Prevalence of autoimmune thyroiditis in children with celiac disease and effect of gluten withdrawal

Vulnerability in Children with Celiac Disease: Findings from a Scoping Review

(1) Background: The scientific literature highlights that children diagnosed with celiac disease (CD) are at a heightened risk of experiencing physical, psychological, and social challenges, impacting their overall healthy childhood development. However, there remains a lack of a clear understanding regarding the factors that contribute to this vulnerability. The purpose of this study is to analyze and map the evidence on the sociopsychosomatic vulnerability of these children and identify gaps in this topic. (2) Methods: Following Joanna Briggs Institute's guidelines for scoping reviews, we executed a detailed search of key electronic databases and explored the grey literature to capture a broad spectrum of studies. Our focus was on identifying research that looked into the multiple dimensions of vulnerability-physical, psychological, and social-in children with CD. We included a diverse range of study designs as well as systematic reviews, ensuring a comprehensive analysis. The selection process was stringent, utilizing clearly defined inclusion and exclusion criteria. (3) Results: We identified 61 studies that met our inclusion criteria. The review highlighted significant adverse health outcomes in children with CD and elucidated various individual and environmental determinants that influenced these vulnerabilities. It also underscored the lack of assessment tools to evaluate the risk of health problems in this population. (4) Conclusions: The findings underscore a critical need for further research to deepen our understanding of the vulnerabilities associated with CD in children. Developing targeted assessment tools will be crucial in stratifying health risks and enhancing care strategies for this vulnerable population.

The association of gluten-free diet with thyroid autoimmunity in patients with celiac disease: a meta-analysis

Background: Thyroid autoimmunity is an immune response to thyroid antigens that causes varying degrees of thyroid dysfunction. The sole effective treatment for Celiac Disease (CD) is a gluten-free diet (GFD). However, the association between GFD and thyroid autoimmunity in patients with CD has not been confirmed. Methods: A comprehensive search of several databases, involving PubMed, Embase, Web of Science, Medline, and Cochrane databases, was conducted to identify studies that primarily addressed the effects of GFD on thyroid autoimmunity in CD subjects. The meta-analysis involved studies that compared the risk of ATPO and ATG antibody positivity in CD patients with GFD, the risk of developing AITD, and the risk of developing thyroid dysfunction. Fixed-effects models or random-effects models were used to calculate the odds ratios (ORs) and their 95% confidence intervals (95% CIs). Results: A total of 10 observational studies met the inclusion criteria and included 6423 subjects. The results indicated that GFD is positively associated with thyroid autoimmunity in the children subgroup of CD patients (OR = 1.61, 95%CI 1.06-2.43, P = 0.02). However, there was no significant difference in thyroid autoimmunity between the group adhering to GFD and the control group in the total CD population. Conclusion: The results seem to indicate that subjects with a more pronounced autoimmunity (such as to have an early onset of CD) appear to have a greater risk of thyroid autoimmunity.

Prevalence of markers of beta cell autoimmunity and thyroid disease in children with coeliac disease

BACKGROUND

Over the last decades, the prevalence of coeliac disease (CD), an autoimmune disorder, rose to 1-2%. Whether patients with CD have higher risk of developing other autoimmune disorders such as type 1 diabetes, Hashimoto thyroiditis, or Graves` disease remains unclear.

AIM

The aim of this study was to determine the prevalence of biomarkers of beta cell and thyroid autoimmunity in children with CD.

METHODS

Retrospective cross-sectional cohort study comparing pediatric patients suffering from CD with age and sex-matched healthy controls (HC). Participant`s serum was tested by immunoassay for following autoantibodies (aAb): TSH-receptor antibodies (TRAb), anti-thyroglobulin (anti-Tg), anti-thyroid peroxidase (anti-TPO), anti-glutamic acid decarboxylase (anti-GAD), anti-zinc transporter 8 (anti-ZnT8), anti-islet antigen 2 (anti-IA2) and anti-insulin.

RESULTS

A total of 95 patients with CD (mean age 8.9 years; 63% female) and 199 matched healthy controls (mean age 9.2 years; 59.8% female) were included in the study. For patients with CD, a seroprevalence of 2.1% (vs. 1.5% in HC) was calculated for anti-GAD, 1.1% for anti-IA2 (vs. 1.5% in HC), 3.2% for anti-ZnT8 (vs. 4.2% in HC), and 1.1% (vs. 1% in HC) for anti-insulin. For thyroid disease, a seroprevalence of 2.2% for TRAb (vs. 1% in HC), 0% for anti-TPO (vs. 2.5% in HC) and 4.3% for anti-Tg (vs. 3.5% in HC) was found for patients with CD.

CONCLUSION

This study suggests a higher prevalence of autoimmune antibodies againstthyroid in children with CD compared to HC, whilst it is similar for pancreatic antibodies. Prospective cohort studies are needed to first evaluate the occurrence of autoimmune antibodies against beta cells and thyroid over a longer follow-up time and second to explore their clinical relevance.

Celiac crisis as the life-threatening onset of celiac disease in children: a case report

Celiac disease (CD) is an immune-mediated enteropathy caused by a permanent sensitivity to gluten in genetically susceptible individuals. In rare cases, CD may occur with a severe potential life-threatening manifestation known as a celiac crisis (CC). This may be a consequence of a delayed diagnosis and expose patients to possible fatal complications. We report the case of a 22-month-old child admitted to our hospital for a CC characterized by weight loss, vomiting, and diarrhea associated with a malnutrition state. Early identification of symptoms of CC is essential to provide a prompt diagnosis and management.

Type 3 autoimmune polyglandular syndrome (APS-3) or type 3 multiple autoimmune syndrome (MAS-3): an expanding galaxy

BACKGROUND

The number of recognised distinct autoimmune diseases (AIDs) has progressively increased over the years with more than 100 being reported today. The natural history of AIDs is characterized by progression from latent and subclinical to clinical stages and is associated with the presence of the specific circulating autoantibodies. Once presented, AIDs are generally chronic conditions. AIDs have the tendency to cluster and co-occur in a single patient. Autoimmune thyroid diseases (AITD) are the most prevalent of AIDs in the world population, and about one-third of the AITD patients also present with a non-thyroid AID during their life-span. Furthermore, patient with non-thyroid AIDs often presents with a form of AITD as a concurrent condition. Many of the clusters of AIDs are well characterized as distinctive syndromes, while some are infrequent and only described in case reports.

PURPOSE

In this review, we describe the wide spectrum of the combinations and the intricate relationships between AITD and the other AIDs, excluding Addison's disease. These combinations are collectively termed type 3 Autoimmune Polyglandular Syndrome (APS-3), also called type 3 Multiple Autoimmune Syndrome (MAS-3), and represent the most frequent APS in the world populations.

CONCLUSIONS

Numerous associations of AITD with various AIDs could be viewed as if the other AIDs were gravitating like satellites around AITD located in the center of a progressively expanding galaxy of autoimmunity.

Extra-intestinal manifestations of Celiac disease in children: their prevalence and association with human leukocyte antigens and pathological and laboratory evaluations

BACKGROUND

Celiac disease (CD) is an autoimmune disease caused by gluten intake. Traditionally CD was believed to be a disease of the gut, although a wide range of extra-intestinal manifestations (EIM) was recognized. The exact prevalence of EIM and the associated risk factors have not been well studied.

AIM

We aimed to assess the prevalence of EIM in children with CD and their association with human leukocyte antigen (HLA) typing, and pathological and laboratory indices.

METHOD

We conducted a cross-sectional study on children and adolescents with a definite diagnosis of CD. They were followed in the main Celiac Clinic of Southern Iran.

