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Haberman Y, Iqbal NT, Ghandikota S, Mallawaarachchi I, Tzipi Braun, Dexheimer PJ, Rahman N, Hadar R, Sadiq K, Ahmad Z, Idress R, Iqbal J, Ahmed S, Hotwani A, Umrani F, Ehsan L, Medlock G, Syed S, Moskaluk C, Ma JZ, Jegga AG, Moore SR, Ali SA, Denson LA. Mucosal Genomics Implicate Lymphocyte Activation and Lipid Metabolism in Refractory Environmental Enteric Dysfunction. Gastroenterology 2021; 160:2055-2071.e0. [PMID: 33524399 PMCID: PMC8113748 DOI: 10.1053/j.gastro.2021.01.221] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Environmental enteric dysfunction (EED) limits the Sustainable Development Goals of improved childhood growth and survival. We applied mucosal genomics to advance our understanding of EED. METHODS The Study of Environmental Enteropathy and Malnutrition (SEEM) followed 416 children from birth to 24 months in a rural district in Pakistan. Biomarkers were measured at 9 months and tested for association with growth at 24 months. The duodenal methylome and transcriptome were determined in 52 undernourished SEEM participants and 42 North American controls and patients with celiac disease. RESULTS After accounting for growth at study entry, circulating insulin-like growth factor-1 (IGF-1) and ferritin predicted linear growth, whereas leptin correlated with future weight gain. The EED transcriptome exhibited suppression of antioxidant, detoxification, and lipid metabolism genes, and induction of anti-microbial response, interferon, and lymphocyte activation genes. Relative to celiac disease, suppression of antioxidant and detoxification genes and induction of antimicrobial response genes were EED-specific. At the epigenetic level, EED showed hyper-methylation of epithelial metabolism and barrier function genes, and hypo-methylation of immune response and cell proliferation genes. Duodenal coexpression modules showed association between lymphocyte proliferation and epithelial metabolic genes and histologic severity, fecal energy loss, and wasting (weight-for-length/height Z < -2.0). Leptin was associated with expression of epithelial carbohydrate metabolism and stem cell renewal genes. Immune response genes were attenuated by giardia colonization. CONCLUSIONS Children with reduced circulating IGF-1 are more likely to experience stunting. Leptin and a gene signature for lymphocyte activation and dysregulated lipid metabolism are implicated in wasting, suggesting new approaches for EED refractory to nutritional intervention. ClinicalTrials.gov, Number: NCT03588013. (https://clinicaltrials.gov/ct2/show/NCT03588013).
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Affiliation(s)
- Yael Haberman
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio,Department of Pediatrics, Sheba Medical Center, Tel-HaShomer, affiliated with the Tel-Aviv University, Israel
| | - Najeeha T. Iqbal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan,Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Sudhir Ghandikota
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center Cincinnati, Department of Computer Science, University of Cincinnati College of Engineering, Cincinnati, Ohio
| | | | - Tzipi Braun
- Department of Pediatrics, Sheba Medical Center, Tel-HaShomer, affiliated with the Tel-Aviv University, Israel
| | - Phillip J. Dexheimer
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Najeeb Rahman
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Rotem Hadar
- Department of Pediatrics, Sheba Medical Center, Tel-HaShomer, affiliated with the Tel-Aviv University, Israel
| | - Kamran Sadiq
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zubair Ahmad
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Romana Idress
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Junaid Iqbal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan,Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Sheraz Ahmed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Aneeta Hotwani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Fayyaz Umrani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Lubaina Ehsan
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Greg Medlock
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Sana Syed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan,Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Chris Moskaluk
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Jennie Z. Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Anil G. Jegga
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio,Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center Cincinnati, Department of Computer Science, University of Cincinnati College of Engineering, Cincinnati, Ohio
| | - Sean R. Moore
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia,Sean R. Moore, MD, MS, Division of Pediatric Gastroenterology, Hepatology, & Nutrition, University of Virginia, 409 Lane Rd., Charlottesville, VA 22908.
| | - Syed Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Lee A. Denson
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio,Correspondence Address correspondence to: Lee A Denson, MD, Division of Pediatric Gastroenterology, Hepatology, & Nutrition, Cincinnati Children’s Hospital Medical Center, MLC 2010, 3333 Burnet Avenue, Cincinnati, Ohio 45229. fax: (513) 636-558.
