 y) underwent 151 CEs and 23 DBEs. The DY of CE was 46%. Patients older than age 50 years (at CE examination or at CD diagnosis) with a CD duration shorter than 5 years were at higher risk of positive CE (relative risk, 1.6 and 1.7 in case of enrollement or CD diagnosis after 50 years of age, and 1.5 in case of short CD duration; P < .05) than their counterparts. Up to 40% of SB lesions were unreachable by upper endoscopy. At the end of the diagnostic work-up, 25 patients with premalignant/malignant lesions were identified: 12 type 1 refractory CD (RCD-1), 7 type 2 RCD (RCD-2), and 6 enteropathy-associated T-cell lymphoma (EATL). Six patients died: 2 patients with RCD-2 and 4 patients with EATL. CONCLUSIONS In case of suspected CCD, CE should be the first-line approach to detect complications and to identify patients deserving DBE. Older and symptomatic patients with suspected CCD deserve a careful evaluation of the SB, especially during the first years after diagnosis.
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Affiliation(s)
- Francesca Ferretti
- Center for the Prevention and Diagnosis of Celiac Disease, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Federica Branchi
- Center for the Prevention and Diagnosis of Celiac Disease, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Stefania Orlando
- Center for the Prevention and Diagnosis of Celiac Disease, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Leda Roncoroni
- Center for the Prevention and Diagnosis of Celiac Disease, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, Milan, Italy
| | - Giulio Barigelletti
- Cancer Registry Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori Milano, Milan Italy
| | - Sabrina Fabiano
- Cancer Registry Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori Milano, Milan Italy
| | - Maurizio Vecchi
- Center for the Prevention and Diagnosis of Celiac Disease, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Luisa Doneda
- Department of Biomedical, Surgical and Dental Sciences, Milan, Italy
| | - Luca Elli
- Center for the Prevention and Diagnosis of Celiac Disease, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
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8
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van Wanrooij RLJ, Bontkes HJ, Neefjes-Borst EA, Mulder CJ, Bouma G. Immune-mediated enteropathies: From bench to bedside. J Autoimmun 2021; 118:102609. [PMID: 33607573 DOI: 10.1016/j.jaut.2021.102609] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 12/13/2022]
Abstract
Immune-mediated enteropathies are caused by excessive reactions of the intestinal immune system towards non-pathogenic molecules. Enteropathy leads to malabsorption-related symptoms and include (severe) chronic diarrhea, weight loss and vitamin deficiencies. Parenteral feeding and immunosuppressive therapy are needed in severe cases. Celiac disease has long been recognized as the most common immune-mediated enteropathy in adults, but the spectrum of immune-mediated enteropathies has been expanding. Histological and clinical features are sometimes shared among these enteropathies, and therefore it may be challenging to differentiate between them. Here, we provide an overview of immune-mediated enteropathies focused on clinical presentation, establishing diagnosis, immunopathogenesis, and treatment options.
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Affiliation(s)
- Roy L J van Wanrooij
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam, the Netherlands.
| | - Hetty J Bontkes
- Amsterdam UMC, Laboratory Medical Immunology, Department of Clinical Chemistry, AI & I Institute, AGEM Research Institute, Amsterdam, the Netherlands
| | | | - Chris J Mulder
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam, the Netherlands
| | - Gerd Bouma
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam, the Netherlands
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9
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Cellular and molecular bases of refractory celiac disease. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2021; 358:207-240. [PMID: 33707055 DOI: 10.1016/bs.ircmb.2020.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Refractory celiac disease (RCD) encompasses biologically heterogeneous disorders that develop in a small proportion (0.3%) of individuals with celiac disease that are associated with high morbidity. Two broad categories are currently recognized, type I (RCD I) and type II (RCD II), based on immunophenotypic and molecular features of the intraepithelial lymphocytes (IELs). RCD I is characterized by a polyclonal expansion of IELs displaying a normal immunophenotype, while RCD II represents a clonal proliferation of immunophenotypically "aberrant" IELs, and is considered a low-grade lymphoproliferative disorder. The pathogenesis of RCD I has not been clarified, but limited studies suggest multifactorial etiology. On the other hand, recent immunologic, molecular and immunophenotypic analyses have proposed lineage-negative innate IELs to be the cell of origin of a proportion of RCD II cases. Furthermore, sequencing studies have identified frequent, recurrent, activating mutations in members of the JAK-STAT pathway in RCD II. This finding, in conjunction with prior in vitro experimental observations, suggests roles of deregulated cytokine signaling in disease pathogenesis. In this review, we describe current understanding of environmental, immune and genetic factors associated with the development of RCD and briefly discuss diagnostic and therapeutic considerations.
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10
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Immunophenotypic Spectrum and Genomic Landscape of Refractory Celiac Disease Type II. Am J Surg Pathol 2021; 45:905-916. [PMID: 33544565 DOI: 10.1097/pas.0000000000001658] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Refractory celiac disease type II (RCD II), also referred to as "cryptic" enteropathy-associated T-cell lymphoma (EATL) or "intraepithelial T-cell lymphoma," is a rare clonal lymphoproliferative disorder that arises from innate intraepithelial lymphocytes. RCD II has a poor prognosis and frequently evolves to EATL. The pathogenesis of RCD II is not well understood and data regarding the immunophenotypic spectrum of this disease and underlying genetic alterations are limited. To gain further biological insights, we performed comprehensive immunophenotypic, targeted next-generation sequencing, and chromosome microarray analyses of 11 RCD II cases: CD4-/CD8- (n=6), CD8+ (n=4), and CD4+ (n=1), and 2 of 3 ensuing EATLs. Genetic alterations were identified in 9/11 (82%) of the RCD II cases. All 9 displayed mutations in members of the JAK-STAT signaling pathway, including frequent, recurrent STAT3 (7/9, 78%) and JAK1 (4/9, 44%) mutations, and 9/10 evaluable cases expressed phospho-STAT3. The mutated cases also harbored recurrent alterations in epigenetic regulators (TET2, n=5 and KMT2D, n=5), nuclear factor-κB (TNFAIP3, n=4), DNA damage repair (POT1, n=3), and immune evasion (CD58, n=2) pathway genes. The CD4-/CD8- and other immunophenotypic subtypes of RCD II exhibited similar molecular features. Longitudinal genetic analyses of 4 RCD II cases revealed stable mutation profiles, however, additional mutations were detected in the EATLs, which occurred at extraintestinal sites and were clonally related to antecedent RCD II. Chromosome microarray analysis demonstrated copy number changes in 3/6 RCD II cases, and 1 transformed EATL with sufficient neoplastic burden for informative analysis. Our findings provide novel information about the immunophenotypic and genomic characteristics of RCD II, elucidate early genetic events in EATL pathogenesis, and reveal potential therapeutic targets.
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11
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Tan IL, Withoff S, Kolkman JJ, Wijmenga C, Weersma RK, Visschedijk MC. Non-classical clinical presentation at diagnosis by male celiac disease patients of older age. Eur J Intern Med 2021; 83:28-33. [PMID: 33218785 DOI: 10.1016/j.ejim.2020.09.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/21/2020] [Accepted: 09/21/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND . In a biopsy-proven adult celiac disease (CeD) cohort from the Netherlands, male patients were diagnosed with CeD at significantly older ages than female patients. OBJECTIVES To identify which factors contribute to diagnosis later in life and whether diagnostic delay influences improvement of symptoms after starting a gluten-free diet (GFD). METHODS . We performed a questionnaire study in 211 CeD patients (67:144, male:female) with median age at diagnosis of 41.8 years (interquartile range: 25-58) and at least Marsh 2 histology. RESULTS . Classical symptoms (diarrhea, fatigue, abdominal pain and/or weight loss) were more frequent in women than men, but sex was not significantly associated with age at diagnosis. In a multivariate analysis, a non-classical presentation (without any classical symptoms) and a negative family history of CeD were significant predictors of older age at diagnosis (coefficients of 8 and 12 years, respectively). A delay of >3 years between first symptom and diagnosis was associated with slower improvement of symptoms after start of GFD, but not with sex, presentation of classical symptoms or age at diagnosis. CONCLUSION . Non-classical CeD presentation is more prevalent in men and is associated with a diagnosis of CeD later in life. Recognizing CeD sooner after onset of symptoms is important because a long diagnostic delay is associated with a slower improvement of symptoms after starting a GFD.