RESULTS

We included 204 children who were visited between 2012 and 2017. Nearly 85% of them were positive for HLA-DQ2 and 40.6% for HLA-DQ8. The most prevalent intestinal complaints reported were abdominal pain (42.6%) and chronic constipation (19.1%). Failure-to-thrive (32.7%), iron deficiency anemia (25%), short stature (20.5%), and eczema (18.6%) were the most common EIMs. However, failure-to-thrive and short stature were presented at significantly younger ages, whereas those patients with concomitant type 1 diabetes mellitus (DM) were significantly older. We also found significant relationships between autoimmune thyroid disease and HLA-DQ5, and the presence of headaches with HLA-DQ7. The prevalence of HLA types of DQ2, DQ8, DQ6, and DQ7 significantly varied among different Marsh groups. Patients who were positive for HLA-DQ8, were significantly older, taller, and weightier. No significant association was found between HLA types and any of the gastrointestinal symptoms, anti-tTG and compliance to gluten free diet. Moreover, there were no statistically significant differences detected between the presence of each individual EIM, the level of IgA anti-tTG, sex, and Marsh typing.

CONCLUSION

This study highlights the presence of EIM in CD and their associated factors. We show the potential role of HLA typing in some EIMs, which may shed light for future studies.

Clinical spectrum & changing presentation of celiac disease in Indian children

Background & objectives

Celiac disease (CD) is a genetic immune mediated disorder characterised by gluten intolerance. This single centre study, from north India was aimed to assess the clinical, serological and histological profile of CD in a large cohort of children and the changing trends in its presentation.

Methods

A review of clinical details of CD children diagnosed between 2000 and 2019 and currently on follow up was performed. Information on demography, symptoms, associated conditions, serology, biopsy findings and gluten-free diet were analyzed.

Results

The mean age (±standard deviation) of 891 children included in the study, at onset and at diagnosis was 4.0±2.7 and 6.2±3.1 yr, respectively. Growth faltering, abdominal pain, abdominal distension and diarrhoea were presenting symptoms in 70, 64.2, 61.2 and 58.2 per cent, respectively. A positive family history of CD was present in 14 per cent and autoimmune conditions in 12.3 per cent of children. Thyroid disorders were seen in 8.5 per cent of children and Type 1 diabetes mellitus (T1DM) in 5.7 per cent. The duration of breastfeeding had a weak positive correlation with age at onset and diagnosis of CD (P<0.001). Non-classical CD was significantly more common in children aged >10 yr and in those presenting after 2010 (P<0.01). T1DM and hypothyroidism occurred more frequently in non-compliant children.

Interpretation & conclusions

This was the largest single centre study, pertaining to the presentation and follow up of CD in children. Infants and young children were more likely to present with classical symptoms of diarrhoea, abdominal distension and growth failure while older children presented with non-classical CD. There was a trend towards non-classical forms of CD in recent years.

Autoimmune Thyroid Disorders Are More Prevalent in Patients with Celiac Disease: A Retrospective Case-Control Study

Background. Among patients with celiac disease (CD), there is an increased incidence of autoimmune thyroid disorders (AITDs), with hypothyroidism being more frequent than hyperthyroidism. This retrospective case-control study aimed to explore the prevalence of TDs in a population of adult celiac patients from Northern Sardinia, a geographic area with a high prevalence of autoimmune disorders. Methods. Data were collected from consecutive patients with CD (cases) and without CD (controls) who were undergoing upper endoscopy and referred to a tertiary gastroenterology section of a teaching hospital (University of Sassari, Italy). Thyroid disorders were stratified as (i) autoimmune: including Hashimoto’s disease in euthyroidism or with hypofunction, and Graves’ disease; or (ii) non-autoimmune: thyroid nodules/goiter, iatrogenic thyroid hypo/hyperfunction, and thyroidectomy for any reason, including cancer. Results. Among a total of 8489 participants (females 5839, 64.7%) enrolled, there were 623 (7.3%) celiac patients and 7866 controls (92.7%). The overall frequency of TDs was 1177 (13.9%) and was higher (26.0%) in celiac patients than in controls (12.9%) (p < 0.001). The difference between AITDs (15.4% vs. 7.5%) and no-AITDs (2.7% vs. 1.1%) was statistically significant in CD patients compared with controls, respectively, and prevailed in the fifth and sixth decades. Hashimoto’s thyroiditis was more commonly associated with gland hypofunction. Odds ratios with their 95% confidence intervals (CIs) for the presence of AITDs were calculated, adjusting for sex, age, body mass index, smoking habits, occupation, and residence, and they were 2.387 (95% CI 1.857−3.068, p < 0.001) in CD patients, 5.855 (95% CI 4.434−7.731, p < 0.001) for female sex, and 1.012 (95% CI, 1.007−1.017, p < 0.001) for age. Conclusion. These results suggest the need for surveillance for TDs in patients with CD at onset and during follow-up.

ESPGHAN Position Paper on Management and Follow-up of Children and Adolescents With Celiac Disease

OBJECTIVES

To gather the current evidence and to offer recommendations for follow-up and management.

METHODS

The Special Interest Group on Celiac Diseases of the European Society of Paediatric Gastroenterology Hepatology and Nutrition formulated ten questions considered to be essential for follow-up care. A literature search (January 2010-March 2020) was performed in PubMed or Medline. Relevant publications were identified and potentially eligible studies were assessed. Statements and recommendations were developed and discussed by all coauthors. Recommendations were voted upon: joint agreement was set as at least 85%.

RESULTS

Publications (n = 2775) were identified and 164 were included. Using evidence or expert opinion, 37 recommendations were formulated on: The need to perform follow-up, its frequency and what should be assessed, how to assess adherence to the gluten-free diet, when to expect catch-up growth, how to treat anemia, how to approach persistent high serum levels of antibodies against tissue-transglutaminase, the indication to perform biopsies, assessment of quality of life, management of children with unclear diagnosis for which a gluten-challenge is indicated, children with associated type 1 diabetes or IgA deficiency, cases of potential celiac disease, which professionals should perform follow-up, how to improve the communication to patients and their parents/caregivers and transition from pediatric to adult health care.

CONCLUSIONS

We offer recommendations to improve follow-up of children and adolescents with celiac disease and highlight gaps that should be investigated to further improve management.

Rotavirus vaccination is not associated with incident celiac disease or autoimmune thyroid disease in a national cohort of privately insured children

Rotavirus infection is a potential trigger for autoimmune diseases, and previous reports note associations between rotavirus vaccination and type 1 diabetes. In this report, we examine the association between rotavirus vaccination and autoimmune diseases associated with type 1 diabetes: celiac disease and autoimmune thyroiditis. We conducted a retrospective cohort study using de-identified claims data (Optum Clinformatics^® Data Mart). Eligible infants were born between 2001 and 2018 and continuously enrolled from birth for at least 365 days (n = 2,109,225). Twenty-nine percent (n = 613,295) of infants were born prior to the introduction of rotavirus vaccine in 2006; 32% (n = 684,214) were eligible for the vaccine but were not vaccinated; 9.6% (n = 202,016) received partial vaccination, and 28.9% received full vaccination (n = 609,700). There were 1379 cases of celiac disease and 1000 cases of autoimmune thyroiditis. Children who were born prior to the introduction of rotavirus vaccine in 2006 had lower risk of celiac disease compared to unvaccinated children born after 2006 (hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.59, 0.85). However, children who were partially vaccinated (HR 0.90, 95% CI 0.73, 1.11) or fully vaccinated (HR 1.03, 95% CI 0.88, 1.21) had similar risk to eligible, unvaccinated children. Risk of autoimmune thyroiditis was similar by vaccination status. We conclude that rotavirus vaccination is not associated with increased or decreased risk for celiac disease or autoimmune thyroiditis.