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Persistent Alterations in Plasma Lipid Profiles Before Introduction of Gluten in the Diet Associated With Progression to Celiac Disease. Clin Transl Gastroenterol 2020; 10:1-10. [PMID: 31082858 PMCID: PMC6602763 DOI: 10.14309/ctg.0000000000000044] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Celiac disease (CD) is a chronic enteropathy characterized by an autoimmune reaction in the small intestine of genetically susceptible individuals. The underlying causes of autoimmune reaction and its effect on host metabolism remain largely unknown. Herein, we apply lipidomics to elucidate the early events preceding clinical CD in a cohort of Finnish children, followed up in the Type 1 Diabetes Prediction and Prevention study.
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Defining the Celiac Disease Transcriptome using Clinical Pathology Specimens Reveals Biologic Pathways and Supports Diagnosis. Sci Rep 2019; 9:16163. [PMID: 31700112 PMCID: PMC6838157 DOI: 10.1038/s41598-019-52733-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/21/2019] [Indexed: 01/30/2023] Open
Abstract
Celiac disease is provoked by gluten exposure, but the complete pathogenic process in the duodenum and the loss of tolerance to gluten is not well understood. We aimed to define the core celiac transcriptomic signature and pathologic pathways in pre-treatment formalin-fixed paraffin-embedded (FFPE) duodenum biopsies used for clinical diagnosis. We use mRNAseq to define pre-treatment diagnostic duodenum gene expression in 54 pediatric celiac patients and non-celiac controls, and we validate our key findings in two independent cohorts of 67 adults and pediatric participants that used fresh frozen biopsies. We further define similar and divergent genes and pathways in 177 small bowel Crohn disease patients and controls. We observe a marked suppression of mature epithelial metabolic functions in celiac patients, overlapping substantially with the Crohn disease signature. A marked adaptive immune response was noted for the up-regulated signature including interferon response, alpha-beta, and gamma-delta T-cells that overlapped to some extent with the Crohn disease signature. However, we also identified a celiac disease specific signature linked to increased cell proliferation, nuclear division, and cell cycle activity that was localized primarily to the epithelia as noted by CCNB1 and Ki67 staining. Lastly, we demonstrate the utility of the transcriptomic date to correctly classify disease or healthy states in the discovery and validation cohorts. Our data supplement recently published datasets providing insights into celiac pathogenesis using clinical pathology FFPE samples, and can stimulate new approaches to address this highly prevalent condition.
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Alsaadi D, Shah NJ, Charabaty A, Atkins MB. A case of checkpoint inhibitor-induced celiac disease. J Immunother Cancer 2019; 7:203. [PMID: 31383006 PMCID: PMC6683380 DOI: 10.1186/s40425-019-0694-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/24/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have now become standard of care treatment for many malignancies. ICIs are associated with unique immune mediated adverse events (irAEs) due to dysregulation of immune activation. As treatment with ICIs is becoming more common, rare irAEs are also being recognized. Here we report a case of ICI-induced celiac disease. CASE A 74-year-old Caucasian female with metastatic renal carcinoma received second line nivolumab (anti-PD1 antibody) after initial disease progression on sunitinib. Ipilimumab was added after she failed to respond to six cycles of nivolumab monotherapy. One week after her first cycle of combination treatment, she presented with nausea, vomiting, grade 1 diarrhea, and weight loss. She underwent endoscopy, which showed bile stasis in the stomach, normal appearing stomach mucosa, and nonbleeding erythematous mucosa in the duodenal bulb. Stomach biopsy showed moderate active chronic gastritis. Duodenal biopsy showed moderate chronic active duodenitis with focal neutrophilic cryptitis, mucosal erosions, villous atrophy, mildly increased intraepithelial lymphocytes, and moderate chronic inflammation in the lamina propria pathognomonic of celiac disease. Symptoms improved with gluten-free diet, twice-daily omeprazole and anti-emetics and she was able to continue on treatment. CONCLUSIONS There has been only one published case reporting ICI-induced celiac disease. Our case report highlights a rare irAE (celiac disease) associated with ICI treatment. It is unclear whether the patient had previously undiagnosed celiac disease or whether ICIs triggered her enteritis. Our patient was able to continue treatment with ICIs with dietary modifications, suggesting correct diagnosis is critical for optimal patient outcome.