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Affiliation(s)
- Ineke L Tan
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, 9700 RB Groningen, Groningen, the Netherlands; Department of Genetics, University of Groningen and University Medical Center Groningen, 9700 RB Groningen, Groningen, the Netherlands
| | - Sebo Withoff
- Department of Genetics, University of Groningen and University Medical Center Groningen, 9700 RB Groningen, Groningen, the Netherlands
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, 9700 RB Groningen, Groningen, the Netherlands; Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, 7500 KA Enschede, the Netherlands
| | - Cisca Wijmenga
- Department of Genetics, University of Groningen and University Medical Center Groningen, 9700 RB Groningen, Groningen, the Netherlands
| | - Rinse K Weersma
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, 9700 RB Groningen, Groningen, the Netherlands; Department of Genetics, University of Groningen and University Medical Center Groningen, 9700 RB Groningen, Groningen, the Netherlands
| | - Marijn C Visschedijk
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, 9700 RB Groningen, Groningen, the Netherlands; Department of Genetics, University of Groningen and University Medical Center Groningen, 9700 RB Groningen, Groningen, the Netherlands.
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12
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Abadie V. [A new mouse model of coeliac disease with villous atrophy]. Med Sci (Paris) 2020; 36:969-972. [PMID: 33151855 DOI: 10.1051/medsci/2020184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Valérie Abadie
- Département de médecine, Service de gastro-entérologie, hépatologie et nutrition, Université de Chicago, KCBD 900E. 57th street MB9 60637 Chicago, États-Unis
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13
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Soderquist CR, Hsiao S, Mansukhani MM, Alobeid B, Green PH, Bhagat G. Refractory celiac disease type II: An atypical case highlighting limitations of the current classification system. Hematol Oncol 2020; 38:399-405. [PMID: 32010998 DOI: 10.1002/hon.2720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/17/2020] [Accepted: 01/24/2020] [Indexed: 12/16/2022]
Abstract
Refractory celiac disease (RCD) is a rare condition associated with high morbidity that develops in individuals with celiac disease. It is known to be biologically heterogeneous, and currently two types are recognized based on immunophenotypic and molecular features, type I (RCD I) and type II (RCD II). Differentiating between RCD I and RCD II is critical, as patients with RCD II have substantially worse outcomes and a high risk of developing enteropathy-associated T-cell lymphoma. However, the current RCD classification is limited in scope, and atypical presentations and immunophenotypes are not recognized at present. Herein, we describe a unique case of RCD II with atypical clinical (primarily neurologic manifestations and lack of significant gastrointestinal symptoms), histopathologic (no villous atrophy), immunophenotypic (virtual absence of cytoplasmic CD3 expression), and molecular features (absence of clonal TR rearrangement and identification of pathogenic STAT3 and KMT2D mutations). This case highlights limitations of the current RCD classification system and the utility of next generation sequencing (NGS) studies in the diagnostic workup of RCD. Future algorithms need to recognize extraintestinal manifestations and incorporate atypical histopathologic and immunophenotypic features, as well as results of NGS analysis for RCD II classification.
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Affiliation(s)
- Craig R Soderquist
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Susan Hsiao
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Mahesh M Mansukhani
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Bachir Alobeid
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Peter H Green
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, New York, USA
| | - Govind Bhagat
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
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14
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Uhde M, Yu X, Bunin A, Brauner C, Lewis SK, Lebwohl B, Krishnareddy S, Alaedini A, Reizis B, Ghosh S, Green PH, Bhagat G. Phenotypic shift of small intestinal intra-epithelial type 1 innate lymphoid cells in celiac disease is associated with enhanced cytotoxic potential. Clin Exp Immunol 2020; 200:163-175. [PMID: 31907928 DOI: 10.1111/cei.13414] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2019] [Indexed: 12/17/2022] Open
Abstract
The small intestinal (SI) epithelium harbors a heterogeneous population of lymphocytes that mediate mucosal damage and repair in celiac disease (CD). The composition and roles of human proximal SI intra-epithelial innate lymphoid cells (ILCs), and their alterations in CD, are not well understood. We report that duodenal intra-epithelial ILCs predominantly consist of natural killer (NK)p44+ CD127- cytotoxic ILC1s and NKp44- CD127+ helper ILC1s, while ILC3s only represent a minor population. In patients with newly diagnosed or active CD (ACD) and refractory CD type 1 (RCD I), the frequency of SI NKp44+ ILCs is decreased, with restoration of NKp44+ ILC frequency observed in patients adhering to a gluten-free diet who show evidence of mucosal healing. Moreover, the frequency of SI NKp44- ILCs is increased in ACD and RCD I patients and correlates with the severity of villous atrophy and epithelial damage, as assessed by serum levels of fatty acid binding protein 2 (FABP2). We show that the ILC alterations in CD represent a phenotypic shift of cytotoxic ILC1s rather than an increase in helper ILC1s or transdifferentiation of ILC1s to ILC3s, and activation-induced loss of NKp44 by cytotoxic ILC1s is associated with increased interferon (IFN)-γ expression and release of lytic granules. These findings suggest that intra-epithelial NKp44- CD127- cytotoxic ILC1s may contribute to mucosal damage in CD.
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Affiliation(s)
- M Uhde
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA
| | - X Yu
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA
| | - A Bunin
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA
| | - C Brauner
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA
| | - S K Lewis
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA
| | - B Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA
| | - S Krishnareddy
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA
| | - A Alaedini
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA.,Institute of Human Nutrition, Columbia University Irving Medical Center, New York, NY, USA
| | - B Reizis
- Department of Pathology, Department of Medicine, New York University Langone Medical Center, New York, NY, USA
| | - S Ghosh
- Department of Microbiology and Immunology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - P H Green
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA
| | - G Bhagat
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA.,Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
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15
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Janeczko-Czarnecka M, Kałwak K, Ussowicz M. Familial Celiac Disease Remission as a Result of a Full Donor Immunologic Recovery After Sibling Cord Blood Transplantation for Chronic Granulomatous Disease: A Case Report. Transplant Proc 2019; 51:3155-3158. [PMID: 31611125 DOI: 10.1016/j.transproceed.2019.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 05/25/2019] [Accepted: 06/24/2019] [Indexed: 10/25/2022]
Abstract
We present a case report of a boy diagnosed with both chronic granulomatous disease (CGD) and familial celiac disease (CD) who underwent cord blood transplantation from a partially matched sibling donor. The presentation of CD resembled Crohn-like enteropathy, which is a canonical manifestation of CGD. Nearly 1 year post-hematopoietic stem cell transplantation (HSCT), a gluten-containing diet was reintroduced, and no reappearance of clinical, serologic, or histologic markers of CD was observed. The relatively high incidence of rare genetic diseases in pediatric patients suggests the need for additional caution in the interpretation of symptoms mimicking already known hallmarks of more common conditions. In addition, the presented data confirm the previous rare observations that allogeneic HSCT leads to durable induction of gluten tolerance in patients with CD, which can warrant its use in patients with refractory subtypes of CD.
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Affiliation(s)
| | - Krzysztof Kałwak
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplantation, Wroclaw Medical University, Poland
| | - Marek Ussowicz
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplantation, Wroclaw Medical University, Poland
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16
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Malamut G, Cording S, Cerf-Bensussan N. Recent advances in celiac disease and refractory celiac disease. F1000Res 2019; 8:F1000 Faculty Rev-969. [PMID: 31297187 PMCID: PMC6600866 DOI: 10.12688/f1000research.18701.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 12/21/2022] Open
Abstract
Celiac disease (CeD), defined as gluten-induced enteropathy, is a frequent and largely underdiagnosed disease. Diagnosis relies on the detection of highly specific serum IgA anti-transglutaminase auto-antibodies and on the demonstration of duodenal villous atrophy. Treatment necessitates a strict gluten-free diet, which resolves symptoms and enables histological recovery. However, regular follow-up is necessary to assess mucosal healing, which emerges as an important prognostic factor. Recent work on CeD pathogenesis has highlighted how the cross-talk between gluten-specific CD4 + T cells and interleukin-15 can activate cytotoxic intraepithelial lymphocytes and trigger epithelial lesions. Moreover, acquisition by a subset of intraepithelial lymphocytes of somatic gain-of-function mutations in the JAK-STAT pathway was shown to be a decisive step in the progression toward lymphomas complicating CeD, thus opening new therapeutic perspectives for these rare but life-threatening complications.
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Affiliation(s)
- Georgia Malamut
- Gastroenterology, Hôpital Cochin APHP, Paris, France
- Université Paris Descartes, Paris, France
- Inserm, UMR1163 and Institut Imagine, Laboratory Intestinal Immunity, Paris, France
| | - Sascha Cording
- Université Paris Descartes, Paris, France
- Inserm, UMR1163 and Institut Imagine, Laboratory Intestinal Immunity, Paris, France
| | - Nadine Cerf-Bensussan
- Université Paris Descartes, Paris, France
- Inserm, UMR1163 and Institut Imagine, Laboratory Intestinal Immunity, Paris, France
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17
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Jassim SH, Smith LB. New/Revised Entities in Gastrointestinal Lymphoproliferative Disorders. Surg Pathol Clin 2019; 12:733-743. [PMID: 31352985 DOI: 10.1016/j.path.2019.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The gastrointestinal tract is a common extranodal site of involvement by lymphomas. These may be diagnostically challenging because they can mimic a variety of benign conditions and may be difficult to subclassify when malignant. The classification of gastrointestinal lymphomas is an evolving area with some recent changes. Although some of these entities are rare, they are important to recognize because of the variable clinical presentations, comorbidities, and treatment implications. This article explores new and revised entities in gastrointestinal lymphoproliferative disorders.