Review on pediatric coeliac disease from a clinical perspective

Coeliac disease is an immune-mediated condition characterized by chronic inflammation of the small bowel with villous atrophy driven by gluten ingestion in genetically predisposed individuals. It occurs frequently in both children and adults, affecting 1-4% of the population. The disease is associated with both gastrointestinal and extra-intestinal symptoms related to malabsorption and/or immune activation, and autoantibodies to tissue transglutaminase. Removal of gluten from the diet results in resolution of symptoms and enteropathy in the majority of patients. A good diagnostic work-up is important to avoid unnecessary restrictive diets in children. In this review on pediatric coeliac disease, we address epidemiology including predisposing environmental factors and possible preventive strategies, as well as the clinical presentation, diagnosis and follow-up. What is Known: •Primary prevention of coeliac disease is not possible; however, secondary prevention by targeting high-risk groups is recommended. •The diagnosis is safe without duodenal biopsies if specific conditions are met, also in asymptomatic children. What is New: •HLA-DQ typing is not routinely required for the diagnosis, whereas it can rule out coeliac disease if HLA-DQ2 and HLA-DQ8 are absent. •Follow-up could be improved by a more rational use of (laboratory) tests, increased intention to dietary compliance and quality of life.

Follow-up practices for children and adolescents with celiac disease: results of an international survey

Adequate follow-up in celiac disease is important to improve dietary compliance and treat disease-related symptoms and possible complications. However, data on the follow-up of celiac children is scarce. We aimed to assess current pediatric celiac follow-up practices across Europe. Pediatricians and pediatric gastroenterologists from 35 countries in Europe, Israel, Turkey, and Russia completed an anonymous survey which comprised a 52-item questionnaire developed by the ESPGHAN Special Interest Group on Celiac Disease. A total of 911 physicians, the majority of whom exclusively worked in pediatric care (83%) and academic institutions (60%), completed the questionnaire. Mean age and mean experience with celiac care were 48.7 years (± 10.6) and 15.7 years (± 9.9), respectively. The vast majority (≥ 92%) always assessed anthropometry, dietary adherence, and tissue-transglutaminase IgA-antibodies at every visit, with the first visit being between 3 and 6 months after diagnosis. Other parameters (% always tested) were as follows: complete blood count (60%), iron status (48%), liver enzymes (42%), thyroid function (38%), and vitamin D (26%). Quality of life was never assessed by 35% of the responding physicians. Transition to adult care was mostly completed via a written transition report (37%) or no formal transition at all (27%).Conclusions: Follow-up of celiac children and adolescents in Europe may be improved, especially regarding a more rational use of (laboratory) tests, dietary and QoL assessment, and transition to adult care. Evidence-based advice from international scientific societies is needed. What is Known: • Follow-up in celiac disease is important to treat disease-related symptoms, improve dietary compliance, and prevent possible complications. • There is a lack of consensus about the appropriate follow-up. What is New: • Almost all European physicians assess anthropometry, tissue-transglutaminase IgA-antibodies, and dietary adherence at every visit, but there are large variations in other follow-up aspects. • Follow-up could be improved by a more rational use of (laboratory) tests, increased intention to dietary compliance, and quality of life together with transition programs to adult care.

Gluten-free diet can ameliorate the symptoms of non-celiac autoimmune diseases

CONTEXT

A gluten-free diet (GFD) is the recommended treatment for gluten-dependent disease. In addition, gluten withdrawal is popular and occasionally is suggested as a treatment for other autoimmune diseases (ADs).

OBJECTIVE

The current systematic review summarizes those entities and discusses the logic behind using a GFD in classical non-gluten-dependentADs.

DATA SOURCES

A search for medical articles in PubMed/MEDLINE, Web of Sciences, LILACS, and Scielo published between 1960 and 2020 was conducted, using the key words for various ADs and GFDs.

DATA EXXTRACTION

Eight-three articles were included in the systematic review (using PRISMA guidelines).

DATA ANALYSIS

Reduction in symptoms of ADs after observance of a GFD was observed in 911 out of 1408 patients (64.7%) and in 66 out of the 83 selected studies (79.5%). The age of the patients ranged from 9 months to 69 years. The duration of the GFD varied from 1 month to 9 years. A GFD can suppress several harmful intraluminal intestinal events. Potential mechanisms and pathways for the action of GFD in the gut - remote organs' axis have been suggested.

CONCLUSION

A GFD might represent a novel nutritional therapeutic strategy for classical non-gluten-dependent autoimmune conditions.

Whether a Gluten-Free Diet Should Be Recommended in Chronic Autoimmune Thyroiditis or Not?-A 12-Month Follow-Up

Elimination diets have recently become extremely popular among people with autoimmune diseases. A gluten-free diet is indicated in celiac disease (CD), but some studies show its effectiveness in cases of autoimmunity. The aim of this study was to assess whether the use of a gluten-free diet is also effective in patients with chronic autoimmune thyroid disease (cAITD), which is the most common thyroid autoimmune pathology associated with chronic inflammation, over-reactivity of the immune system, auto-destruction of thyrocytes and hypothyroidism. The final analysis of the study included 62 Caucasian women randomized into a control group (CG: n = 31) and an experimental group on a gluten-free diet (GFDG: n = 31), were subject to a 12-month follow-up, during which the concentrations of thyrotropin (TSH), free triiodothyronine (fT3), free thyroxine (fT4), anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-TG) antibodies were assessed at baseline and after 3, 6 and 12 months. During the 12-month follow-up between the CG and the GFDG, no differences were found in anti-TPO and anti-TG antibodies, fT3 or fT4 levels, except a significant reduction in TSH levels in the GFDG. Additionally, performed analysis between individual appointments presented no significant differences in changes in the median concentrations of anti-TPO, anti-TG or fT3, but confirmed a significant decrease in TSH and showed accessory an increase in fT4 after 12 months in GFDG. Statistical analyses performed separately for both groups indicated a constant reduction of anti-TG concentrations in the GFDG. In conclusion, a GFD may be administered in cAITD after ruling out celiac disease, but it is necessary to perform more studies to assess if cAITD patients achieve the benefits of following a GFD. Patients with cAITD should be offered proper nutrition education combined with a healthy lifestyle promotion.

Iodine Absorption in Celiac Children: A Longitudinal Pilot Study

Background: non-autoimmune thyroid disorder is a common finding in celiac patients, more frequent than in the general population. An impairment of iodine absorption has been hypothesized, but it has never been investigated so far. We aimed to evaluate the iodine absorption in children and adolescents with newly diagnosed celiac disease. Methods: 36 consecutive celiac patients (age 7.4 years, range 2.4-14.5 years) before starting a gluten-free diet (GFD) were enrolled. We assayed the urinary iodine concentration (UIC) in a 24-h urine sample, at baseline (T0) after 3 (T1) and 12 months (T2) of GFD. Results: UIC at T0 was 64 μg/L (IQR 45-93.25 μg/L) with an iodine deficiency rate of 77.8%. UIC was not different according to histological damage, clinical presentation (typical vs atypical); we found no correlation with the thyroid function tests and auxological parameters. UIC was not statistically different at T1 (76 μg/L) and T2 (89 μg/L) vs T0. UIC at T2 was similar between patients with positive and negative anti-transglutaminase antibodies at T2. No patients presented overt hypothyroidism during the study. Conclusions: We found that iodine absorption in celiac children is impaired compared to the general population; it increases slightly, but not significantly, during the GFD. We should regularly reinforce the need for a proper iodine intake in celiac disease patients to reduce iodine deficiency risk.