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Affiliation(s)
- Dana Alsaadi
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Neil J Shah
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, 3800 Reservoir Road, NW, Washington, DC, 20007, USA
| | - Aline Charabaty
- Sibley Memorial Hospital, Johns Hopkins University, 5255 Loughboro Road NW, Washington, DC, 20016, USA
| | - Michael B Atkins
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, 3800 Reservoir Road, NW, Washington, DC, 20007, USA.
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Leonard MM, Bai Y, Serena G, Nickerson KP, Camhi S, Sturgeon C, Yan S, Fiorentino MR, Katz A, Nath B, Richter J, Sleeman M, Gurer C, Fasano A. RNA sequencing of intestinal mucosa reveals novel pathways functionally linked to celiac disease pathogenesis. PLoS One 2019; 14:e0215132. [PMID: 30998704 PMCID: PMC6472737 DOI: 10.1371/journal.pone.0215132] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 03/27/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND & AIMS The early steps in the pathophysiology of celiac disease (CD) leading to loss of tolerance to gluten are poorly described. Our aim was to use RNA sequencing of duodenal biopsies in patients with active CD, CD in remission, and non-CD controls to gain insight into CD pathophysiology, identify additional genetic signatures linked to CD, and possibly uncover targets for future therapeutic agents. METHODS We performed whole transcriptome shotgun sequencing of intestinal biopsies in subjects with active and remission CD and non-CD controls. We also performed functional pathway analysis of differentially expressed genes to identify statistically significant pathways that are up or down regulated in subjects with active CD compared to remission CD. RESULTS We identified the upregulation of novel genes including IL12R, ITGAM and IGSF4 involved in the immune response machinery and cell adhesion process in the mucosa of subjects with active CD compared to those in remission. We identified a unique signature of genes, related to innate immunity, perturbed exclusively in CD irrespective of disease status. Finally, we highlight novel pathways of interest that may contribute to the early steps of CD pathogenesis and its comorbidities such as the spliceosome, pathways related to the innate immune response, and pathways related to autoimmunity. CONCLUSIONS Our study confirmed previous findings based on GWAS and immunological studies pertinent to CD pathogenesis and describes novel genes and pathways that with further validation may be found to contribute to the early steps in the pathogenesis of CD, ongoing inflammation, and comorbidities associated with CD.
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Affiliation(s)
- Maureen M. Leonard
- Mass General Hospital for Children and Division of Pediatric Gastroenterology and Nutrition, Harvard Medical School, Boston, Massachusetts, United States of America
- Center for Celiac Research and Treatment, Mucosal Immunology and Biology Research Center, Boston, Massachusetts, United States of America
- Celiac Research Program, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Yu Bai
- Regeneron Pharmaceuticals, Tarrytown, New York, United States of America
| | - Gloria Serena
- Center for Celiac Research and Treatment, Mucosal Immunology and Biology Research Center, Boston, Massachusetts, United States of America
- Celiac Research Program, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kourtney P. Nickerson
- Center for Celiac Research and Treatment, Mucosal Immunology and Biology Research Center, Boston, Massachusetts, United States of America
| | - Stephanie Camhi
- Center for Celiac Research and Treatment, Mucosal Immunology and Biology Research Center, Boston, Massachusetts, United States of America
| | - Craig Sturgeon
- Graduate Program in Life Sciences, University of Maryland, Baltimore, Maryland, United States of America
| | - Shu Yan
- Center for Celiac Research and Treatment, Mucosal Immunology and Biology Research Center, Boston, Massachusetts, United States of America
| | - Maria R. Fiorentino
- Center for Celiac Research and Treatment, Mucosal Immunology and Biology Research Center, Boston, Massachusetts, United States of America
| | - Aubrey Katz
- Mass General Hospital for Children and Division of Pediatric Gastroenterology and Nutrition, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Barbara Nath
- Department of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - James Richter
- Department of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Matthew Sleeman
- Regeneron Pharmaceuticals, Tarrytown, New York, United States of America
| | - Cagan Gurer
- Regeneron Pharmaceuticals, Tarrytown, New York, United States of America
| | - Alessio Fasano
