Associated disorders in coeliac disease: clinical aspects

Celiac Disease as a Rare Cause of Membranous Nephropathy: A Case Report

Membranous nephropathy is the most common cause of nephrotic syndrome in adults. A non-negligible number of cases are associated with systemic conditions. We report a case of a 50-year-old man who presented with nephrotic syndrome six months after being diagnosed with celiac disease. Although the patient showed disappearance of circulating immunoglobulin A (IgA) anti-tissue transglutaminase antibodies following a gluten-free diet, he had a sudden onset of nephrotic syndrome presenting with severe hypoalbuminemia. Other secondary causes were promptly excluded leading to the assumption of celiac disease-associated membranous nephropathy with remission after treatment with angiotensin system blockade and a gluten-free diet. The goal of this case report is to alert the clinic towards this rare association aiming for an early diagnosis and adequate selection of long-term therapy.

Serological screening for coeliac disease in patients with juvenile idiopathic arthritis

BACKGROUND AND STUDY AIMS

Juvenile idiopathic arthritis (JIA) is characterized by autoimmune aetiology. A gene locus 4q27 related to rheumatoid arthritis, psoriatic arthritis, and coeliac disease is associated with susceptibility to JIA. There are reports indicating several patients with JIA had been diagnosed with CD. We aimed to assess the frequency of coeliac disease (CD) in patients with juvenile idiopathic arthritis (JIA).

PATIENTS AND METHODS

This prospective study was carried out from October 2015 to August 2016 and included 96 patients with JIA. All patients were evaluated in terms of clinical and laboratory findings of CD. Levels of total IgA and tissue transglutaminase antibody (tTG) IgA were measured in all patients. Those with increased level of tTG IgA were further tested for anti-endomysium IgA antibodies (EMA). Gastroduodenoscopy were planned for a definite diagnosis of CD in patients with positive EMA.

RESULTS

Of the 96 patients in our study, 34 (35.4%) had oligoarticular form of JIA, 29 (30.2%) had polyarticular form, 12 (12.5%) had ERA form, 11 (11.5%) had systemic form, and 10 (10.4%) had psoriatic form. Sixteen of our patients (16.6%) were not using any drugs during the study. Neither EMA IgA antibodies were analysed nor gastro-duodenoscopy was performed because no patients were positive for tTG IgA. There was no difference in terms of tTG levels between the patients using NSAIDs or other drugs.

CONCLUSION

We did not find CD in children with JIA. Long term studies with more JIA patients are needed to provide more precise interpretation.

Neurologic complications of celiac disease

Neurologic complications of celiac disease (CD) include ataxia and peripheral neuropathy, which can be the presenting symptoms and signs. Early diagnosis and intervention could prevent development of further neurologic and systemic complications. Questions remain regarding the prevalence of the neurologic complications, the pathophysiological mechanisms, and the effectiveness of therapy or response to a gluten-free diet.

Regulatory T-cell function is impaired in celiac disease

Celiac disease (CD) is characterized by intolerance to gluten and high risk of developing autoimmune phenomena. Possible defects in immune tolerance could have a role in the pathogenesis of the disease. As regulatory T-cells (Tregs) are the main population involved in maintaining peripheral tolerance, we investigated the number of these cells in celiac patients as compared with healthy donors. Moreover, we analyzed the suppressive function of CD4+CD25+ T-cells from celiac disease patients and controls on autologous responder T-cells (CD4+CD25-). The percentage of CD4+CD25+FOXP3+ cells was not different in celiacs and in healthy controls, and among positive cells the level of expression of the two regulatory markers was comparable. However, the suppressor activity of Tregs was significantly impaired in CD patients. These results suggest that a defect in Tregs function could play a role in the pathogenesis of CD and in CD-associated autoimmunity.

