Association of Tissue Transglutaminase Antibody Titer with Duodenal Histological Changes in Children with Celiac Disease

Celiac disease and idiopathic pulmonary hemosiderosis: A literature review of the Lane-Hamilton Syndrome

Lane-Hamilton syndrome (LHS) presents a medical emergency, with 14% mortality due to Idiopathic Pulmonary Hemosiderosis (IPH) in acute phase. Despite the clinical severity of this entity, there has been no published review in the international literature, resulting in lack of awareness and delayed diagnosis.A rigorous search of international databases yielded a total of 80 LHS cases from January 1971 to August 2020. We analyzed 44 children (8.56±4.72years, 21boys) and 36 adults (33.61±13.41years, 12men), to present the clinical manifestations, radiological and immunological pattern, therapeutic approaches and outcome of LHS. We also elaborated on clinical and laboratory findings' associations to propose diagnostic indexes and clarified differences based on age distribution.Celiac Disease (CD) and IPH diagnosis was made concurrently in 46 patients, whereas in 21 patients the diagnosis of LHS was delayed for 2.5y (3mo-11y). Hemoptysis (n=56, 70%), dyspnea (n=47, 58.8%), anemia (n=72, 90%) and iron deficiency (n=54, 67.5%) were most commonly observed. Medical history revealed recurrent episodes of hemoptysis (n=38) and persistent iron deficiency anemia (n=25) in need of multiple blood transfusions or iron supplementation. Patchy infiltrate opacities to consolidation predominated in children, whereas bilateral diffuse ground glass opacities in adults. Duodenal biopsy was performed in 66 cases (diagnostic 87.8%), BAL in 51 (diagnostic 74.5%) and surgical lung biopsy in 20. Anti-tTG titer was positive in all 24 (54.6%) children and 19 (52.8%) adults that documented this assay. Prednisone or methylprednisolone pulse therapy and GFD were initiated in the acute phase, whereas chronic therapy included GFD, along with long-term prednisone in refractory cases. Three cases with severe respiratory failure or hemodynamic instability were intubated and a further 3 succumbed.A thorough understanding of LHS may reveal further diagnostic indexes and a consensus on therapy guidelines. Screening for CD is essential in all IPH cases for timely recognition and favorable outcome.

Serologic, endoscopic and pathologic findings in pediatric celiac disease: A single center experience in a low/middle income country

BACKGROUND

Studies in Africa, Asia, and Latin America are needed to provide a comprehensive picture of the global incidence of celiac disease (CD).

AIM

To describe the serology, endoscopic and histological findings in typical and atypical presentations of pediatric CD at a tertiary referral hospital in an African low/middle income country (LMIC).

METHODS

This observational study was conducted on 199 patients with CD from 2010 to 2019. The patients were divided into typical and atypical groups according to the presenting symptoms including 120 and 79 patients respectively. Serology, upper gastrointestinal endoscopy with duodenal biopsy were performed for patients who had symptoms suggestive of CD. The severity of the intestinal damage was graded according to the histo-pathologic Marsh-Oberhuber classification.

RESULTS

Chronic diarrhea was the main intestinal presentation in the typical group. Anemia was the most common extraintestinal symptom in both the typical and atypical group. Marsh-Oberhuber type 3b and 3c was significantly higher in the seropositive patients with a P value of 0.007. A significant correlation was observed between the histological grade of the biopsied duodenal mucosa and the clinical presentation (P < 0.001). Age was significantly higher in the atypical group (P value < 0.001).

CONCLUSION

Although typical CD was observed in 120 patients in this study, the clinical variability of the condition was frequently observed. Age only was a significant predictor for the appearance of atypical CD. Therefore, CD presentations in LMIC are not different from industrialized countries.

Unusually high titres of anti-tissue transglutaminase antibodies in monozygotic twins

Anti-tissue transglutaminase antibodies (anti-tTG) play a vital role in the screening process for coeliac disease (CD). Levels above 30 U/ml suggest a possible diagnosis of CD, prompting further investigation, usually by taking a duodenal biopsy. We report an unusual case of 39-year-old male twins, one presenting with iron deficiency anaemia and the other asymptomatic, with anti-tTG antibodies of >4,965.5 U/ml, an extraordinary level. A duodenal biopsy confirmed a diagnosis of CD and following the adoption of a gluten-free diet, anti-tTG levels were found to decrease back to normal levels. This case demonstrates how CD can cause significant biochemical and histological pathology, but present with mild or no symptoms.

Serum transglutaminase antibodies do not always detect the persistent villous atrophy in patients with celiac disease on a gluten-free diet

BACKGROUND AND AIM

Serum transglutaminase antibodies (tTGs) are used for celiac disease screening and to monitor celiac disease patients on a gluten-free diet (GFD). The need for histology of duodenal biopsies to assess mucosal healing after a GFD is still a matter of debate. We evaluated whether tTGs are adequate to detect the persistence of histological lesions of duodenal mucosa in celiac patients after a GFD.