- Mass General Hospital for Children and Division of Pediatric Gastroenterology and Nutrition, Harvard Medical School, Boston, Massachusetts, United States of America
- Center for Celiac Research and Treatment, Mucosal Immunology and Biology Research Center, Boston, Massachusetts, United States of America
- Celiac Research Program, Harvard Medical School, Boston, Massachusetts, United States of America
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Cruz ITSA, Fraiz FC, Celli A, Amenabar JM, Assunção LRS. Dental and oral manifestations of celiac disease. Med Oral Patol Oral Cir Bucal 2018; 23:e639-e645. [PMID: 30341262 PMCID: PMC6260995 DOI: 10.4317/medoral.22506] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 09/04/2018] [Indexed: 01/28/2023] Open
Abstract
Background The objective of this study was to evaluate the dental and oral manifestations in patients with celiac disease. Material and Methods The sample consisted of 40 patients with the disease and 40 without the disease matched by age in southern Brazil. The CD group included patients previously diagnosed by positive anti-endomysial (IgA) examination and confirmed by small intestine biopsy. The presence of dental enamel defects and dental caries was evaluated by a calibrated researcher according to AINE’s and WHO’s criteria, respectively. The history of recurrent aphthous ulcers and dry mouth was obtained through reporting. For the evaluation of the salivary flow, the saliva samples were obtained through the non-stimulated and stimulated saliva collection method. Results There was a significant association between CD and dental enamel defects (OR=2.38, P=0.045) and dry mouth (OR=9.15, P=0.002). No difference was found for the report of recurrent aphthous ulcers and caries experience between the two groups. Patients with CD had normal pattern of unstimulated and stimulated saliva flow rates (0.67 ± 0.38 ml / min and 1.14 ± 0.47 ml / min, respectively). A higher occurrence of dental enamel defects was observed in patients with classic CD (P=0.054). Of the 1,962 permanent teeth, 59 presented dental enamel defects, 71.8% of which were in patients with CD (P=0.001), predominantly in molars (P=0.009). Conclusions CD increased the likelihood of dental enamel defects and dry mouth sensation. The oral examination can be an important auxiliary tool for the identification of cases of the disease. Key words:Celiac disease, oral manifestations, dental enamel hypoplasia.
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Affiliation(s)
- I-T-S-A Cruz
- Department of Stomatology, Universidade Federal do Paraná, Avenida Prefeito Lothário Meissner 632, Curitiba, Paraná, Brazil. Zip code: 80210-170,
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Combination of Gluten-Digesting Enzymes Improved Symptoms of Non-Celiac Gluten Sensitivity: A Randomized Single-blind, Placebo-controlled Crossover Study. Clin Transl Gastroenterol 2018; 9:181. [PMID: 30228265 PMCID: PMC6143542 DOI: 10.1038/s41424-018-0052-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 07/26/2018] [Accepted: 08/04/2018] [Indexed: 02/07/2023] Open
Abstract
Introduction Recently, the population of individuals with non-celiac gluten sensitivity (NCGS) who do not have celiac disease but show improved symptoms with a gluten-free diet, has increased. Enzyme replacement therapy using digestive enzymes is expected to improve the symptoms of NCGS and be sustainable, since gluten-related proteins that are indigestible by the digestive system have been considered triggers of NCGS. Methods We selected patients with NCGS by screening demographic interviews, as well as performing medical evaluations, anti-gluten antibody tests, and gluten challenge tests. We performed a single-blind and crossover clinical trial with these subjects using a gluten challenge with the enzyme mixture or a placebo. Our designed enzyme mixture contained peptidase, semi alkaline protease, deuterolysin, and cysteine protease derived from Aspergillus oryzae, Aspergillus melleus, Penicillium citrinum, and Carica papaya L., respectively. Results Administration of the enzyme mixture significantly decreased the change in the score of the symptom questionnaire before and after the gluten challenge compared with administration of the placebo in patients with NCGS without adverse events. In particular, the changes in the score of the gluten-induced incomplete evacuation feeling and headaches were significantly improved. The serum levels of interleukin (IL)-8, tumor necrosis factor (TNF)-α, andregulated on activation, normal T cell expressed and secreted (RANTES) in subjects were not significantly changed by gluten, as expected from previous studies, and the enzyme mixture did not affect these inflammatory markers. Conclusion In this human clinical study, we demonstrated the efficacy of the enzyme mixture derived from microorganisms and papaya in improving the symptoms of NCGS.