Celiac Disease and the Autoimmune Web of Endocrinopathies

Gluten-sensitive enteropathy or Celiac disease (CD) is a disease that has become very prevalent in most parts of the globe especially in the western world. Resulting from a chaotic interplay between the backgrounds of autoimmunity and genetics, this disorder targets primarily the gastrointestinal tract with ominous extraintestinal counterparts that have a very discrete presentation. Among those counterparts, the one that has been reviewed in this article is the involvement of the endocrine system as concurrence of hormonal disorders with CD possesses numerous challenges that lead to a refractory treatment and a dull prognosis. This review article aims to feature the effect of the CD and endocrine disorders on one another, especially if either of the diseases is asymptomatic, explore the clinical dilemma faced by clinicians in various specialties, and, hence, further pave a path into the importance of rigorous screening and diagnosis.

Frequency of autoimmune thyroiditis in children with Celiac disease and effect of gluten free diet

Objective

To determine the frequency of autoimmune thyroiditis in children with Celiac disease and the effect of gluten free diet on autoimmune thyroiditis.

Methods

We enrolled 100 patients, age 1-12 years of either gender diagnosed as Celiac disease (CD) in this prospective observational study in the Department of Pediatric Medicine, from 1^st January 2018 to 30^th June 2019. Diagnosis of autoimmune thyroiditis was made if anti-thyroperoxidase >35 iu/ml or anti-thyroglobulin >20 iu/ml at diagnosis of CD and then at one year on gluten free diet (GFD) in all cases. Children with repeat anti-tTG levels > 10 times upper limit normal at 6-months after enrollment were labelled as non-compliant to GFD. Descriptive statistics were used to analyze the data.

Results

Mean age of the participants was 5.94±3.16 years and 53% were females. Fourteen cases of autoimmune thyroiditis were detected at enrollment and six (7%, n/N = 6/86) were later diagnosed on follow-up who were initially negative. Seven hypothyroid cases among the autoimmune thyroiditis were treated with thyroxine and became euthyroid on follow-up testing. Compliance to GFD was 52%. Autoimmune thyroiditis improved on gluten free diet in four cases (28.6%). Of the six euthyroid cases at diagnosis three cases became hypothyroid and all were non-compliant.

Conclusion

Frequency of autoimmune thyroiditis was 20% over a follow-up period of one year. Good compliance with the GFD has some effect on improving autoimmune thyroiditis and maintaining euthyroid status of CD patients.

Type 1 diabetes, thyroid, gastric and adrenal humoral autoantibodies are present altogether in almost one third of adult celiac patients at diagnosis, with a higher frequency than children and adolescent celiac patients

Background: No data are available on the frequency of organ-specific humoral autoimmunity at diagnosis of adult celiac disease (CD).Aim: To evaluate the humoral immunoreactivities specific of type 1 diabetes (T1D), thyroid (THD), atrophic-gastritis (AG) and Addison's (AD) diseases in 92 adult CD patients at diagnosis and 237 adult healthy subjects (CTRL).Methods: T1D, THD and AD specific autoantibodies were analyzed by radioimmunoprecipitation assays. AG autoantibodies were detected by enzyme-linked immunosorbent assay.Results: Of 92 CD patients, 31.5% were positive for at least one of the organ-specific autoantibodies investigated (p < .0001 vs CTRL). Thyroid, diabetes, gastric and adrenal-autoantibodies, that increase with age at diagnosis, were detected in 12.0%, 10.9%, 10.9%, 2.2% of CD patients, respectively. Gastric- and diabetes- rather than thyroid- and adrenal-autoimmunity seem to be specifically related to presence of CD.Conclusions: One third of adult CD patients at diagnosis is target of at least one organ-specific autoantibody. A systematic organ-specific autoantibody screening in these patients might be of value to promptly identify, prevent or treat the relative diseases.

Prevalence of coexisting autoimmune thyroidal diseases in coeliac disease is decreasing

BACKGROUND

Coeliac disease (CD) is associated with an increased risk of other immune-mediated conditions. Aim: To investigate the prevalence of coexistent immune-mediated diseases in CD patients, and changes in the prevalence of autoimmune thyroidal diseases over the last 50 years.

METHODS

Medical record data were collected retrospectively from 749 CD patients in Ireland. Prevalence of autoimmune diseases was compared with previously published results from general populations. Patients were divided into four groups based on the year of diagnosis to analyse changes in the prevalence of autoimmune thyroidal disease over time.

RESULTS

Median age at the time of CD diagnosis was 56 years (range 18-91 years). A total of 233 (31.1%) patients had a coexistent immune-mediated condition (IMC). Autoimmune thyroidal diseases were seen in 149 (19.9%) patients, hypothyroidism in 110 (14.7%), type 1 diabetes in 27 (3.6%), psoriasis in 20 (2.7%), inflammatory bowel disease in 14 (1.9%) and rheumatoid arthritis in 12 (1.6%). All conditions were more common in CD patients than in the general population. Type 1 diabetes was diagnosed mainly before CD, whereas there was no such trend in other conditions. Autoimmune thyroidal diseases became less common in female CD patients over time.

CONCLUSIONS

Prevalence of autoimmune diseases is increased in adult CD patients compared with the general population. However, concomitant autoimmune thyroidal diseases became less common over time in women.

The Risk of Autoimmune Disorders in Treated Celiac Disease Patients in Olmsted County, Minnesota

BACKGROUND

Patients with autoimmune disorders (ADs) are at increased risk for celiac disease (CD), but data are conflicting on the risk of ADs in treated patients with CD. We aimed to assess the incidence of ADs in treated patients with CD.

METHODS

Using the Rochester Epidemiology Project, we retrospectively searched for the medical records at Mayo Clinic and Olmsted Medical Center from January 1997 to December 2015 for patients with CD who met accepted diagnostic criteria. For each patient with CD, we identified 2 age and sex-matched controls during the same study period. The incidence rate of AD diagnosis 5 years after index date was calculated using Kaplan-Meier analysis for the CD cases and controls and compared using the log-rank test.

RESULTS

We identified 249 treated patients with CD during the study period and 498 matched controls, with mean (standard deviation) ages of 32 (22) years and 33 (22) years, respectively. One third of patients (n = 85) and controls (n = 170) were boys. Five years after the index date, 5.0% of patients with CD and 1.3% of controls had a de novo AD diagnosis (P = 0.006). In the presence of a prior AD, the cumulative risk of a de novo or additional AD was significantly higher in the CD group compared with controls (P < 0.001). Children had a significantly higher risk of AD development compared with adults (P = 0.010).

CONCLUSIONS

Treated patients with CD are at higher risk for the development of ADs. The risk of a new AD is higher in children, especially when >1 AD diagnosis exists.

Thyroid and celiac disease in pediatric age: a literature review

Chronic autoimmune thyroid disease or Hashimoto thyroiditis (HT) and Graves-Basedow disease (GD) are the main autoimmune thyroid diseases in pediatric age. Both are characterized by the production of anti-thyroid antibodies, by an infiltration of autoreactive B and T lymphocytes into the thyroid parenchyma and by alterations in thyroid function (hyperthyroidism in GD, normal function or subclinical hypothyroidism in HT with possible evolution towards manifest hypothyroidism). Celiac disease (CD) is a systemic autoimmune disease caused by gluten ingestion in genetically predisposed subjects, its prevalence is around 1% in Western Countries. It presents with a pathognomonic enteropathy, a variety of clinical manifestations, positivity for specific antibodies, positivity for typical haplotypes HLA DQ2/DQ8. The clinical manifestations may vary among four types: typical, atypical, silent and latent. Diagnosis can be made in presence of specific histopathologic findings in duodenal biopsies and antibodies positivity. Celiac disease is associated to various endocrine autoimmunities such as thyropathies, diabetes mellitus type 1, Addison disease, multiendocrine syndromes. The most frequent associated thyropaties are HT and GD. The present review aims to explore the associations between thyropathies and celiac disease in pediatric age.