The co-existence of membranoproliferative glomerulonephritis type 1 and coeliac disease: a case report

Coeliac disease is an autoimmune enteropathy characterised by chronic inflammation of the small intestinal mucosa and the presence of typical autoantibodies. Coeliac disease may be a risk factor for renal disease. Immunoglobulin A (IgA) nephropathy is reported in the majority of these cases. Only one adult patient had been reported with membranoproliferative glomerulonephritis (MPGN) and coeliac disease. Here, we report a case in a 12-year-old girl with coeliac disease who presented with severe anaemia and later developed nephrotic syndrome. Renal biopsy of the patient was consistent with MPGN type 1, which has not been previously reported in children with coeliac disease. A gluten-free diet was started. After 6 months of this diet, her nephrotic syndrome resolved completely. This case is presented to draw attention to the rare association of coeliac disease and MPGN type 1.

Effect of gluten-free diet on pregnancy outcome in celiac disease patients with recurrent miscarriages

PURPOSE

Available literature data show that celiac disease (CD) is a frequent cause of recurrent miscarriage. However, data are lacking for pregnancy outcome when the patient is on a gluten-free diet (GFD). A case-control study about the effect of GFD on pregnancy was conducted from 1995 to 2006. A cohort of 13 women (mean age 32 years, range 22-38 years) affected by CD with recurrent miscarriages was observed. In all of them several causes of miscarriage (gynecological, endocrine, hematological, etc.) were excluded. All patients were started on a gluten-free diet and were reassessed throughout a long-term follow-up period to evaluate the outcome of pregnancy.

RESULTS

Six of 13 became pregnant (46.15%) as follows: 1 patient (7.69%) 1 year after GFD was started, 3 patients (23.07%) 2 years after GFD was started, 1 patient (7.69%) after 3 years, and finally 1 (7.69%) 4 years after GFD was started. Moreover, two patients (16.66%) had multiple pregnancies (one had had two childbirths and another had undergone three births within a 7-year follow-up period under GFD).

CONCLUSIONS

GFD seems to favor a positive outcome of pregnancy in most CD patients with recurrent miscarriage.

Is serum citrulline measurement clinically useful in coeliac disease?

Citrulline (CIT), a non-protein amino acid in circulating blood, is almost exclusively contained in the enterocytes of small bowel mucosa and may represent a reliable marker of functioning enterocyte mass. The aim of this study was to evaluate the clinical utility of measuring serum citrulline levels in a group of patients affected by coeliac disease (CD). Fifty healthy volunteers, 21 patients with untreated coeliac disease and 6 patients with refractory coeliac disease took part in the study. Serum citrulline levels and duodenal lesions were evaluated at the time of diagnosis, and after at least 24 months of gluten-free diet. Serum citrulline concentrations were determined by ion exchange chromatography. In comparison to healthy volunteers, serum citrulline concentrations were significantly lower in untreated and refractory coeliac disease patients. No significant difference was found between untreated and refractory coeliac disease patients and between patients with different patterns of clinical presentation or various degrees of duodenal lesions. After a gluten-free diet, the mean of serum citrulline concentration was increased in all but one patient. Although, as expected, serum citrulline levels turned out to be low in coeliac disease, the clinical utility of their measurement is, at least, questionable in this condition.

Secondary cutaneous nodular AA amyloidosis in a patient with primary Sjögren syndrome and celiac disease

We describe a 62-year-old female with primary Sjögren syndrome and myopathy, severe osteoporosis, and vertebral fractures that were attributed to celiac disease. A year after the diagnosis, she developed a skin nodule on the extensor surface of her right elbow, which was due to an amyloid deposit of AA type. Amyloidosis, although relatively common in some chronic inflammatory diseases, has been uncommon in Sjögren syndrome or celiac disease. Visceral amyloid was not found in this patient.