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Almazar AE, Talley NJ, Brantner TL, Larson JJ, Atkinson EJ, Murray JA, Saito YA. Celiac disease is uncommon in irritable bowel syndrome in the USA. Eur J Gastroenterol Hepatol 2018; 30:149-154. [PMID: 29240001 PMCID: PMC5738260 DOI: 10.1097/meg.0000000000001022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Routine serologic testing for celiac disease (CD) may be useful in irritable bowel syndrome (IBS) patients, but this is controversial. We aimed to compare the prevalence of unrecognized CD in a large cohort of patients with and without IBS. PARTICIPANTS AND METHODS This is a family case-control IBS study conducted at a single US academic medical center. Stored serum and DNA were available. Tissue transglutaminase (TTg) immunoglobulin A was performed, followed by indirect immunofluorescence testing for endomysial antibodies with positive or weakly positive TTg results. Individuals were considered to have CD if both results were positive. χ and Fisher's exact tests were used to compare prevalence between the two groups. RESULTS Serum samples were studied from 533 cases and 531 controls. In all, 80% of participants were female, with a median age of 50 years; 65% of cases and 0% controls met the Rome criteria for IBS. Previous serological testing for CD had occurred in 142 (27%) cases and 13 (2%) controls, but none had CD on subsequent testing. Six (1.1%) cases versus five (0.9%) controls had positive or weakly positive TTg test. Six cases (1.1%) versus three (0.6%) controls were confirmed to have CD by endomysial antibody (P=0.51). CONCLUSION No difference in the prevalence of CD between patients with IBS and patients without IBS at a tertiary medical center was observed. Our findings do not support routine celiac serologic or genetic testing in patients with IBS in all US populations.
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Affiliation(s)
- Ann E. Almazar
- Division of Gastroenterology and Hepatology. Mayo Clinic, Rochester, MN
| | - Nicholas J. Talley
- Division of Gastroenterology and Hepatology. Mayo Clinic, Rochester, MN
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | | | - Joseph J. Larson
- Division of Biomedical Statistics and Informatics. Mayo Clinic, Rochester, MN
| | | | - Joseph A. Murray
- Division of Gastroenterology and Hepatology. Mayo Clinic, Rochester, MN
- Department of Immunology, Mayo Clinic, Rochester, MN
| | - Yuri A. Saito
- Division of Gastroenterology and Hepatology. Mayo Clinic, Rochester, MN
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DeGeorge KC, Frye JW, Stein KM, Rollins LK, McCarter DF. Celiac Disease and Gluten Sensitivity. Prim Care 2017; 44:693-707. [PMID: 29132529 DOI: 10.1016/j.pop.2017.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Celiac disease is an immune-mediated enteropathy triggered by gluten that affects genetically predisposed individuals, typically causing intestinal symptoms and malabsorption. Diagnosis requires stepwise evaluation with anti-tissue transglutaminase IgA and histologic analysis of the small bowel. Strict adherence to a gluten-free diet is the primary treatment. Patients with symptoms thought to be related to gluten but without evidence of celiac disease are difficult to diagnose and treat. Consider first advising general nutritional improvements. If symptoms persist, involve a trained dietitian for restrictive diets and consider evaluation for small intestinal bacterial overgrowth or other treatments for irritable bowel syndrome.
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Affiliation(s)
- Katharine C DeGeorge
- Department of Family Medicine, University of Virginia, PO Box 800729, Charlottesville, VA 22908-0543, USA.
| | - Jeanetta W Frye
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Virginia, PO Box 800708, Charlottesville, VA 22908, USA
| | - Kim M Stein
- Department of Family Medicine, University of Virginia, PO Box 800729, Charlottesville, VA 22908-0543, USA
| | - Lisa K Rollins
- Department of Family Medicine, University of Virginia, PO Box 800729, Charlottesville, VA 22908-0543, USA
| | - Daniel F McCarter
- Department of Family Medicine, University of Virginia, PO Box 800729, Charlottesville, VA 22908-0543, USA
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Parzanese I, Qehajaj D, Patrinicola F, Aralica M, Chiriva-Internati M, Stifter S, Elli L, Grizzi F. Celiac disease: From pathophysiology to treatment. World J Gastrointest Pathophysiol 2017; 8:27-38. [PMID: 28573065 PMCID: PMC5437500 DOI: 10.4291/wjgp.v8.i2.27] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 03/08/2017] [Accepted: 03/23/2017] [Indexed: 02/06/2023] Open
Abstract
Celiac disease, also known as "celiac sprue", is a chronic inflammatory disorder of the small intestine, produced by the ingestion of dietary gluten products in susceptible people. It is a multifactorial disease, including genetic and environmental factors. Environmental trigger is represented by gluten while the genetic predisposition has been identified in the major histocompatibility complex region. Celiac disease is not a rare disorder like previously thought, with a global prevalence around 1%. The reason of its under-recognition is mainly referable to the fact that about half of affected people do not have the classic gastrointestinal symptoms, but they present nonspecific manifestations of nutritional deficiency or have no symptoms at all. Here we review the most recent data concerning epidemiology, pathogenesis, clinical presentation, available diagnostic tests and therapeutic management of celiac disease.