METHODS

In total 253 patients with histological diagnosis of celiac disease according to Marsh criteria, both at the time of diagnosis (T0) and 18-24 months after starting a GFD (T2), were included. tTGs were evaluated both at T0 and T2; endomysial antibodies (EMAs) only at T0.

RESULTS

At T0, 9.2% of patients had both tTG and EMA negative values, despite the evidence of duodenal lesions: 33.3% of Marsh 1, 14.3% of Marsh 2 and 5.2% of Marsh 3. At T2, tTGs were negative in 77.6% of patients: 82.2% of Marsh 0, 79.8% of Marsh 1, 70.0% of Marsh 2 and 59.1% of Marsh 3. At T2, approximately 60% of patients with the persistence of mucosal atrophy had negative tTGs. At T0, tTG median values were lower in patients with Marsh 1 and Marsh 2 than patients with Marsh 3 (P < 0.001), whereas no difference was found at T2 regardless of Marsh's grade (P = 0.4).

CONCLUSIONS

The results of our study highlight how histologic evaluation of duodenal biopsies remains the gold standard for both celiac disease diagnosis and the evaluation of mucosal recovery after 18-24 months of a GFD.

Association of Anti-tissue Transglutaminase Antibody Titers and Duodenal Biopsy Findings in Pediatric Patients of Celiac Disease

Aims & Objectives

To ascertain the association of serum anti-tissue transglutaminase (anti-tTG) antibody titers with the severity of duodenal mucosal damage on histology andto predict a possible cut-off value of anti-tTG antibody titers for the diagnosis of Celiac disease. Marsh grading greater than two in conjunction with clinical assessment, which may help avert an invasive endoscopic procedure, especially in medically unfit children.

Materials & Methods

A retrospective study was designed wherein demographic and laboratory data of children aged less than 12 years with raised anti-tTG antibody titers with available histopathology of duodenal biopsies were extracted from the hospital medical records and reviewed.

Results

A total of 134 children were included in the study, which showed female preponderance. Histopathological changes, characteristic of Celiac disease, were observed in 116 cases; seven among the rest showed evidence of Giardiasis, and 13 could be considered potential Celiac. Of the 116 patients, 1.7% belonged to Marsh grade I, 5.2% grade II and 8.6%, 26.7%, and 57.7% to grade IIIA, IIIB, and IIIC, respectively. A significant association was found between anti-tTG antibody titers and Marsh grading. The cut-off value of anti-tTG antibody titer levels for diagnosing Celiac disease using receiver operating characteristics (ROC) curve in predicting Marsh greater than two at histology was observed to be 84.6 U/ml with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 91.7%, 68.4%, 94.2%, and 59%, respectively.

Conclusion

An anti-tTG antibody titer greater than 10 times the upper limit of normal (≥84 U/ml) is significantly associated with Marsh grade greater than two. Standard stool microscopy may be used as a simple tool in the workup of all children with raised anti-tTG antibody levels to rule out Giardiasis to avert unnecessary endoscopic evaluation for Celiac disease in such cases.

Diagnostic utility of multiple site duodenal biopsies in celiac disease

Background

Celiac Disease involves the small intestine patchily affecting more frequently the proximal small bowel but the histological changes have been observed till terminal ileum. Of late in addition to D2, the duodenal bulb (D1 region) biopsies have been found helpful in identifying a small group of patients with CD. Therefore, multiple site biopsies are recommended as histological changes are not uniform throughout small intestine.

Methods

During this present 1.5 years prospective study, we evaluated 84 cases of suspected celiac disease with respect to the light microscopy (D1, D2, and D3 biopsy) and serology (anti tTg and or EMA). Histological examination was done according to Modified Marsh grading system.

Results

Out of 84 cases with raised anti tTg, the segmental biopsies significantly increased the diagnostic accuracy from 39/44 cases (88.6%) to 43/44 cases (97.7%) and 44/44 cases (100%) when D2 alone, D1 + D2 and D1 + D2 + D3 biopsies were evaluated, respectively. Of the suspected cases of celiac disease patients (tTg > 10 ULN and associated weight loss, diarrhea), additional D3 biopsy increased the diagnostic yield by 2.1%, compared to D1, D2 region biopsy and 6.38% compared to standard D2 biopsy alone. Of the 28 cases (tTg > 10 times ULN + EMA positive and associated weight loss, diarrhea), the potential celiac disease (histologically Type 1/Normal) cases reduced from 28.5% (standard D2 region alone) to 21.4% and 17.8% when additional biopsies were taken from D1 region and D3 region, respectively, and additional D3 biopsy increased the diagnostic yield by 10.8% (compared to standard D2 biopsy alone) and 3.7% (compared to D1 and D2 biopsy).

Conclusion

We believe multiple sites duodenal biopsies including D3 region biopsies might increase the diagnostic accuracy of adult celiac disease in addition to sensitive and specific serologic tests.