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Affiliation(s)
- Sarmad H Jassim
- Pathology Department, University of Michigan, 2800 Plymouth Road, North Campus Research Complex, Building 36, Ann Arbor, MI, USA
| | - Lauren B Smith
- Pathology Department, University of Michigan, 2800 Plymouth Road, North Campus Research Complex, Building 36, Ann Arbor, MI, USA.
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18
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Abstract
Refractory celiac disease (RCD) refers to persistence of malnutrition and intestinal villous atrophy for more than 1 to 2 years despite strict gluten-free diet in patients with celiac disease. Diagnosis remains difficult and impacts treatment and follow-up. RCD has been subdivided into 2 subgroups according to the normal (RCDI) or abnormal phenotype of intraepithelial lymphocytes (IELs) (RCDII). RCDII is considered as a low-grade intraepithelial lymphoma and has a poor prognosis due to gastrointestinal and extraintestinal dissemination of the abnormal IELs, and high risk of overt lymphoma.
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Affiliation(s)
- Georgia Malamut
- Paris Descartes University, 15 rue de l'Ecole de Médecine, Paris 75006, France; Gastroenterology Department, Hôpital Européen Georges Pompidou, APHP, 20 rue Leblanc, Paris 75015, France; UMR1163 Institute Imagine, 24 Boulevard du Montparnasse, Paris 75015, France.
| | - Christophe Cellier
- Paris Descartes University, 15 rue de l'Ecole de Médecine, Paris 75006, France; Gastroenterology Department, Hôpital Européen Georges Pompidou, APHP, 20 rue Leblanc, Paris 75015, France; UMR1163 Institute Imagine, 24 Boulevard du Montparnasse, Paris 75015, France
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19
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Elli L, Ferretti F, Orlando S, Vecchi M, Monguzzi E, Roncoroni L, Schuppan D. Management of celiac disease in daily clinical practice. Eur J Intern Med 2019; 61:15-24. [PMID: 30528262 DOI: 10.1016/j.ejim.2018.11.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 11/06/2018] [Accepted: 11/27/2018] [Indexed: 02/06/2023]
Abstract
Celiac disease (CD) is the most common autoimmune enteropathy worldwide. In CD, dietary gluten triggers a T cell driven small intestinal inflammation in a subset of genetically predisposed subjects, expressing the HLA DQ2 and/or DQ8 genes on their antigen presenting cells. HLA DQ2/DQ8 can bind gluten peptides after their prior modification by the CD autoantigen, tissue transglutaminase (TG2). This process leads to the activation of gluten reactive T cells, small bowel villous atrophy, crypt hyperplasia and intraepithelial lymphocytosis, the histological hallmarks of CD. The clinical picture of CD is extremely heterogeneous including intestinal (especially diarrhea, abdominal pain, bloating) and extraintestinal (especially associated autoimmune diseases, anemia, osteoporosis) manifestations. The prevalence of CD in most parts of the world is estimated at 1:100-1:150 and its diagnosis is based on the presence of circulating autoantibodies (anti-TG2) and the histological detection of villous atrophy. Treatment is a lifelong gluten free diet but adjunctive therapies are in development. Although CD is a well-characterized disease, it is grossly underdiagnosed, despite the severe consequences of long-term gluten ingestion in CD, such as enhanced autoimmunity, refractory CD and intestinal T cell lymphoma. The aim of the presented review is to provide a clinical guide and to summarize the most recent clinical progress in CD research.
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Affiliation(s)
- Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease, Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, Italy.
| | - Francesca Ferretti
- Center for Prevention and Diagnosis of Celiac Disease, Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via Festa del Perdono, 20122 Milano, Italy
| | - Stefania Orlando
- Center for Prevention and Diagnosis of Celiac Disease, Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, Italy
| | - Maurizio Vecchi
- Center for Prevention and Diagnosis of Celiac Disease, Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via Festa del Perdono, 20122 Milano, Italy
| | - Erika Monguzzi
- Center for Prevention and Diagnosis of Celiac Disease, Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via Festa del Perdono, 20122 Milano, Italy; Institute for Translational Immunology, Research Center for Immunotherapy (FZI), Johannes Gutenberg University (JGU) Medical Center, 55101 Mainz, Germany
| | - Leda Roncoroni
- Center for Prevention and Diagnosis of Celiac Disease, Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via Festa del Perdono, 20122 Milano, Italy; Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Via Festa del Perdono, 20122 Milano, Italy
| | - Detlef Schuppan
- Institute for Translational Immunology, Research Center for Immunotherapy (FZI), Johannes Gutenberg University (JGU) Medical Center, 55101 Mainz, Germany; Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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Chander U, Leeman-Neill RJ, Bhagat G. Pathogenesis of Enteropathy-Associated T Cell Lymphoma. Curr Hematol Malig Rep 2018; 13:308-317. [PMID: 29943210 DOI: 10.1007/s11899-018-0459-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To provide an update on the pathogenesis of enteropathy-associated T cell lymphoma (EATL) and its relationship with refractory celiac disease (RCD), in light of current knowledge of immune, genetic, and environmental factors that promote neoplastic transformation of intraepithelial lymphocytes (IELs). RECENT FINDINGS EATL frequently evolves from RCD type II (RCD II) but can occur "de novo" in individuals with celiac disease. Recurrent activating mutations in members of the JAK/STAT pathway have been recently described in EATL and RCD II, which suggests deregulation of cytokine signaling to be an early event in lymphomagenesis. Intraepithelial T cells are presumed to be the cell of origin of EATL (and RCD II). Recent in vitro molecular and phenotypic analyses and in vivo murine studies, however, suggest an origin of RCD II from innate IELs (NK/T cell precursors), which could also be the cell of origin of RCD II-derived EATL. The immune microenvironment of the small intestinal mucosa in celiac disease fosters the development of EATL, often in a multistep pathway.
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Affiliation(s)
- Udit Chander
- Department of Pathology and Cell Biology, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
| | - Rebecca J Leeman-Neill
- Department of Pathology and Cell Biology, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
| | - Govind Bhagat
- Department of Pathology and Cell Biology, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA.
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Vinagre-Aragón A, Zis P, Grunewald RA, Hadjivassiliou M. Movement Disorders Related to Gluten Sensitivity: A Systematic Review. Nutrients 2018; 10:E1034. [PMID: 30096784 PMCID: PMC6115931 DOI: 10.3390/nu10081034] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/05/2018] [Accepted: 08/06/2018] [Indexed: 12/25/2022] Open
Abstract
Gluten related disorders (GRD) represent a wide spectrum of clinical manifestations that are triggered by the ingestion of gluten. Coeliac disease (CD) or gluten sensitive enteropathy is the most widely recognised, but extra-intestinal manifestations have also been increasingly identified and reported. Such manifestations may exist in the absence of enteropathy. Gluten sensitivity (GS) is another term that has been used to include all GRD, including those where there is serological positivity for GS related antibodies in the absence of an enteropathy. Gluten ataxia (GA) is the commonest extraintestinal neurological manifestation and it has been the subject of many publications. Other movement disorders (MDs) have also been reported in the context of GS. The aim of this review was to assess the current available medical literature concerning MDs and GS with and without enteropathy. A systematic search was performed while using PubMed database. A total of 48 articles met the inclusion criteria and were included in the present review. This review highlights that the phenomenology of gluten related MDs is broader than GA and demonstrates that gluten-free diet (GFD) is beneficial in a great percentage of such cases.
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Affiliation(s)
- Ana Vinagre-Aragón
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, South Yorkshire, UK.
| | - Panagiotis Zis
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, South Yorkshire, UK.
| | - Richard Adam Grunewald
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, South Yorkshire, UK.
| | - Marios Hadjivassiliou
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, South Yorkshire, UK.