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Bul V, Sleesman B, Boulay B. Celiac Disease Presenting as Profound Diarrhea and Weight Loss - A Celiac Crisis. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:559-61. [PMID: 27492679 PMCID: PMC4978208 DOI: 10.12659/ajcr.898004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patient: Male, 46 Final Diagnosis: Celiac crisis Symptoms: Abdominal pain • chronic diarrhea • lightheadedness • weakness • weight loss Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Vadim Bul
- Department of Internal Medicine, University of Illinois - Chicago, Chicago, IL, USA
| | - Brett Sleesman
- Department of Gastroenterology, University of Illinois - Chicago, Chicago, IL, USA
| | - Brian Boulay
- Department of Gastroenterology, University of Illinois - Chicago, Chicago, IL, USA
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Pantazes RJ, Reifert J, Bozekowski J, Ibsen KN, Murray JA, Daugherty PS. Identification of disease-specific motifs in the antibody specificity repertoire via next-generation sequencing. Sci Rep 2016; 6:30312. [PMID: 27481573 PMCID: PMC4969583 DOI: 10.1038/srep30312] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 07/04/2016] [Indexed: 12/12/2022] Open
Abstract
Disease-specific antibodies can serve as highly effective biomarkers but have been identified for only a relatively small number of autoimmune diseases. A method was developed to identify disease-specific binding motifs through integration of bacterial display peptide library screening, next-generation sequencing (NGS) and computational analysis. Antibody specificity repertoires were determined by identifying bound peptide library members for each specimen using cell sorting and performing NGS. A computational algorithm, termed Identifying Motifs Using Next- generation sequencing Experiments (IMUNE), was developed and applied to discover disease- and healthy control-specific motifs. IMUNE performs comprehensive pattern searches, identifies patterns statistically enriched in the disease or control groups and clusters the patterns to generate motifs. Using celiac disease sera as a discovery set, IMUNE identified a consensus motif (QPEQPF[PS]E) with high diagnostic sensitivity and specificity in a validation sera set, in addition to novel motifs. Peptide display and sequencing (Display-Seq) coupled with IMUNE analysis may thus be useful to characterize antibody repertoires and identify disease-specific antibody epitopes and biomarkers.
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Affiliation(s)
- Robert J Pantazes
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA.,Serimmune, Inc, Santa Barbara, CA 93105, USA
| | - Jack Reifert
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA.,Serimmune, Inc, Santa Barbara, CA 93105, USA
| | - Joel Bozekowski
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA
| | - Kelly N Ibsen
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Patrick S Daugherty
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA.,Serimmune, Inc, Santa Barbara, CA 93105, USA
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The prevalence of celiac disease in patients with irritable bowel syndrome and its subtypes. GASTROENTEROLOGY REVIEW 2016; 11:276-281. [PMID: 28053683 PMCID: PMC5209460 DOI: 10.5114/pg.2016.57941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/22/2015] [Indexed: 12/13/2022]
Abstract
Introduction Irritable bowel syndrome (IBS) and celiac disease (CD) share some gastrointestinal symptoms. Celiac disease should be considered in a differential diagnosis of IBS. Aim To estimate the prevalence of predispositions to CD in patients with IBS and its subtypes. Material and methods The study included 48 patients (40 women, 8 men; average age: 41.1 ±14.6 years) with IBS, and a control group: 20 healthy volunteers. All participants completed a questionnaire on their current gastrointestinal symptoms and had a blood sample taken to determine the HLA-DQ2/DQ8 antigens and serum concentration of anti-tTG IgA and anti-DGP IgA and IgG. Results The presence of HLA-DQ2 or DQ8 was found in 50% of patients (n = 24) with IBS. In the control group the presence of HLA-DQ2 was found in 4 (20%) patients and nobody had HLA-DQ8. Increased levels of anti-tTG IgA were found in 5 (10.42%) patients with IBS, anti-DGP in 4 (8.33%), and anti-DGP IgG in 3 (6.25%). In the control group positive test result for anti-tTG was found in 2 (10%) patients; nobody had elevated anti-DGP IgA or IgG. A concomitant positive result of genetic testing and any elevated serum antibodies specific to CD was found in 12.5% of IBS patients (n = 6) and in none of the control group. Conclusions Patients with IBS, regardless of the subtype, significantly more often than healthy controls have the predisposing genetic factors (HLA-DQ2/DQ8) underlying the development of CD.