Celiac Disease in Kosovar Albanian Children: Evaluation of Clinical Features and Diagnosis

BACKGROUND

Celiac disease is an immune-mediated disorder characterized by variable clinical manifestations, specific antibodies, HLA-DQ2/DQ8 haplotypes, and enteropathy.

OBJECTIVES

The aim of this study was to present the clinical spectrum and patterns of celiac disease in Kosovar Albanian children.

METHODS

A cross-sectional retrospective study was performed with Albanian children aged 0-18 years, treated for celiac disease in the Pediatric Clinic, University Clinical Center of Kosovo from 2005 to 2016.

RESULTS

During the study period, 63 children were treated for celiac disease. The mean age at diagnosis was 5.5 years (SD ± 3.31). The mean age at celiac disease onset was 3.3 years (SD ± 2.02), while the mean delay from the first symptoms indicative of celiac disease to diagnosis was 2.2 years (SD ± 2.09). More than 70% of the patients were diagnosed in the first 7 years of life, mainly presented with gastrointestinal symptoms, while primary school children and adolescents mostly showed atypical symptoms (p<0.001). The classical form of celiac disease occurred in 78% of the cases. Sixty (95%) patients carried HLA-DQ2.5, DQ2.2 and/or HLA-DQ8 heterodimers, and only three of them tested negative.

CONCLUSION

Kosovo, as the majority of developing countries, is still facing the classical form of celiac disease as the dominant mode of presentation; as a result, most children with other forms of the celiac disease remain undiagnosed. Physicians should be aware of the wide range of clinical presentations and utilize low testing thresholds in order to prevent potential long-term problems associated with untreated celiac disease.

High Prevalence of Celiac Disease Among Screened First-Degree Relatives

OBJECTIVE

To investigate the prevalence of first-degree relatives (FDRs) with celiac disease detected at screening and diagnostic significance of anti-tissue transglutaminase (anti-TTG).

PATIENTS AND METHODS

We performed a retrospective cohort study of 104 patients with a diagnosis of celiac disease and their FDRs, collecting data from electronic records of Mayo Clinic and celiac disease registry from December 20, 1983, to May 22, 2017. We collected demographics, presenting symptoms, indication for testing, family history, number of other family members screened, biopsy reports, and results of serologic tests.

RESULTS

Of 477 FDRs identified, 360 were screened (mean screening rate per family, 79%±25%) and 160 FDRs (44.4%) were diagnosed with celiac disease, at a mean age 31.9±21.6 years (62% female). All diagnosed FDRs had positive anti-TTG titers. Clinical features were documented in 148 diagnosed FDRs, of those 9 (6%) had classic, 97 (66%) had non-classic symptoms, and 42(28%) had no reported symptoms. Histology reports were available from 155 FDRs: 12 (8%) had Marsh 1, 77 (50%) had Marsh 3a, and 66 (43%) had Marsh 3b. A level of anti-TTG greater than or equal to 2.75 of the upper limit of normal identified FDRs with villous atrophy with 87% sensitivity, 82% specificity, and a positive predictive value of 95%.

CONCLUSION

In a retrospective cohort study of patients diagnosed with celiac disease, we found a high prevalence of celiac disease among screened FDRs. High anti-TTG titers associated with villous atrophy on small bowel biopsies, irrespective of symptoms.

Celiac Disease in South Jordan

PURPOSE

Celiac disease, an autoimmune enteropathy triggered by exposure to gluten, is not uncommon in South Jordan. However, its prevalence is underestimated due to lack of physician awareness of the diversity of disease presentation. The clinical spectrum includes classic gastrointestinal manifestations, as well as rickets, iron-deficiency anemia, short stature, elevated liver enzymes, and edema. Our goal was to evaluate celiac disease presentation in clinically diagnosed children.

METHODS

Retrospective study included all children diagnosed with celiac disease between September 2009 and September 2015. Hospital charts were reviewed. Demographic data, clinical characteristics, and follow-up were recorded.

RESULTS

Thirty-five children were diagnosed with celiac disease during the study period. Mean age±standard deviation was 6.7±3.8 years (range, 2.0-14 years). There were 17 (48.6%) female patients. The average duration between onset of symptoms and diagnosis was 16.3±18.7 months. Fifteen (42.9%) patients presented with classic malabsorption symptoms, whereas 7 (20.0%) patients presented with short stature. Positive tissue transglutaminase antibodies (tTg)-immunoglobulin A (IgA) was seen in 34 (97.1%) patients. The one patient with negative tTg-IgA had IgA deficiency. Although tTG-IgA values were not available for objective documentation of compliance, clinical data (resolution of presenting abnormalities and growth improvement) assured acceptable compliance in 22 (62.9%) patients.

CONCLUSION

CD in children may present with diverse picture. Although of the small number, the non-classical presentations are not uncommon in our rural community. Gluten-free diet is the main strategy for treatment and associated with usually correction of laboratory abnormalities and improvement of growth.