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Hussein S, Gindin T, Lagana SM, Arguelles-Grande C, Krishnareddy S, Alobeid B, Lewis SK, Mansukhani MM, Green PHR, Bhagat G. Clonal T cell receptor gene rearrangements in coeliac disease: implications for diagnosing refractory coeliac disease. J Clin Pathol 2018; 71:825-831. [DOI: 10.1136/jclinpath-2018-205023] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 12/31/2022]
Abstract
AimsRefractory coeliac disease type II (RCDII), a rare complication of coeliac disease (CD) associated with high morbidity, requires identification of a clonal population of phenotypically aberrant intraepithelial lymphocytes (IELs) for diagnosis. However, data regarding the frequency and significance of clonal T cell receptor (TCR) gene rearrangements (TCR-GRs) in small bowel (SB) biopsies of patients without RCDII are limited.MethodsWe analysed results of TCR-GR analyses performed on SB biopsies at our institution over a 3-year period, which were obtained from eight active CD, 172 CD on gluten-free diet (GFD), 33 RCDI, and three RCDII patients and 14 patients without CD. TCR-GR patterns were divided into clonal, polyclonal and prominent clonal peaks (PCPs) and these patterns were correlated with clinical and pathological features.ResultsClonal TCR-GR products were detected in biopsies from 67% of patients with RCDII, 17% of patients with RCDI and 6% of patients with GFD. PCPs were observed in all disease phases (range 12%–33%). There was no significant difference in the TCR-GR patterns between the non-RCDII disease categories (p=0.39). A higher frequency of surface CD3(−) IELs was noted in cases with clonal TCR-GR, but the PCP pattern did not show associations with any clinical or pathological feature. Persistence of clonal or PCP pattern on repeat biopsy was seen for up to 2 years without evidence of RCDII.ConclusionsClonal TCR-GRs are not infrequent in cases lacking features of RCDII, while PCPs are frequent in all disease phases. TCR-GR results should be assessed in conjunction with immunophenotypic, histological and clinical findings for appropriate diagnosis and classification of RCD.
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Ritter J, Zimmermann K, Jöhrens K, Mende S, Seegebarth A, Siegmund B, Hennig S, Todorova K, Rosenwald A, Daum S, Hummel M, Schumann M. T-cell repertoires in refractory coeliac disease. Gut 2018; 67:644-653. [PMID: 28188172 PMCID: PMC5868243 DOI: 10.1136/gutjnl-2016-311816] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 12/01/2016] [Accepted: 12/08/2016] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Refractory coeliac disease (RCD) is a potentially hazardous complication of coeliac disease (CD). In contrast to RCD type I, RCD type II is a precursor entity of enteropathy-associated T-cell lymphoma (EATL), which is associated with clonally expanding T-cells that are also found in the sequentially developing EATL. Using high-throughput sequencing (HTS), we aimed to establish the small-intestinal T-cell repertoire (TCR) in CD and RCD to unravel the role of distinct T-cell clonotypes in RCD pathogenesis. DESIGN DNA extracted from duodenal mucosa specimens of controls (n=9), active coeliacs (n=10), coeliacs on a gluten-free diet (n=9), RCD type I (n=8), RCD type II (n=8) and unclassified Marsh I cases (n=3) collected from 2002 to 2013 was examined by TCRβ-complementarity-determining regions 3 (CDR3) multiplex PCR followed by HTS of the amplicons. RESULTS On average, 106 sequence reads per sample were generated consisting of up to 900 individual TCRβ rearrangements. In RCD type II, the most frequent clonotypes (ie, sequence reads with identical CDR3) represent in average 42.6% of all TCRβ rearrangements, which was significantly higher than in controls (6.8%; p<0.01) or RCD type I (6.7%; p<0.01). Repeat endoscopies in individual patients revealed stability of clonotypes for up to several years without clinical symptoms of EATL. Dominant clonotypes identified in individual patients with RCD type II were unique and not related between patients. CD-associated, gliadin-dependent CDR3 motifs were only detectable at low frequencies. CONCLUSIONS TCRβ-HTS analysis unravels the TCR in CD and allows detailed analysis of individual TCRβ rearrangements. Dominant TCRβ sequences identified in patients with RCD type II are unique and not homologous to known gliadin-specific TCR sequences, supporting the assumption that these clonal T-cells expand independent of gluten stimulation.
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Affiliation(s)
- Julia Ritter
- Institute of Pathology, Charité—University Medicine, Berlin, Germany
| | - Karin Zimmermann
- Institute of Pathology, Charité—University Medicine, Berlin, Germany
| | - Korinna Jöhrens
- Institute of Pathology, Charité—University Medicine, Berlin, Germany
| | - Stefanie Mende
- Institute of Pathology, Charité—University Medicine, Berlin, Germany
| | - Anke Seegebarth
- Institute of Pathology, Charité—University Medicine, Berlin, Germany
| | - Britta Siegmund
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité—University Medicine, Berlin, Germany
| | | | - Kremena Todorova
- Center for Tumor Medicine, Charité—University Medicine, Berlin, Germany
| | - Andreas Rosenwald
- Institute of Pathology, University of Würzburg, and Comprehensive Cancer Center Mainfranken (CCCMF), Würzburg, Germany
| | - Severin Daum
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité—University Medicine, Berlin, Germany
| | - Michael Hummel
- Institute of Pathology, Charité—University Medicine, Berlin, Germany
| | - Michael Schumann
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité—University Medicine, Berlin, Germany,Berlin Institute of Health, Berlin, Germany,Berlin-Brandenburg School for Regenerative Therapies, Berlin, Germany
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Attarwala H, Clausen V, Chaturvedi P, Amiji MM. Cosilencing Intestinal Transglutaminase-2 and Interleukin-15 Using Gelatin-Based Nanoparticles in an in Vitro Model of Celiac Disease. Mol Pharm 2017; 14:3036-3044. [DOI: 10.1021/acs.molpharmaceut.7b00233] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Husain Attarwala
- Department of Pharmaceutical
Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts 02115, United States
- Alnylam Pharmaceuticals, Inc., Cambridge, Massachusetts 02142, United States
| | - Valerie Clausen
- Alnylam Pharmaceuticals, Inc., Cambridge, Massachusetts 02142, United States
| | - Prasoon Chaturvedi
- Alnylam Pharmaceuticals, Inc., Cambridge, Massachusetts 02142, United States
| | - Mansoor M. Amiji
- Department of Pharmaceutical
Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts 02115, United States
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25
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Attarwala H, Han M, Kim J, Amiji M. Oral nucleic acid therapy using multicompartmental delivery systems. WILEY INTERDISCIPLINARY REVIEWS-NANOMEDICINE AND NANOBIOTECHNOLOGY 2017; 10. [PMID: 28544521 DOI: 10.1002/wnan.1478] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 11/12/2016] [Accepted: 03/31/2017] [Indexed: 12/18/2022]
Abstract
Nucleic acid-based therapeutics has the potential for treating numerous diseases by correcting abnormal expression of specific genes. Lack of safe and efficacious delivery strategies poses a major obstacle limiting clinical advancement of nucleic acid therapeutics. Oral route of drug administration has greater delivery challenges, because the administered genes or oligonucleotides have to bypass degrading environment of the gastrointestinal (GI) tract in addition to overcoming other cellular barriers preventing nucleic acid delivery. For efficient oral nucleic acid delivery, vector should be such that it can protect encapsulated material during transit through the GI tract, facilitate efficient uptake and intracellular trafficking at desired target sites, along with being safe and well tolerated. In this review, we have discussed multicompartmental systems for overcoming extracellular and intracellular barriers to oral delivery of nucleic acids. A nanoparticles-in-microsphere oral system-based multicompartmental system was developed and tested for in vivo gene and small interfering RNA delivery for treating colitis in mice. This system has shown efficient transgene expression or gene silencing when delivered orally along with favorable downstream anti-inflammatory effects, when tested in a mouse model of intestinal bowel disease. WIREs Nanomed Nanobiotechnol 2018, 10:e1478. doi: 10.1002/wnan.1478 This article is categorized under: Biology-Inspired Nanomaterials > Nucleic Acid-Based Structures Nanotechnology Approaches to Biology > Nanoscale Systems in Biology Therapeutic Approaches and Drug Discovery > Emerging Technologies.
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Affiliation(s)
- Husain Attarwala
- Department of Pharmaceutical Sciences, School of Pharmacy, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Murui Han
- Department of Pharmaceutical Sciences, School of Pharmacy, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Jonghan Kim
- Department of Pharmaceutical Sciences, School of Pharmacy, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Mansoor Amiji
- Department of Pharmaceutical Sciences, School of Pharmacy, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
- Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
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Valitutti F, Trovato CM, Montuori M, Cucchiara S. Pediatric Celiac Disease: Follow-Up in the Spotlight. Adv Nutr 2017; 8:356-361. [PMID: 28298278 PMCID: PMC5347098 DOI: 10.3945/an.116.013292] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The follow-up of celiac disease (CD) is challenging due to the scarcity of published data and the lack of standardized evidence-based protocols. The worldwide frequency and methods of CD follow-up appear to be heavily influenced by expert opinions of the individual physicians who assess children with CD. The aim of this review was to summarize the available studies on CD follow-up in children. We conducted a literature search with the use of PubMed, Medline, and Embase (from 1900 to 15 December 2016) for terms relevant to this review, including CD, follow-up, dietary adherence or dietary compliance, nutrition, comorbidities, complications, and quality of life. The aims of follow-up are as follows: to ensure strict adherence to a gluten-free diet, to ensure nutritional adequacy, to improve quality of life, and to prevent disease complications. For the correct evaluation of children with CD at follow-up, a clinical and biochemical evaluation is necessary on a regular basis. It is advisable to assess compliance, nutrition, comorbidities, or possible complications once a year at the referral center. Laboratory tests might be useful for a thorough evaluation of any patient with CD to rule out a micronutrient deficiency (full blood count, ferritin, folic acid, vitamin B-6, and vitamin B-12) and possible cardiovascular risk factors (glucose, LDL cholesterol, triglycerides). Biochemical evaluation is essential when there are clinical problems and should be customized on the basis of the specific clinical suspicion. Associated autoimmune thyroiditis should also be screened for yearly by measuring thyroid-stimulating hormone and thyroid autoantibody concentrations, regardless of symptoms, because hypothyroidism is often subtle and methods for early treatment are available and desirable. Although evidence-based recommendations for follow-up of pediatric patients with CD have not yet been established, we advise a yearly follow-up visit as the safest approach.