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Talaie R. Does gluten free diet have more implications than treatment of celiac disease? GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2015; 8:160-6. [PMID: 25926942 PMCID: PMC4403029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/04/2015] [Indexed: 11/23/2022]
Abstract
AIM This study was aimed to evaluate symptomatic as well as histopathologic response to GFD in patients with gluten-sensitive enteropathies including celiac disease, lymphocytic duodenosis and non-specific duodenitis. BACKGROUND Gluten-free diet (GFD) is the main treatment of celiac disease. However, its impact on other disorders of gluten sensitivity spectrum is less clear. PATIENTS AND METHODS In a prospective observational study in Modarres hospital Tehran, Iran, 35 patients with chronic manifestations including low BMI, diarrhea, greasy stool and bloating were evaluated using serology for anti-tTG, endoscopy and histopathology. Patients were categorized in three diagnostic groups accordingly including celiac disease (CD), lymphocytic doudenosis (LD) and non-specific duodenitis (NSD). All patients were put on a GFD for 6 months, and subjective symptomatic response, serology, endoscopy and histopathologic tests were repeated and compared with baselines and among groups. RESULTS Of the total 35 patients, 5 had CD (14.3%), 9 had LD (25.7%) and 21 (60%) had NSD. Bloating was the most common symptom followed by diarrhea. Majority of patients (80%) had low BMI. All symptoms alleviated following a GFD but bloating was the only significant one. A significant increase was found in total mean BMI (17.3±0.7 v.s. 17.9±0.9). Histopathologic examination showed a complete resolution in 48.5% (n=17) patients, 10 in NSD group, 4 in LD group and 3 in CD group. Final prevalence of gluten-sensitive enteropathy (LD and NSD cases that responded to GFD) was 46.6%. CONCLUSION GFD may have more implications other than celiac disease. Other gluten-sensitive enteropathies, like LD and NSD, might also respond to this treatment particularly in patients with low BMI.
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Di Pisa M, Buccato P, Sabatino G, Real Fernández F, Berti B, Cocola F, Papini AM, Rovero P. Epitope mapping of the N-terminal portion of tissue transglutaminase protein antigen to identify linear epitopes in celiac disease. J Pept Sci 2014; 20:689-95. [PMID: 24831711 DOI: 10.1002/psc.2650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 04/17/2014] [Accepted: 04/17/2014] [Indexed: 12/27/2022]
Abstract
Celiac disease (CD) is an autoimmune mediated disease with complex and multifactorial etiology. Gluten intake triggers a composite immune response involving T-cells and B-cells and leading to the secretion of autoantibodies if a genetic predisposition is present. Untreated CD patients show high levels of circulating autoantibodies directed to different auto-antigens present in the intestinal mucosa. The most important auto-antigen is the endomysial enzyme tissue transglutaminase (tTG). Both IgA and IgG antibody isotypes to tTG are known, but only the IgA antibodies demonstrate the highest disease specificity and thus are considered disease biomarkers. Because the pathogenicity and exact tTG binding properties of these autoantibodies are still unclear, the characterization of tTG antigenic domains is a crucial step in understanding CD onset and the autoimmune pathogenesis. Overlapping peptide libraries can be used for epitope mapping of selected protein portions to determine antigenic fragments contributing to the immunological activity and possibly develop innovative peptide-based tools with high specificity and sensitivity for CD. We performed an epitope mapping study to characterize putative linear auto-antigenic epitopes present in the tTG N-terminal portion (1-230). A library of 23 overlapping peptides spanning tTG(1-230) was generated by Fmoc/tBu solid-phase peptide synthesis and screened by immunoenzymatic assays employing patients' sera. The results indicate that four synthetic peptides, that is, Ac-tTG(1-15)-NH2 , Ac-tTG(41-55)-NH2 , Ac-tTG(51-65)-NH2 , and Ac-tTG(151-165)-NH2 , are recognized by IgA autoantibodies circulating in CD patients' sera. These results offer important insight on the nature of the antigen-antibody interaction.