Celiac disease in children

Celiac disease is a common immune-mediated disease, that may present, after gluten ingestion, with various and heterogeneous symptoms that can vary according to patients' age. The diagnostic screening test is serum anti-tissue transglutaminase IgA level. In doubt cases, antiendomysium IgA and the antideamidated gliadin peptides IgG could be useful to confirm the suspicion, before a biopsy will be perform. Since 2012, guidelines have made it possible to avoid the biopsy in symptomatic pediatric patients with high levels of antitransglutaminase IgA, positivity to antiendomysium IgA, and with HLA DQ2 or DQ8. In all other cases duodenal biopsy is still mandatory to confirm the diagnosis. The therapy of celiac disease is a lifelong gluten free diet. In children prognosis of celiac disease is good, without complications. Here we review and discuss the present literature about celiac disease in childhood.

Impact of Thyroid Autoimmunity on Thyroid Function in 12-year-old Children With Celiac Disease

OBJECTIVES

Celiac disease (CD) is associated with thyroid autoimmunity and other autoimmune diseases. Data are, however, lacking regarding the relationship between thyroid autoimmunity and thyroid function, especially in regard to CD. Our aim was to investigate the impact of thyroid autoimmunity on thyroid function in 12-year-old children with CD compared to their healthy peers.

METHODS

A case-referent study was conducted as part of a CD screening of 12-year-olds. Our study included 335 children with CD and 1695 randomly selected referents. Thyroid autoimmunity was assessed with antibodies against thyroid peroxidase (TPOAb). Thyroid function was assessed with thyroid-stimulating hormone and free thyroxine.

RESULTS

TPOAb positivity significantly increased the risk of developing hypothyroidism in all children. The odds ratios (with 95% confidence intervals) were 5.3 (2.7-11) in healthy 12-year-olds, 10 (3.2-32) in screening-detected CD cases, 19 (2.6-135) in previously diagnosed CD cases, and 12 (4.4-32) in all CD cases together. Among children with TPOAb positivity, hypothyroidism was significantly more common (odds ratio 3.1; 95% CI 1.03-9.6) in children with CD (10/19) than in children without CD (12/46).

CONCLUSIONS

The risk of thyroid dysfunction due to thyroid autoimmunity is larger for those with CD than their healthy peers. Our study indicates that a gluten-free diet does not reduce the risk of thyroid dysfunction. Further studies are required for improved understanding of the role of the gluten-free diet for the risk of autoimmune diseases in children with CD.

Celiac Disease and Glandular Autoimmunity

Celiac disease is a small intestinal inflammatory disease with autoimmune features that is triggered and maintained by the ingestion of the storage proteins (gluten) of wheat, barley, and rye. Prevalence of celiac disease is increased in patients with mono- and/or polyglandular autoimmunity and their relatives. We have reviewed the current and pertinent literature that addresses the close association between celiac disease and endocrine autoimmunity. The close relationship between celiac disease and glandular autoimmunity can be largely explained by sharing of a common genetic background. Further, between 10 and 30% of patients with celiac disease are thyroid and/or type 1 diabetes antibody positive, while around 5–7% of patients with autoimmune thyroid disease, type 1 diabetes, and/or polyglandular autoimmunity are IgA anti-tissue transglutaminase antibody positive. While a gluten free diet does not reverse glandular autoimmunity, its early institution may delay or even prevent its first manifestation. In conclusion, this brief review highlighting the close association between celiac disease and both monoglandular and polyglandular autoimmunity, aims to underline the need for prospective studies to establish whether an early diagnosis of celiac disease and a prompt gluten-free diet may positively impact the evolution and manifestation of glandular autoimmunity.

REVIEW OF CELIAC DISEASE PRESENTATION IN A PEDIATRIC TERTIARY CENTRE

ABSTRACT BACKGROUND: Celiac disease is an immune-mediated disorder with a multiform presentation and therefore a challenging diagnosis. OBJECTIVE: Our purpose is to identify the epidemiological, clinical, laboratory and histologic characteristics of children with celiac disease at diagnosis and on follow-up. METHODS: Children with previously established or newly diagnosed celiac disease, admitted in a tertiary centre in a two-year period (2014-2016) were recruited. Data was collected retrospectively from electronic medical records and clinical notes, and subsequently analysed with SPSS version 20.0. RESULTS: A total of 159 patients, out of 312, were included. Age ranged from 1 to 17 years (mean ± SD: 8.5±4.5 years, 69% girls). Disease presentation was classical in 60%, non-classical in 25%, subclinical in 10% and 5% classified as potential celiac disease. Non-classical and subclinical profiles had a higher mean age at presentation but not statistically significant (P-value 0.24). The most frequent gastrointestinal features at presentation were abdominal pain (58%), diarrhea (43%) and bloating (27%). A positive family history for celiac disease was present in 24% (n=35). We found anaemia in 23%, low ferritin in 63% and a moderate to severe deficiency of 25-hydroxyvitamin D in 62%. celiac disease -specific serologic testing and esophagogastroduodenoscopy were performed in 99%. Histology revealed modified Marsh 2 or 3 enteropathy in 94%, the remaining had normal histology but positive human leukocyte antigen typing. Clinical improvement at 12 months of gluten-free diet was complete in 51% and partial in 49%. IgA tTG normalized after 12-30 months of gluten-free diet in 45%. On growth assessment at diagnosis and after 12-28 months of gluten-free diet, 100% had height increase (mean ±SD: 7.11±4.43 cm) and 96% weight gain (mean ±SD: 5.60±4.91 kg). CONCLUSION: Our findings outline the diverse clinical presentations of pediatric celiac disease that should be considered irrespective of age. Increased clinician’s awareness will enable an early diagnosis and treatment, with subsequent symptom and nutritional status improvement.

Review article: coeliac disease in later life must not be missed

BACKGROUND

The presenting symptoms of coeliac disease are often subtle and the diagnosis is frequently delayed or overlooked. Therefore, especially elderly patients may be denied the benefits conferred by gluten free diet which can be dramatically life-changing.

AIM

To review the occurrence, clinical features, diagnosis and management in coeliac patients detected later in life.

METHODS

To review manuscripts concerned with coeliac disease in the elderly and to derive subgroups of elderly people from publications on the disorder.

RESULTS

Approximately a quarter of all diagnoses are now made at the age of 60 years or more and a fifth at 65 years or over. About 4% are diagnosed at 80 years or above. Around 60% remain undetected, since their symptoms are often subtle: tiredness, indigestion, reduced appetite. Good compliance with gluten free diet, resolution of symptoms and improvement in laboratory indices can be achieved in over 90% of patients.

CONCLUSIONS

Coeliac disease not uncommonly presents for the first time in older patients and is an important diagnosis to make.

Chronic autoimmune disorders are increased in coeliac disease: A case-control study

Coeliac disease (CD) is an autoimmune disorder of the small bowel associated with increased risk of additional autoimmune diseases (ADs).To investigate the prevalence of ADs in a population of adult coeliac patients.This was a retrospective case-control study. Data from coeliac patients and controls referred to a tertiary center between 2013 and 2016 were collected. The frequency of ADs and the unadjusted and adjusted odds ratios (ORs) for age, gender, disease duration, and body mass index with their 95% confidence intervals (CIs) were evaluated.Two hundred fifty-five patients with CD (median age 37.1 years; 206 women) were matched with 250 controls. ADs were more frequent (35.3%) in coeliac patients than in controls (15.2%). Adjusted ORs for the presence of only 1, at least 1, and more than 1 AD were 3.13 (95% CI 1.81-5.42, P < .0001), 3.31 (95% CI 2.00-5.46, P < .0001), and 3.93 (95% CI 1.49-10.36, P = .006), respectively. Hashimoto thyroiditis was the most prevalent AD (24.3% vs. 10%) OR = 2.55 (95% CI 1.39-4.70, P < .0001), followed by psoriasis (4.3% vs. 1.6%), type 1 diabetes (2.7% vs. 0.4%), and Sjögren syndrome (2.4% vs. 0.4%).These findings suggest a need for a careful surveillance of autoimmune status, especially for Hashimoto thyroiditis in patients with celiac disease.