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Affiliation(s)
- Francesco Valitutti
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Chiara Maria Trovato
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Monica Montuori
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Salvatore Cucchiara
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
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27
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Gastrointestinal diseases and their oro-dental manifestations: Part 3: Coeliac disease. Br Dent J 2017; 222:126-129. [DOI: 10.1038/sj.bdj.2017.80] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2016] [Indexed: 12/20/2022]
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Abstract
Refractory celiac disease (RCD) affects patients who have failed to heal after 6-12 months of a strict gluten-free diet (GFD) and when other causes of symptoms (including malignancy) have been ruled out. It may also occur in patients who previously had responded to a long-term GFD. RCD may be categorized as RCD1 (normal immunophenotype) and RCD2 (aberrant immunophenotype). RCD1 usually responds to a continued GFD, nutritional support, and therapeutic agents such as corticosteroids. In contrast, clinical response in RCD2 is incomplete and prognosis is often poor. RCD (particularly RCD2) is associated with serious complications, such as ulcerative jejunitis and enteropathy-associated T-cell lymphoma (EATL). Strict clinical and laboratory criteria should be used to diagnose RCD and specialized tests for aberrancy and clonality should be interpreted in the context of their sensitivity and specificity. Adequate nutritional support and anti-inflammatory treatment may even allow patients with RCD2 to attain a clinical remission.
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Affiliation(s)
- Abdul R Rishi
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Alberto Rubio-Tapia
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Joseph A Murray
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
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Sedda S, De Simone V, Marafini I, Bevivino G, Izzo R, Paoluzi OA, Colantoni A, Ortenzi A, Giuffrida P, Corazza GR, Vanoli A, Di Sabatino A, Pallone F, Monteleone G. High Smad7 sustains inflammatory cytokine response in refractory coeliac disease. Immunology 2016; 150:356-363. [PMID: 27861825 DOI: 10.1111/imm.12690] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/02/2016] [Accepted: 11/07/2016] [Indexed: 12/20/2022] Open
Abstract
Refractory coeliac disease (RCD) is a form of coeliac disease (CD) resistant to gluten-free diet and associated with elevated risk of complications. Many effector cytokines over-produced in the gut of patients with RCD are supposed to amplify the tissue-destructive immune response, but it remains unclear if the RCD-associated mucosal inflammation is sustained by defects in counter-regulatory mechanisms. The aim of the present study was to determine whether RCD-related inflammation is marked by high Smad7, an intracellular inhibitor of transforming growth factor-β1 (TGF-β1 ) activity. Smad7 was evaluated in duodenal biopsy samples of patients with RCD, patients with active CD, patients with inactive CD and healthy controls by Western blotting, immunohistochemistry and real-time PCR. In the same samples, TGF-β1 and phosphorylated (p)-Smad2/3 were evaluated by ELISA and immunohistochemistry, respectively. Pro-inflammatory cytokine expression was evaluated in RCD samples cultured with Smad7 sense or antisense oligonucleotide. Smad7 protein, but not RNA, expression was increased in RCD compared with active and inactive CD patients and healthy controls and this was associated with defective TGF-β1 signalling, as marked by diminished p-Smad2/3 expression. TGF-β1 protein content did not differ among groups. Knockdown of Smad7 in RCD biopsy samples reduced interleukin-6 and tumour necrosis factor-α expression. In conclusion, in RCD, high Smad7 associates with defective TGF-β1 signalling and sustains inflammatory cytokine production. These results indicate a novel mechanism by which the mucosal cytokine response is amplified in RCD and suggest that targeting Smad7 can be therapeutically useful in RCD.
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Affiliation(s)
- Silvia Sedda
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Veronica De Simone
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Irene Marafini
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Gerolamo Bevivino
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Roberta Izzo
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | | | - Alfredo Colantoni
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Angela Ortenzi
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paolo Giuffrida
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Gino R Corazza
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alessandro Vanoli
- Department of Molecular Medicine, San Matteo Hospital, University of Pavia, Pavia, Italy
| | - Antonio Di Sabatino
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Francesco Pallone
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
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Rubio-Tapia A, Malamut G, Verbeek WH, van Wanrooij RL, Leffler DA, Niveloni SI, Arguelles-Grande C, Lahr BD, Zinsmeister AR, Murray JA, Kelly CP, Bai JC, Green PH, Daum S, Mulder CJ, Cellier C. Creation of a model to predict survival in patients with refractory coeliac disease using a multinational registry. Aliment Pharmacol Ther 2016; 44:704-14. [PMID: 27485029 PMCID: PMC5018234 DOI: 10.1111/apt.13755] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/09/2016] [Accepted: 07/14/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Refractory coeliac disease is a severe complication of coeliac disease with heterogeneous outcome. AIM To create a prognostic model to estimate survival of patients with refractory coeliac disease. METHODS We evaluated predictors of 5-year mortality using Cox proportional hazards regression on subjects from a multinational registry. Bootstrap resampling was used to internally validate the individual factors and overall model performance. The mean of the estimated regression coefficients from 400 bootstrap models was used to derive a risk score for 5-year mortality. RESULTS The multinational cohort was composed of 232 patients diagnosed with refractory coeliac disease across seven centres (range of 11-63 cases per centre). The median age was 53 years and 150 (64%) were women. A total of 51 subjects died during a 5-year follow-up (cumulative 5-year all-cause mortality = 30%). From a multiple variable Cox proportional hazards model, the following variables were significantly associated with 5-year mortality: age at refractory coeliac disease diagnosis (per 20 year increase, hazard ratio = 2.21; 95% confidence interval, CI: 1.38-3.55), abnormal intraepithelial lymphocytes (hazard ratio = 2.85; 95% CI: 1.22-6.62), and albumin (per 0.5 unit increase, hazard ratio = 0.72; 95% CI: 0.61-0.85). A simple weighted three-factor risk score was created to estimate 5-year survival. CONCLUSIONS Using data from a multinational registry and previously reported risk factors, we create a prognostic model to predict 5-year mortality among patients with refractory coeliac disease. This new model may help clinicians to guide treatment and follow-up.
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Affiliation(s)
| | | | | | | | - Daniel A. Leffler
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | | | | | | | | | | | - Ciaran P. Kelly
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Julio C. Bai
- Hospital Dr. Carlos Nonorino Udaondo, Buenos Aires, Argentina
| | - Peter H. Green
- Columbia University Medical Center, New York, New York, United States
| | - Severin Daum
- Charite-University Medicine Berlin, Berlin, Germany
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[Histological diagnosis and complications of celiac disease. Update according to the new S2k guidelines]. DER PATHOLOGE 2016; 36:197-205; quiz 206-7. [PMID: 25820446 DOI: 10.1007/s00292-015-0006-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Celiac disease is a relatively common immunological systemic disease triggered by the protein gluten in genetically predisposed individuals. Classical symptoms like chronic diarrhea, steatorrhea, weight loss and growth retardation are nowadays relatively uncommon. Diagnostic workup includes serological tests for IgA antibodies against tissue transglutaminase 2 (anti-TG2-IgA) and total IgA and histology of duodenal biopsies. Histomorphological classification should be done according to the modified Marsh-Oberhuber classification. Diagnosis of celiac disease should be based on serological, clinical, and histological findings. The only treatment is a life-long gluten-free diet. Unchanged or recurrent symptoms under gluten-free diet may indicate refractory celiac disease. Enteropathy-associated T-cell lymphoma and adenocarcinomas of the small intestine are known complications of celiac disease.