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Affiliation(s)
- Margherita Di Pisa
- Laboratory of Peptide and Protein Chemistry and Biology, University of Florence, I-50019, Sesto Fiorentino, Italy; Department of Chemistry 'Ugo Schiff', University of Florence, I-50019, Sesto Fiorentino, Italy
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Yokoyama S, Perera PY, Waldmann TA, Hiroi T, Perera LP. Tofacitinib, a janus kinase inhibitor demonstrates efficacy in an IL-15 transgenic mouse model that recapitulates pathologic manifestations of celiac disease. J Clin Immunol 2013; 33:586-94. [PMID: 23269601 PMCID: PMC3594487 DOI: 10.1007/s10875-012-9849-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 12/03/2012] [Indexed: 12/12/2022]
Abstract
Celiac disease (CD) is an immune-mediated, inflammatory disorder of the small intestines with a defined genetic etiological component associated with the expression of HLA-DQ2 and/or HLA-DQ8 haplotypes. The dietary consumption of gluten-rich cereals triggers a gluten-specific immune response in genetically susceptible individuals leading to a spectrum of clinical manifestations ranging from an inapparent subclinical disease, to overt enteropathy that can in some individuals progress to enteropathy-associated T cell lymphoma (EATL). The tissue-destructive pathologic process of CD is driven by activated NK-like intraepithelial CD8(+) lymphocytes and the proinflammatory cytokine IL-15 has emerged to be pivotal in orchestrating this perpetual tissue destruction and inflammation. Moreover, transgenic mice that over-express human IL-15 from an enterocyte-specific promoter (T3(b)-hIL-15 Tg) recapitulate many of the disease-defining T and B cell-mediated pathologic features of CD, further supporting the evolving consensus that IL-15 represents a valuable target in devising therapeutic interventions against the form of the disease that is especially refractory to gluten-free diet. In the present study, we evaluated the potential efficacy of tofacitinib, a pan-JAK inhibitor that abrogates IL-15 signaling, as a therapeutic modality against CD using T3(b)-hIL-15 Tg mice. We demonstrate that tofacitinib therapy leads to a lasting reversal of pathologic manifestations in the treated mice, thereby highlighting the potential value of tofacitininb as a therapeutic modality against refractory CD for which no effective therapy exists currently. Additionally, the visceral adiposity observed in the tofacitinib-treated mice underscores the importance of continued evaluation of the drug's impact on the lipid metabolism.
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Affiliation(s)
- Seiji Yokoyama
- Department of Allergy and Immunology, The Tokyo Metropolitan Institute of Medical Science, Setagayaku, Tokyo, 156-8506, Japan
| | - Pin-Yu Perera
- Veterans Affairs Medical Center, Washington D.C. 20422, USA
| | - Thomas A. Waldmann
- Metabolism Branch, National Cancer Institute, Bethesda, MD 20892-1374, USA
| | - Takachika Hiroi
- Department of Allergy and Immunology, The Tokyo Metropolitan Institute of Medical Science, Setagayaku, Tokyo, 156-8506, Japan
| | - Liyanage P. Perera
- Metabolism Branch, National Cancer Institute, Bethesda, MD 20892-1374, USA
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Abstract
Chronic diarrhea is a common patient complaint, with an estimated prevalence of 5 %. Diarrhea is defined as >200 g/day of stool with decreased consistency, and chronic diarrhea is defined as lasting more than 4 weeks. The purpose of this review is to guide the clinician's diagnostic evaluation and management of chronic diarrhea, rather than providing a textbook comprehensive review of the subject, focusing on the patient in developed countries and excluding the immune suppressed patient. While the investigation and treatment of chronic diarrhea can be challenging due to its myriad causes, when the clinician employs a practical approach, dividing chronic diarrhea into bloody, fatty, and watery causes, it simplifies and streamlines the work-up and management plan and leads to improved patient outcomes.
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