Pediatric Celiac Disease: Follow-Up in the Spotlight

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.

Celiac disease: a clinical review

Celiac disease (CD) is an immune-mediated inflammatory enteropathy triggered by gluten exposure in genetically susceptible individuals. It has a high prevalence approaching 1% of the US population. A high index of suspicion is warranted to diagnose CD as frequently patients present with extraintestinal or atypical manifestations. CD is diagnosed by a combination of serum serologies and duodenal biopsies. The majority of patients will respond to a lifelong gluten-free diet which is the cornerstone of therapy. Complications such as refractory CD, ulcerative jejunoileitis, enteropathy associated T-cell lymphoma and small bowel adenocarcinoma occur in a minority of patients.

Increased Incidence of Thyroid Disease in Patients with Celiac Disease: A Systematic Review and Meta-Analysis

The prevalence of thyroid disease is likely increased among individuals with celiac disease (CD). In addition, exposure to gluten-free treatment may be associated with a risk of thyroid disease, but this association remains controversial. A systematic review was performed to evaluate the association between thyroid disease and CD. The articles were obtained from the PubMed, Web of Science, Embase, and Chinese WanFang bibliographical databases for the period up to May 2016. The results were analysed in a meta-analysis with odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs). There were 13 articles in this meta-analysis, including 15629 CD cases and 79342 controls. Overall, the prevalence of thyroid disease in patients with CD was significantly increased compared with that in the control groups (OR 3.08, 95% CI 2.67-3.56, P<0.001). Moreover, there was no significant difference in the OR between the gluten-treated and untreated groups (OR 1.08, 95% CI 0.61-1.92, P = 0.786). The results of our meta-analysis support the hypothesis that the prevalence of thyroid disease in patients with CD is increased compared with that in controls, which suggests that CD patients should be screened for thyroid disease. The effect of gluten-free treatment on thyroid disease needs further investigation.

Evidence-Informed Expert Recommendations for the Management of Celiac Disease in Children

Although the need for effective long-term follow-up for patients with celiac disease (CD) has been recognized by many expert groups, published practice guidelines have not provided a clear approach for the optimal management of these patients. In an attempt to provide a thoughtful and practical approach for managing these patients, a group of experts in pediatric CD performed a critical review of the available literature in 6 categories associated with CD to develop a set of best practices by using evidence-based data and expert opinion. The 6 categories included the following: bone health, hematologic issues, endocrine problems, liver disease, nutritional issues, and testing. Evidence was assessed by using standardized criteria for evaluating the quality of the data, grade of evidence, and strength of conclusions. Over 600 publications were reviewed, and 172 were chosen for inclusion. The thorough review of the results demonstrated that the quality of the data available was often insufficient to provide unequivocal best practices. However, using the available data and the clinical experience of the panel, a practical framework for the management of children with CD was created. These recommendations were developed by our expert panel and do not necessarily reflect the policy of the American Academy of Pediatrics. The potential usefulness of these best practices is underscored by the fact that consensus, measured by the outcome of anonymous voting, was reached by the panel for 24 of the 25 questions. We hope that these best practices may be useful to the pediatric gastroenterology and larger general pediatric communities.

Gluten-free diet does not influence the occurrence and the Th1/Th17-Th2 nature of immune-mediated diseases in patients with coeliac disease

INTRODUCTION

Coeliac disease (CD) is the most common Th1-mediated enteropathy, frequently associated with other immune-mediated disorders (IMD).

AIMS

To evaluate: (1) the prevalence of IMD at the time of and after CD diagnosis; (2) a possible change in immune response to gluten free diet (GFD); (3) the potential role of GFD in reducing and/or preventing IMD in CD.

METHODS

Prospective study including all consecutive adult CD patients who underwent investigations for Th1-Th17/Th2-IMD at the time of CD diagnosis and after a 5-year follow-up period.

RESULTS

1255 CD were enrolled. Of these, 257 patients (20.5%) showed IMD at the time of CD diagnosis, with 58.4% presenting a Th1/Th17-IMD. After a 5-year follow-up period, 682 patients (54.3%) showed new IMD despite GFD. Of these, 57.3% presented a Th1/Th17-IMD and 42.7% a Th2-IMD (p=0.8). When compared the prevalence of each type of IMD before and after CD diagnosis, we did not identify any significant "switch" from Th1/Th17- to Th2-IMD or vice versa. The number of patients with Th1/Th17- and/or Th2-IMD increased during the GFD period (20.5% vs 54.3%; p<0.01; OR 1.9).

CONCLUSIONS

The prevalence of IMD at the time of CD diagnosis is high and it seems to increase in the follow-up period despite GFD.

Celiac Disease and Risk of Autoimmune Disorders: A Population-Based Matched Birth Cohort Study

OBJECTIVES

To estimate the relative risk of developing type 1 diabetes mellitus (T1DM) and autoimmune thyroid disease in children with celiac disease (CD).

STUDY DESIGN

A matched cohort design with linkage of administrative data was adopted. A total of 1215 cases of CD and 6075 references matched by sex and year of birth born in Friuli Venezia Giulia Region (Italy) between 1989 and 2011 were included. Cox regression models were used to estimate hazard ratios (HRs) for autoimmune diseases in patients with CD compared with references, stratified by sex and age at diagnosis.

RESULTS

Individuals with CD had an increased risk of subsequent hypothyroidism (HR 4.64 [95% CI 2.88-7.46]) and T1DM (HR 2.50 [95% CI 0.94-6.66]), the latter not statistically significant. Risk of hypothyroidism was higher in males (HR 20.00; 95% CI 5.64-70.87) than females (HR 3.21; 95% CI 1.85-5.57) (P value <.01). No differences were observed between males and females risks for diabetes or age at CD diagnosis. The small number of hyperthyroidism cases identified precluded any statistical analysis.

CONCLUSIONS

Children and youth with CD are at increased risk of developing autoimmune hypothyroidism and to some extent T1DM. This suggests the need for surveillance of children with CD in order to timely detect the onset of such comorbidities.

Complementary Serologic Investigations in Children with Celiac Disease Is Unnecessary during Follow-Up

OBJECTIVES

To determine the frequency of nutritional deficiencies and thyroid dysfunction in children with celiac disease (CD) and during follow-up after initiation of a gluten-free diet. Laboratory investigations of hemoglobin, ferritin, calcium, folate, vitamin B12, vitamin D, and thyroid function are regularly ordered in children with CD despite sufficient evidence for these.

STUDY DESIGN

Between 2009 and 2014, test results of hemoglobin, ferritin, folate, vitamin B12, calcium, vitamin D (25[OH]D), free thyroxin, and thyroid stimulating hormone of children with CD regularly seen at the Leiden University Medical Center were investigated. Laboratory reference ranges were used to define abnormal results. Pearson χ(2) test for trend, unpaired t test, and 1-way ANOVA were used for statistical analysis.

RESULTS

Of the 182 children evaluated, 119 were newly diagnosed. On average, 17% of results per year were missing because of incomplete blood investigations. Iron deficiency (28%) and iron deficiency anemia (9%) were found at the time of diagnosis of CD. Folate (14%), vitamin B12 (1%), and vitamin D deficiencies (27%) were also seen. No hypocalcemia or thyroid dysfunction was found. At follow-up, iron deficiency, iron deficiency anemia, and folate and vitamin D deficiency were observed in 8%, 2%, 3%, and 25% of patients, respectively. Vitamin B12 deficiency, hypocalcemia, and thyroid disease were not found.