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Fabian E, Schiller D, Wenzl H, Lackner C, Donnerer J, Ziachehabi A, Silye R, Schöfl R, Krejs GJ. Clinical-Pathological Conference Series from the Medical University of Graz: Case No 156: 82-year-old woman with chronic diarrhea and weight loss of 20 kilograms. Wien Klin Wochenschr 2015; 127:974-80. [PMID: 26610650 PMCID: PMC4679112 DOI: 10.1007/s00508-015-0882-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 10/10/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Elisabeth Fabian
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Dietmar Schiller
- Department of Internal Medicine IV, Elisabethinen Hospital, Linz, Austria
| | - Heimo Wenzl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Carolin Lackner
- Department of Pathology, Medical University of Graz, Graz, Austria
| | - Josef Donnerer
- Department of Experimental and Clinical Pharmacology, Medical University of Graz, Graz, Austria
| | | | - Rene Silye
- Department of Clinical Pathology, General Hospital, Linz, Austria
| | - Rainer Schöfl
- Department of Internal Medicine IV, Elisabethinen Hospital, Linz, Austria
| | - Guenter J Krejs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
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Abstract
A small subset of patients with coeliac disease become refractory to a gluten-free diet with persistent malabsorption and intestinal villous atrophy. The most common cause of this condition is inadvertent gluten exposure, but concomitant diseases leading to villous atrophy should also be considered and excluded. After exclusion of these conditions, patients are referred to as having refractory coeliac disease, of which two categories are recognized based on the absence (type I) or presence (type II) of a clonal expansion of premalignant intraepithelial lymphocyte population with a high potential for transformation into an overt enteropathy-associated T-cell lymphoma. Type I disease usually has a benign course that can be controlled by mild immunosuppressive treatment, but type II can be more severe with cladribine with or without autologous stem cell transplantation effective as treatment. Patients who fail to respond to cladribine therapy, however, still have a high risk of malignant transformation. Insights into the immunophenotype of these cells and the recognition that type II disease is a low-grade, no-mass lymphoma opens avenues for new treatment strategies, including chemotherapeutic and immunomodulating strategies. This Review will provide an overview of refractory coeliac disease, discussing mechanisms, diagnosis and management.
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Stein J, Schuppan D. Coeliac Disease - New Pathophysiological Findings and Their Implications for Therapy. VISZERALMEDIZIN 2015; 30:156-65. [PMID: 26288589 PMCID: PMC4513807 DOI: 10.1159/000365099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Coeliac disease (CD) is one of the most common diseases worldwide, resulting from a combination of environmental (gluten) and genetic (human leucocyte antigen (HLA) and non-HLA genes) factors. Depending on the geographical location, the prevalence of CD has been estimated to approximate 0.5-1%. The only treatment currently available for CD is a gluten-free diet (GFD) excluding gluten-containing cereals such as wheat, rye, and barley, and other foodstuffs with natural or added gluten. However, adherence rates and patient acceptance are often poor. Moreover, even in fully adherent patients, the diet may fail to induce clinical or histological improvement. Hence, it is unsurprising that studies show CD patients to be highly interested in non-dietary alternatives. The following review focuses on current pathophysiological concepts of CD, spotlighting those pathways which may serve as new possible, non-dietary therapeutic targets in the treatment of CD.
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Affiliation(s)
- Jürgen Stein
- Department of Gastroenterology and Clinical Nutrition, Sachsenhausen Hospital, Teaching Hospital of the Goethe University Frankfurt, Germany ; Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/M., Germany
| | - Detlef Schuppan
- Institute of Translational Immunology, University Medical Center, Hospital Mainz, Germany ; Division of Gastroenterology, Beth Israel deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Abstract
Within the past 20 years the spectrum of complications of coeliac disease (CD) has been considerably extended. Besides the classic complications, autoimmune diseases and osteopenia, numerous forms of CD non-responsive to a gluten-free diet have been recently identified. Among the non-responsive CD, the majority of patients presents as long term responders. However a small subset of CD patients becomes refractory to a gluten-free diet with persistent malabsorption and intestinal villous atrophy. Whereas refractory coeliac disease type I (RCDI) is hardly distinguishable from active CD, the type II (RCDII) has a severe clinical presentation and a very poor prognosis. Enteropathy Associated T cell Lymphoma (EATL) is even more aggressive with a five year survival of 20%. Classic adriamycin-based chemotherapy is poorly efficient in the lymphomatous complications of CD and current therapeutic strategies focus on more intensive regimen with autologous or allogenic stem cell transplantation. Notable pathogenic advances let us to test targeted therapy both in low (RCDII) and high grade lymphomatous (EATL) complications associated with CD.
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Kruis T, Jöhrens K, Moos V, Puls I, Siegmund B, Daum S, Schumann M. A case series in patients with enteropathy and granulomatous diseases. BMC Gastroenterol 2015; 15:62. [PMID: 26001889 PMCID: PMC4493942 DOI: 10.1186/s12876-015-0292-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 05/18/2015] [Indexed: 12/13/2022] Open
Abstract
Background Although sarcoidosis and celiac disease are both chronic immunologic disorders involving multiple organ systems, reports about association of diseases in individual patients are sparse. While sarcoidosis is a chronic granulomatous disease presumably reflecting an exaggerated response to an unknown antigen, celiac disease is a T cell-driven disease triggered by ingestion of gluten, a protein composite found in wheat and related grains. Case presentation We present three cases with a longstanding history of sarcoidosis that have been additionally diagnosed with celiac-like enteropathy. In two cases, celiac disease was established applying celiac-specific serology and duodenal histology, while one case was revealed as an AIE-75-positive autoimmune enteropathy. The HLA-DR3/DQ2 haplotype was confirmed in both celiac patients, hence confirming previous data of linkage disequilibrium as a cause for disease association. Remarkably, one celiac patient presented with granulomatous nodulae in the ileum, thus reflecting an intestinal sarcoid manifestation. In contrast the patient with an autoimmune enteropathy, was HLA-DQ9/DQ6-positive, also arguing against CD. Conclusions Associations of sarcoidosis and celiac disease are rare but do occur. Determining the HLA status in patients with complex autoimmune associations might help classifying involved disease entities.
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Affiliation(s)
- Tassilo Kruis
- Medical Department I (Gastroenterology, Infectious Diseases, Rheumatology), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin, 12200, Germany.
| | - Korinna Jöhrens
- Institute for Pathology, Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany.
| | - Verena Moos
- Medical Department I (Gastroenterology, Infectious Diseases, Rheumatology), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin, 12200, Germany.
| | - Imke Puls
- Department for Psychiatry, Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany.
| | - Britta Siegmund
- Medical Department I (Gastroenterology, Infectious Diseases, Rheumatology), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin, 12200, Germany.
| | - Severin Daum
- Medical Department I (Gastroenterology, Infectious Diseases, Rheumatology), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin, 12200, Germany.
| | - Michael Schumann
- Medical Department I (Gastroenterology, Infectious Diseases, Rheumatology), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin, 12200, Germany.
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Abstract
A small subset of celiac disease (CD) patients becomes refractory to a gluten-free diet with persistent malabsorption and intestinal villous atrophy. This is a rare (probably less than 2% of adult CD patients), but serious disorder, with a high risk of progression to an overt T-cell lymphoma. Diagnosis of this condition defined as refractory CD (RCD) is made after exclusion of other small bowel diseases with villous atrophy. RCD has been subdivided into two subgroups according to the normal (RCDI) or abnormal phenotype of intraepithelial lymphocytes (RCDII). Whereas RCDI is hardly distinguishable from active noncompliant CD, RCDII has a severe clinical presentation and a very poor prognosis. We precisely describe below the different types of RCD and propose diagnostic and therapeutic guidelines for its clinical management.
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de Baaij LR, Berkhof J, van de Water JMW, Sieniawski MK, Radersma M, Verbeek WHM, Visser OJ, Oudejans JJ, Meijer CJLM, Mulder CJJ, Lennard AL, Cillessen SAGM. A New and Validated Clinical Prognostic Model (EPI) for Enteropathy-Associated T-cell Lymphoma. Clin Cancer Res 2015; 21:3013-9. [PMID: 25779949 DOI: 10.1158/1078-0432.ccr-14-2195] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 02/06/2015] [Indexed: 12/23/2022]
Abstract
PURPOSE Enteropathy-associated T-cell lymphoma (EATL) is a rare intestinal non-Hodgkin lymphoma with a poor, though variable prognosis. The International Prognostic Index (IPI) and the prognostic index for peripheral T-cell lymphoma (PIT) have limited predictive value for outcome of EATL. The purpose of this study was to develop and validate a prognostic model for EATL, which can identify high-risk patients who need more aggressive therapy. EXPERIMENTAL DESIGN This retrospective multicenter study was based on 92 patients and included 45 patients diagnosed with EATL between 1999 and 2009 from the Netherlands and 47 patients from England and Scotland, diagnosed with EATL between 1994 and 1998. A new EATL prognostic index (EPI) was constructed using the RPART (recursive partitioning and regression trees) procedure. Validation was performed applying the bootstrap method. RESULTS Three risk groups were distinguished (P < 0.0001): a high-risk group, characterized by the presence of B-symptoms [median overall survival (OS) of 2 months]; an intermediate-risk group, comprising patients without B-symptoms and an IPI score ≥ 2 (7 months); and a low-risk group, representing patients without B-symptoms and an IPI score of 0 to 1 (34 months). Internal validation showed stability of statistical significance and prognostic discrimination. In contrast with the IPI and PIT, the EPI better classified patients in risk groups according to their clinical outcome. CONCLUSIONS Our new, validated, prognostic model EPI accurately predicts survival outcome in EATL and may be used for patient selection for new therapeutic strategies and evaluation of clinical trials.