CONCLUSIONS

Complementary blood investigations are relevant at the time of diagnosis of CD but have little diagnostic yield during follow-up visits once the patient is placed on a gluten-free diet. Thus, we recommend that these variables only be assessed on indication, such as fatigue or abnormal growth.

Relevance, pathogenesis and clinical implications of thyroid disorders in children with celiac disease

Celiac disease is a frequent chronic inflammatory small bowel disease which may present itself with associated autoimmune comorbidities. Among these comorbidities, thyroid disorders show a significant prevalence; even in the pediatric population. However, the exact epidemiology and clinical significance of such alterations are yet to be fully elucidated. The most updated guidelines do not currently offer any specific support. Focusing on the pediatric population, we will review the recent available literature that we believe might be helpful in advancing the clinician's knowledge-base regarding this issue. We also discuss which, to our knowledge, are the key pathophysiologic concepts behind the association between these two entities. Finally, we offer our own clinical perspective, recommending routine laboratory thyroid screening, possibly followed by an echographic thyroid evaluation as we believe such an approach to be appropriate when caring for children with celiac disease.

Antithyroid antibodies and thyroid function in pediatric patients with celiac disease

Objective. Aim of the study was to determine the prevalence of autoimmune thyroid disease, persistence of antithyroid antibodies, effect of gluten-free diet, and long-term outcome of thyroid function in pediatric patients with celiac disease (CD). Methods. 67 patients with CD aged from 1 year to 16 years were screened for thyroid antithyroperoxidase, antithyroglobulin and anti-TSH receptor antibodies, serum free triiodothyronine, free thyroxine, and thyroid-stimulating hormone (TSH) at diagnosis and during follow-up. Results. None of the patients had antithyroid antibodies at diagnosis. Antithyroid antibodies became positive in 16.4% of the patients (11/67) 2 to 3 years after the diagnosis of CD. Clinical hypothyroidism was observed only in 3 of 11 CD patients with positive antithyroid antibodies (27.2%). The antithyroid antibodies positive and negative patients did not differ significantly according to compliance to GFD (P > 0.05). A statistically significant difference was observed only in age, in which the patients with positive antithyroid antibodies were younger than the patients with negative antithyroid antibodies (P = 0.004). None of the patients had any change in their thyroid function and antibody profile during their follow-up. Conclusion. Antithyroid antibodies were detected in younger pediatric patients with CD and the prevalence of antithyroid antibodies did not correlate with the duration of gluten intake.

Thyroid-associated orbitopathy is linked to gastrointestinal autoimmunity

Common autoimmune disorders tend to co-exist in the same subjects and cluster in families. The objective of this study was to determine the prevalence of autoimmune co-morbidity in patients with autoimmune thyroid disease (AITD) with and without thyroid-associated orbitopathy (TAO). This was a cross-sectional study conducted at an academic tertiary referral centre. Of 1310 patients with AITD [n = 777 or 59% with Graves' disease (GD) and n = 533, 41% with Hashimoto's thyroiditis (HT)] followed at a specialized joint thyroid-eye out-patient clinic, 176 (13·4%) had an adult type of the autoimmune polyglandular syndrome, 129 (9·8%) type 1 diabetes, 111 (8·5%) coeliac disease, 60 (4·6%) type A autoimmune gastritis, 57 (4·4%) vitiligo and 25 (1·9%) Addison's disease. Coeliac disease and autoimmune gastritis were associated positively with GD [odds ratio (OR) = 2·18; P = 0·002 and OR = 6·52; P < 0·001], whereas type 1 diabetes, Addison's disease, autoimmune primary hypogonadism, alopecia areata, rheumatoid arthritis and Sjögren's syndrome were 'protective' for GD and thus linked to HT, OR = 0·49 (P < 0·001), 0·06 (P < 0·001), 0·25 (P < 0·001), 0·50 (P = 0·090) and 0·32 (P = 0·003), respectively. Of 610 (46·6%) AITD patients with TAO, 584 (95·7%) and 26 (4·3%) had GD and HT, respectively (P < 0·001). TAO was most prevalent in GD patients with coeliac disease (94%, OR = 1·87, P < 0·001). Multivariate analysis showed high OR for coeliac disease and autoimmune gastritis (3·4 and 4·03, both P < 0·001) pertaining to the association with TAO while type 1 diabetes, Addison's disease and alopecia areata were protective for TAO. In patients with TAO, coeliac disease is the most prevalent co-morbid autoimmune condition and rates are increased compared to GD patients without TAO.

Epidemiology of coeliac disease and comorbidity in Norwegian children

OBJECTIVES

The aim of this study was to describe the occurrence of clinically diagnosed coeliac disease in children ages 0 to 12 years in Norway, including regional variation and coexisting type 1 diabetes mellitus, thyroid disease, and Down syndrome.

METHODS

The Norwegian Patient Register (NPR) contains individual-level hospital data from 2008 onward. Small-bowel biopsies for establishing the coeliac disease diagnosis are only performed at public hospitals reporting to the NPR. Data on all hospital contacts during 2008-2011 when a diagnosis of coeliac disease was registered were retrieved from the NPR for patients born between 1999 and 2011, allowing estimation of the proportion registered with coeliac disease at ages 0 to 12 years in a cohort study.

RESULTS

A total of 3006 individuals (58.2% girls) were recorded as having coeliac disease among 797,360 children, corresponding to a proportion of 3.8/1000 (95% confidence interval [CI] 3.7-3.9/1000) children, 4.5 (CI 4.3-4.7) among girls and 3.1 (CI 2.9-3.3/1000) among boys (P < 0.001). The proportion increased with age up to approximately 6 years and was 5.0/1000 (CI 4.5-5.6) at the age of 12 years, and was slightly higher in the south/west (3.9/1000) as compared to the middle/north (3.5/1000) regions of Norway (P = 0.013). A total of 214 of 3006 (7.1%) patients with coeliac disease were registered with coexisting conditions: type 1 diabetes mellitus (n = 142, 4.7%), Down syndrome (n = 47, 1.6%), or thyroid disease (n = 41, 1.4%).

CONCLUSIONS

In this first nationwide study of clinically diagnosed coeliac disease in Norwegian children, we found a high occurrence, comparable with that in Sweden. Comorbidity was common, but routine screening of high-risk groups contributed to a limited number of cases.

Celiac disease and autoimmunity: review and controversies

Celiac disease (CD) is an autoimmune condition affecting the small intestine, triggered by the ingestion of gluten, the protein fraction of wheat, barley, and rye. There is a strong linkage between CD and HLA-DQ2 and HLA-DQ8 haplotypes. Multiple case reports and small series suggest concordance between CD and other autoimmune disorders. This paper provides a brief overview of the pathogenesis of CD and reviews the literature regarding associations between CD and other autoimmune diseases, including the potential effects of gluten-free diet therapy on the prevention or amelioration of associated diseases.

Celiac disease and autoimmune-associated conditions

Celiac disease (CD) is frequently accompanied by a variety of extradigestive manifestations, thus making it a systemic disease rather than a disease limited to the gastrointestinal tract. This is primarily explained by the fact that CD belongs to the group of autoimmune diseases. The only one with a known etiology is related to a permanent intolerance to gluten. Remarkable breakthroughs have been achieved in the last decades, due to a greater interest in the diagnosis of atypical and asymptomatic patients, which are more frequent in adults. The known presence of several associated diseases provides guidance in the search of oligosymptomatic cases as well as studies performed in relatives of patients with CD. The causes for the onset and manifestation of associated diseases are diverse; some share a similar genetic base, like type 1 diabetes mellitus (T1D); others share pathogenic mechanisms, and yet, others are of unknown nature. General practitioners and other specialists must remember that CD may debut with extraintestinal manifestations, and associated illnesses may appear both at the time of diagnosis and throughout the evolution of the disease. The implementation of a gluten-free diet (GFD) improves the overall clinical course and influences the evolution of the associated diseases. In some cases, such as iron deficiency anemia, the GFD contributes to its disappearance. In other disorders, like T1D, this allows a better control of the disease. In several other complications and/or associated diseases, an adequate adherence to a GFD may slow down their evolution, especially if implemented during an early stage.

A gluten-free diet effectively reduces symptoms and health care consumption in a Swedish celiac disease population

Background

A gluten-free diet is the only available treatment for celiac disease. Our aim was to investigate the effect of a gluten-free diet on celiac disease related symptoms, health care consumption, and the risk of developing associated immune-mediated diseases.

Methods

A questionnaire was sent to 1,560 randomly selected members of the Swedish Society for Coeliacs, divided into equal-sized age- and sex strata; 1,031 (66%) responded. Self-reported symptoms, health care consumption (measured by health care visits and hospitalization days), and missed working days were reported both for the year prior to diagnosis (normal diet) and the year prior to receiving the questionnaire while undergoing treatment with a gluten-free diet. Associated immune-mediated diseases (diabetes mellitus type 1, rheumatic disease, thyroid disease, vitiligo, alopecia areata and inflammatory bowel disease) were self-reported including the year of diagnosis.

Results

All investigated symptoms except joint pain improved after diagnosis and initiated gluten-free diet. Both health care consumption and missed working days decreased. Associated immune-mediated diseases were diagnosed equally often before and after celiac disease diagnosis.

Conclusions

Initiated treatment with a gluten-free diet improves the situation for celiac disease patients in terms of reduced symptoms and health care consumption. An earlier celiac disease diagnosis is therefore of great importance.

Celiac disease and hypothyroidism

BACKGROUND

Celiac disease is more common in patients with hypothyroidism. Malabsorption of levothyroxine has not been studied in this population. We sought to determine if levothyroxine dosing was influenced by the presence and treatment of celiac disease.

METHODS

This retrospective study was conducted at an academic medical center. Cases had hypothyroidism and celiac disease. Controls had hypothyroidism alone and were selected randomly through the endocrinology clinic records. Celiac disease was defined as representative pathology with positive serology. Age, sex, height, weight, body mass index, creatinine, and medical comorbidity were assessed for cases and controls. The levothyroxine dose and weight-based levothyroxine dose necessary to maintain a euthyroid state was evaluated for controls, and before and after celiac disease therapy for cases.

RESULTS

Celiac disease was identified in 152 patients, and 22 patients had concomitant hypothyroidism (14.5%). Seven cases met inclusion criteria. Overall, 200 control patients were identified. The mean celiac disease pretreatment levothyroxine dose and weight-based levothyroxine dose needed to maintain a euthyroid state were higher in cases than in controls (154 μg vs 106 μg, P=.007, and 2.6 μg/kg vs 1.3 μg/kg, P <.001). Doses decreased significantly after treatment of celiac disease (154 μg vs 111 μg, P=.03; and 2.64 μg/kg vs 1.89 μg/kg, P=.04). All cases required at least 125 μg of levothyroxine initially to maintain a euthyroid state.

CONCLUSIONS

Levothyroxine malabsorption likely occurs with hypothyroidism and untreated celiac disease. Absorption may improve after celiac disease treatment. Screening for celiac disease in patients with hypothyroidism requiring elevated levothyroxine doses warrants further investigation.

Gluten-free diet and autoimmune thyroiditis in patients with celiac disease. A prospective controlled study

OBJECTIVE

Early diagnosis and dietary treatment with a gluten-free diet might slow down the progression of associated autoimmune diseases in celiac disease, but the data are contradictory. We investigated the course of autoimmune thyroid diseases in newly diagnosed celiac disease patients before and after gluten-free dietary treatment.

MATERIAL AND METHODS

Twenty-seven consecutive adults with newly diagnosed celiac disease were investigated at the time of diagnosis and after 1 year on gluten-free diet. Earlier diagnosed and subclinical autoimmune thyroid diseases were recorded and examined. Thyroid gland volume and echogenicity were measured by ultrasound. Autoantibodies against celiac disease and thyroiditis, and thyroid function tests were determined. For comparison, 27 non-celiac controls on normal gluten-containing diet were examined.

RESULTS

At the time of diagnosis, the celiac disease patients had more manifest (n = 7) or subclinical (n = 3) thyroid diseases than the controls (10/27 vs. 3/27, p = 0.055). During the follow-up, the thyroid volume decreased significantly in the patients with celiac disease compared with the controls, indicating the progression of thyroid gland atrophy despite the gluten-free diet.

CONCLUSIONS

Celiac patients had an increased risk of thyroid autoimmune disorders. A gluten-free diet seemed not to prevent the progression of autoimmune process during a follow-up of 1 year.

Celiac disease in children, adolescents, and young adults with autoimmune thyroid disease

OBJECTIVE

To determine the prevalence of antibodies associated with celiac disease and biopsy-proven celiac disease in children with autoimmune thyroid disease.

STUDY DESIGN

A total of 302 patients with positive anti-thyroid antibodies were prospectively studied. Total immunoglobulin A (IgA) and tissue transglutaminase-IgA (tTG-IgA) levels were obtained. Those with a positive tTG-IgA titer were offered biopsy for definitive diagnosis of celiac disease.

RESULTS

A total of 4.6% of subjects with autoimmune thyroid disease had positive tTG-IgA titers. The prevalence of biopsy-confirmed celiac disease was 2.3%. Our population was enriched with patients with type 1 diabetes mellitus (4.3%) and Down syndrome (3.4%). Excluding individuals with these co-morbidities, the prevalence of celiac disease in autoimmune thyroid disease is 1.3%, similar to that of the general population. The positive predictive value of biopsy-proven celiac disease in patients with autoimmune thyroid disease and positive tTG-IgA titer was 54%.

CONCLUSION

The increase in prevalence of celiac disease in autoimmune thyroid disease in our study was largely caused by enrichment with co-morbidities. Without comorbidities or symptoms, screening for celiac disease may not be justified in this population. The specificity of tTG-IgA titer for the diagnosis of celiac disease was decreased in patients with autoimmune thyroid disease compared with the general population.

Risk of morbidity in contemporary celiac disease

Celiac disease is one of the most common chronic diseases encountered in the Western world with a serological prevalence of approximately 1%. Since it is so common, much comorbidity will occur either as associations or simply by chance, or as complications of the disorder. Many of the published studies purporting to establish the frequency of these occurrences have been limited by factors such as the source and number of patients considered, choice of control groups and ascertainment bias. Recent epidemiological studies have attempted to minimize these sources of error and provide more reliable information. Autoimmune diseases constitute clinically important associations, of which Type 1 diabetes mellitus and thyroid disorders are the most important. Several liver disorders, including primary biliary cirrhosis and primary sclerosing cholangitis, are also associated. The frequency of malignant complications of celiac disease is much lower than earlier studies have indicated, with lymphoma increased by approximately fivefold and the absolute number of tumors is small. The increase in fracture risk in celiac disease is only modest. Although neurological and psychiatric conditions affect celiac patients, no disorder specifically associated with celiac disease has been identified. Reproductive problems have been overexaggerated. It is important that these co-morbidities are recognized because if not, symptoms will be falsely attributed to deliberate or inadvertent ingestion of gluten, rather than prompt a search for a second diagnosis. Furthermore, in a patient with an established diagnosis that is considered falsely to account for the whole clinical picture, celiac disease is likely to remain undetected.