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Affiliation(s)
- Laura R de Baaij
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands
| | - Johannes Berkhof
- Department of Clinical Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, the Netherlands
| | - Jolanda M W van de Water
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands
| | - Michal K Sieniawski
- Hematological Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Marijn Radersma
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands
| | - Wieke H M Verbeek
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands
| | - Otto J Visser
- Department of Hematology, VU University Medical Center Amsterdam, the Netherlands
| | - Joost J Oudejans
- Department of Pathology, Diakonessenhuis, Utrecht, the Netherlands. Department of Pathology, VU University Medical Center, Amsterdam, the Netherlands
| | - Chris J L M Meijer
- Department of Pathology, VU University Medical Center, Amsterdam, the Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands
| | - Anne L Lennard
- Hematological Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
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Abstract
Interleukin-15 (IL-15) exerts many biological functions essential for the maintenance and function of multiple cell types. Although its expression is tightly regulated, IL-15 upregulation has been reported in many organ-specific autoimmune disorders. In celiac disease, an intestinal inflammatory disorder driven by gluten exposure, the upregulation of IL-15 expression in the intestinal mucosa has become a hallmark of the disease. Interestingly, because it is overexpressed both in the gut epithelium and in the lamina propria, IL-15 acts on distinct cell types and impacts distinct immune components and pathways to disrupt intestinal immune homeostasis. In this article, we review our current knowledge of the multifaceted roles of IL-15 with regard to the main immunological processes involved in the pathogenesis of celiac disease.
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Affiliation(s)
- Valérie Abadie
- Sainte-Justine Hospital Research Center, Department of Microbiology and Immunology, Faculty of Medicine, University of Montreal, Montreal, Canada
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40
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Remission of Refractory Celiac Disease With Infliximab in a Pediatric Patient. ACG Case Rep J 2015; 2:121-3. [PMID: 26157934 PMCID: PMC4435386 DOI: 10.14309/crj.2015.25] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 12/10/2014] [Indexed: 12/25/2022] Open
Abstract
Refractory celiac disease (RCD) is a rare but life-threatening complication of celiac disease (CD), and only 1 pediatric case has been reported. We report a case of a 14-year-old girl with CD presenting with persistent symptoms and positive tissue celiac-specific antibodies despite a gluten-free diet. Push enteroscopy showed jejunal scalloping and partial villous atrophy on histology. She was diagnosed with RCD and treated with infliximab with subsequent complete serological and histological remission.
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41
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Zamora Mur A, García Ronquillo JC, Burgasé Estallo I, Zamora Catevilla A. [Chronic diarrhea syndrome secondary to celiac disease in an octogenarian]. Rev Esp Geriatr Gerontol 2015; 50:45-46. [PMID: 25439050 DOI: 10.1016/j.regg.2014.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 07/16/2014] [Accepted: 07/29/2014] [Indexed: 06/04/2023]
Affiliation(s)
- Alfredo Zamora Mur
- Servicio de Geriatría, Hospital de Barbastro, Barbastro, Huesca, España.
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42
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Abadie V, Jabri B. Immunopathology of Celiac Disease. Mucosal Immunol 2015. [DOI: 10.1016/b978-0-12-415847-4.00080-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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43
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Al-toma A, Nijeboer P, Bouma G, Visser O, Mulder CJJ. Hematopoietic stem cell transplantation for non-malignant gastrointestinal diseases. World J Gastroenterol 2014; 20:17368-17375. [PMID: 25516648 PMCID: PMC4265595 DOI: 10.3748/wjg.v20.i46.17368] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 04/30/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
Both, autologous and allogeneic hematopoietic stem cell transplantation (HSCT) can be used to cure or ameliorate a variety of malignant and non-malignant diseases. The rationale behind this strategy is based on the concept of immunoablation using high-dose chemotherapy, with subsequent regeneration of naive T-lymphocytes derived from reinfused hematopoietic progenitor cells. In addition, the use of HSCT allows for the administration of high-dose chemotherapy (whether or not combined with immunomodulating agents such as antithymocyte globulin) resulting in a prompt remission in therapy-refractory patients. This review gives an update of the major areas of successful uses of HSCT in non-malignant gastrointestinal disorders. A Medline search has been conducted and all relevant published data were analyzed. HSCT has been proved successful in treating refractory Crohn’s disease (CD). Patients with refractory celiac disease type II and a high risk of developing enteropathy associated T-cell lymphoma have shown promising improvement. Data concerning HSCT and mesenchymal SCT in end-stage chronic liver diseases are encouraging. In refractory autoimmune gastrointestinal diseases high-dose chemotherapy followed by HSCT seems feasible and safe and might result in long-term improvement of disease activity. Mesenchymal SCT for a selected group of CD is promising and may represent a significant therapeutic alternative in treating fistulas in CD.
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44
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Sarrigiannis PG, Hoggard N, Aeschlimann D, Sanders DS, Grünewald RA, Unwin ZC, Hadjivassiliou M. Myoclonus ataxia and refractory coeliac disease. CEREBELLUM & ATAXIAS 2014; 1:11. [PMID: 26331035 PMCID: PMC4552176 DOI: 10.1186/2053-8871-1-11] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 06/20/2014] [Indexed: 01/06/2023]
Abstract
Background Cortical myoclonus with ataxia has only rarely been reported in association with Coeliac Disease (CD). Such reports also suggested that it is unresponsive to gluten-free diet. We present detailed electro-clinical characteristics of a new syndrome of progressive cortical hyperexcitability with ataxia and refractory CD. At our gluten/neurology clinic we have assessed and regularly follow up over 600 patients with neurological manifestations due to gluten sensitivity. We have identified 9 patients with this syndrome. Results All 9 patients (6 male, 3 female) experienced asymmetrical irregular myoclonus involving one or more limbs and sometimes face. This was often stimulus sensitive and became more widespread over time. Three patients had a history of Jacksonian march and five had at least one secondarily generalised seizure. Electrophysiology showed evidence of cortical myoclonus. Three had a phenotype of epilepsia partialis continua at onset. There was clinical, imaging and/or pathological evidence of cerebellar involvement in all cases. All patients adhered to a strict gluten-free diet with elimination of gluten-related antibodies in most. However, there was still evidence of enteropathy in all, suggestive of refractory celiac disease. Two died from enteropathy-associated lymphoma and one from status epilepticus. Five patients were treated with mycophenolate and one in addition with rituximab and IV immunoglobulins. Their ataxia and enteropathy improved but myoclonus remained the most disabling feature of their illness. Conclusions This syndrome may well be the commonest neurological manifestation of refractory CD. The clinical involvement, apart from ataxia, covers the whole clinical spectrum of cortical myoclonus. Electronic supplementary material The online version of this article (doi:10.1186/2053-8871-1-11) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Nigel Hoggard
- Neuroradiology, Royal Hallamshire Hospital, Sheffield, S10 2JF UK
| | - Daniel Aeschlimann
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, CF14 4XY UK
| | - David S Sanders
- Gastroenterology, Royal Hallamshire Hospital, Sheffield, S10 2JF UK
| | | | - Zoe C Unwin
- Departments of Neurophysiology, Royal Hallamshire Hospital, Sheffield, S10 2JF UK
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Ng KYB, Mehta R, Mohamed S, Mohamed Z, Arnold J. Severe refractory coeliac disease with response only to parenteral nutrition. Case Rep Gastroenterol 2014; 8:297-303. [PMID: 25473387 PMCID: PMC4241638 DOI: 10.1159/000368394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Refractory coeliac disease (RCD) is characterised by recurrent or persistent malabsorptive symptoms and villous atrophy, despite strict adherence to a gluten-free diet for at least 6 months and where other causes of malabsorption including malignancy have been excluded. There is limited evidence and guidance on the effective management of these patients. We describe a case of severe RCD in our hospital, with symptoms controlled effectively only by total parenteral nutrition (TPN). This 68-year-old woman initially presented to the clinic with persistent non-bloody diarrhoea and vomiting. A diagnosis of coeliac disease was confirmed with a positive tissue transglutaminase assay and histology. A strict gluten-free diet was ineffective and she represented 6 months later with 13 kg weight loss (16.7%), ongoing abdominal pain and diarrhoea, with bowels opening 16 times a day. She was oedematous, had an albumin of 12 g/l and required hospital admission. She was treated for pancreatic insufficiency and presumptively for small bowel bacterial overgrowth with no resolution of symptoms. We ruled out infectious causes and investigated for small bowel malignancy; all results were negative. Small bowel enteroscopy showed ulcerative jejunitis. She was given 5 days of TPN, following which her symptoms improved and albumin normalised. This was sustained with symptom resolution and weight gain seen at follow-up. TPN successfully and rapidly induced remission in this case. Thus, a short period of TPN should be considered as a potential component of management in patients with severe RCD.
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Affiliation(s)
| | - Ravi Mehta
- Gastroenterology Department, Ealing Hospital, Southall, UK
| | - Salma Mohamed
- Gastroenterology Department, Ealing Hospital, Southall, UK
| | - Zameer Mohamed
- Gastroenterology Department, Ealing Hospital, Southall, UK
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Ludvigsson JF, Bai JC, Biagi F, Card TR, Ciacci C, Ciclitira PJ, Green PHR, Hadjivassiliou M, Holdoway A, van Heel DA, Kaukinen K, Leffler DA, Leonard JN, Lundin KEA, McGough N, Davidson M, Murray JA, Swift GL, Walker MM, Zingone F, Sanders DS. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut 2014; 63:1210-28. [PMID: 24917550 PMCID: PMC4112432 DOI: 10.1136/gutjnl-2013-306578] [Citation(s) in RCA: 710] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A multidisciplinary panel of 18 physicians and 3 non-physicians from eight countries (Sweden, UK, Argentina, Australia, Italy, Finland, Norway and the USA) reviewed the literature on diagnosis and management of adult coeliac disease (CD). This paper presents the recommendations of the British Society of Gastroenterology. Areas of controversies were explored through phone meetings and web surveys. Nine working groups examined the following areas of CD diagnosis and management: classification of CD; genetics and immunology; diagnostics; serology and endoscopy; follow-up; gluten-free diet; refractory CD and malignancies; quality of life; novel treatments; patient support; and screening for CD.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
| | - Julio C Bai
- Department of Medicine, Dr C. Bonorino Udaondo Gastroenterology Hospital, Del Salvador University, Buenos Aires, Argentina
| | - Federico Biagi
- Coeliac Centre/1st Department of Internal Medicine, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Timothy R Card
- University of Nottingham, Department of Epidemiology and Public Health, Nottingham City Hospital, Nottingham, UK
| | - Carolina Ciacci
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Paul J Ciclitira
- Gastroenterology, Division of Nutritional Sciences, King's College London, The Rayne Institute, St Thomas Hospital, London, UK
| | - Peter H R Green
- Coeliac Disease Center at Columbia University, New York, New York, USA
| | | | - Anne Holdoway
- Registered dietitian and representative of the British Dietetic Association, Bath, Somerset, UK
| | - David A van Heel
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Katri Kaukinen
- School of Medicine, University of Tampere, Tampere, Finland Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland Department of Medicine, Seinäjoki Central Hospital, Finland
| | - Daniel A Leffler
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan N Leonard
- Department of Dermatology, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Knut E A Lundin
- Department of Gastroenterology, Centre for Immune Regulation, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | | | - Mike Davidson
- Patient Representative & Regional Chairman for Coeliac UK, Sheffield, UK
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Department of Immunology Mayo Clinic, Rochester, Minnesota, USA
| | - Gillian L Swift
- Department of Gastroenterology, University Hospital Llandough, Wales, UK
| | - Marjorie M Walker
- Anatomical Pathology, University of Newcastle, Faculty of Health and Medicine, School of Medicine & Public Health, Callaghan, Australia
| | - Fabiana Zingone
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - David S Sanders
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital & University of Sheffield, Sheffield, UK
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47
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van Wanrooij RLJ, Müller DMJ, Neefjes-Borst EA, Meijer J, Koudstaal LG, Heideman DAM, Bontkes HJ, von Blomberg BME, Bouma G, Mulder CJJ. Optimal strategies to identify aberrant intra-epithelial lymphocytes in refractory coeliac disease. J Clin Immunol 2014; 34:828-35. [PMID: 25062848 DOI: 10.1007/s10875-014-0075-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 07/02/2014] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Different strategies have been developed to identify those refractory celiac disease (RCD) patients who are at risk to develop an enteropathy associated T-cell lymphoma (EATL). Flow cytometric analysis of intra-epithelial lymphocytes (IEL) with an aberrant phenotype is considered the golden standard but is not widely available. Immunohistochemistry (IHC) and T-cell receptor (TCR) rearrangement studies are commonly available but may lack sensitivity and specificity. Here, we compared the three different methods in the workup of patients suspected for RCD. METHODS Duodenal biopsies from control patient (n = 5), RCD patients with moderately increased aberrant IEL populations (20-50 %: n = 14), and RCD patients with high numbers of aberrant IEL (>50 %: n = 5) as determined by flow cytometry were analysed by IHC and TCR-γ chain rearrangement analysis. Three pathologists scored the slides independently. RESULTS Sensitivity of IHC and TCR-γ rearrangement analysis in RCD patients with high numbers of aberrant IELs was 100 and 71 %, respectively. RCD patients with aberrant cells between 25 and 50 % however, were missed by IHC and TCR in 50 and 57 % of cases, respectively. In addition, inter-rater reliability analysis of the IHC scoring revealed coder-pair Kappa coefficients between 0.28 and 0.85. CONCLUSION Immunohistochemistry and to a lesser extent TCR-γ clonality analysis are sensitive in identifying patients with high numbers of aberrant IEL populations, yet miss half of RCD patients with moderately increased numbers. In addition, IHC has a high inter-observer variability. Therefore, patients suspected for RCD should undergo flow cytometric analysis of the duodenum.
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Affiliation(s)
- R L J van Wanrooij
- Department of Gastroenterology and Hepatology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands,
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48
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Abstract
Interleukin-15 (IL-15) exerts many biological functions essential for the maintenance and function of multiple cell types. Although its expression is tightly regulated, IL-15 upregulation has been reported in many organ-specific autoimmune disorders. In celiac disease, an intestinal inflammatory disorder driven by gluten exposure, the upregulation of IL-15 expression in the intestinal mucosa has become a hallmark of the disease. Interestingly, because it is overexpressed both in the gut epithelium and in the lamina propria, IL-15 acts on distinct cell types and impacts distinct immune components and pathways to disrupt intestinal immune homeostasis. In this article, we review our current knowledge of the multifaceted roles of IL-15 with regard to the main immunological processes involved in the pathogenesis of celiac disease.
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Affiliation(s)
- Valérie Abadie
- Sainte-Justine Hospital Research Center, Department of Microbiology and Immunology, Faculty of Medicine, University of Montreal, Montreal, Canada
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49
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Makharia GK. Current and emerging therapy for celiac disease. Front Med (Lausanne) 2014; 1:6. [PMID: 25705619 PMCID: PMC4335393 DOI: 10.3389/fmed.2014.00006] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 03/13/2014] [Indexed: 12/12/2022] Open
Abstract
At present, strict and lifelong gluten-free diet is the only effective treatment for celiac disease. Even small amounts of gluten (50 mg/day) can be immunogenic; therefore all food and food items and drugs that contain gluten and its derivatives must be eliminated completely from the diet. While prescribing gluten-free diet is easy; the key to the success is the dietary counseling by a nutrition specialist and maintenance of adherence to GFD by the patient. In recent times, a number of targets to halt the process of immunological injury have been explored to find out alternative treatment for celiac disease. These targets include exploration of ancient wheat if they are less immunogenic, intra-luminal digestion of gluten using prolylendopeptidases, pretreatment of whole gluten with bacterial-derived peptidase before ingestion; prevention of passage of immunogenic peptides through the tight junctions such as zonulin antagonists, Blocking of HLA-DQ2 to prevent binding of immunogenic peptides, inhibition of transglutaminase 2, immune-modulation, and induction of tolerance to gluten using gluten tolerizing vaccines, use of gluten-sequestering polymers, use of anti-inflammatory drugs (glucocorticoids, budesonides) and anti-cytokines such as anti TNF-α, and anti-interleukin-15. While many of these targets are still in the pre-clinical phase, some of them including zonulin antagonist and endopeptidases have already reached phase II and phase III clinical trials. Furthermore, while these targets appear very exciting; they at best are likely to be used as adjunctive therapy rather than a complete replacement for gluten-free diet.
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Affiliation(s)
- Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences , New Delhi , India
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50
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Abstract
PURPOSE OF REVIEW Concept of refractory coeliac disease (RCD) emerged in the past decade and refers to persistence of malnutrition and intestinal villous atrophy for more than 1 year strict gluten-free diet in coeliac patients. Diagnosis of this condition remains difficult and conditions treatment and follow-up. RECENT FINDINGS RCD has been subdivided into two subgroups according to the normal [type I RCD (RCDI)] or abnormal phenotype of intraepithelial lymphocytes [type II RCD (RCDII)]. RCDII is considered as a low-grade intraepithelial lymphoma and has a very poor prognosis, leading to intractable ulcerative jejunitis, gastrointestinal and extra-intestinal dissemination of the abnormal intraepithelial lymphocytes, and to their frequent transformation into a high-grade invasive lymphoma. SUMMARY Herein, we review here the distinctive diagnostic features of RCDI and RCDII, the risk of developing overt lymphoma and different therapeutic approaches.
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