Celiac disease and autoimmune thyroid disease

Celiac disease (CD) or gluten sensitive enteropathy is relatively common in western populations with prevalence around 1%. With the recent availability of sensitive and specific serological testing, many patients who are either asymptomatic or have subtle symptoms can be shown to have CD. Patients with CD have modest increases in risks of malignancy and mortality compared to controls. The mortality among CD patients who comply poorly with a gluten-free diet is greater than in compliant patients. The pattern of presentation of CD has altered over the past three decades. Many cases are now detected in adulthood during investigation of problems as diverse as anemia, osteoporosis, autoimmune disorders, unexplained neurological syndromes, infertility and chronic hypertransaminasemia of uncertain cause. Among autoimmune disorders, increased prevalence of CD has been found in patients with autoimmune thyroid disease, type 1 diabetes mellitus, autoimmune liver diseases and inflammatory bowel disease. Prevalence of CD was noted to be 1% to 19% in patients with type 1 diabetes mellitus, 2% to 5% in autoimmune thyroid disorders and 3% to 7% in primary biliary cirrhosis in prospective studies. Conversely, there is also an increased prevalence of immune based disorders among patients with CD. The pathogenesis of co-existent autoimmune thyroid disease and CD is not known, but these conditions share similar HLA haplotypes and are associated with the gene encoding cytotoxic T-lymphocyte-associated antigen-4. Screening high risk patients for CD, such as those with autoimmune diseases, is a reasonable strategy given the increased prevalence. Treatment of CD with a gluten-free diet should reduce the recognized complications of this disease and provide benefits in both general health and perhaps life expectancy. It also improves glycemic control in patients with type 1 diabetes mellitus and enhances the absorption of medications for associated hypothyroidism and osteoporosis. It probably does not change the natural history of associated autoimmune disorders.

Comparison of the interobserver reproducibility with different histologic criteria used in celiac disease

BACKGROUND & AIMS

The Marsh-Oberhuber classification of duodenojejunal mucosal lesions is currently used for celiac disease. A more simplified classification, which is based on 3 villous morphologies (A, non-atrophic; B1, atrophic, villous-crypt ratio <3:1; B2, atrophic, villi no longer detectable) and an intraepithelial lymphocyte count of >25/100 enterocytes, has recently been proposed. The aim of the study was to asses the interobserver agreement between different pathologists in classifying celiac disease lesions according to both Marsh-Oberhuber and the new classification system.

METHODS

Sixty patients were selected for the study: 10 subjects without celiac disease, 13 celiac patients with normal villi but a pathologic increase in intraepithelial lymphocytes >25/100 and hyperplastic crypts, and 37 patients with celiac disease with villous atrophy. Sixty slides were sent to 6 pathologists, who were blinded to each other and were not given any clinical information. Each pathologist received the set of biopsy specimens on 2 separate occasions and had to evaluate them according to both grading systems in a random order. The kappa statistic was used to assess agreement between each pair of pathologists.

RESULTS

Overall, mean kappa values were 0.35 (fair) for the Marsh-Oberhuber classification versus 0.55 (moderate) for the new classification system.

CONCLUSIONS

The new classification for duodenal pathology in celiac disease gives better interobserver agreement compared with the more cumbersome Marsh-Oberhuber classification and contributes to the validity of diagnosis in celiac disease.

Celiac disease in South-West of Iran

AIM: Celiac disease is characterized by life-long gluten intolerance. Clinical features of patients with celiac disease are variable. Studies about the prevalence of celiac disease in our country are scarce and there is no study on the prevalence of celiac disease in southern Iran. In the current study, clinical, laboratory and histo-logical features of 52 patients with celiac disease were evaluated.

METHODS: In a cross sectional study we retrospectively studied the characteristics of 52 celiac patients at Ahwaz JundiShapour University Hospitals (AJSUH) from November 1, 1999 to 1st Sep 2004. Intestinal biopsy and serum antigliadin and anti-endomysium antibodies were used for the diagnosis of patients. Mucosal lesions were classified according to the criteria of Marsh. Antigliadin antibodies were measured with a commercial enzyme-linked immunosorbent assay. Anti-endomysium antibodies were analyzed by indirect immunofluorescence with the use of a section of monkey esophagus. Routine hematological and biochemical analyses and measurement of immunoglobulin levels were undertaken.

RESULTS: Male: female ratio was 1.08. The mean ± SD patient age was 21 ± 4.5 years (range 10-70 years) and the most common symptoms were diarrhea and weight loss (78.8%) followed by fatigue (73.1%), pallor (65.4%), anorexia (40.4%), abdominal distention (32.7%), and failure to thrive (23.1%). Diarrhea and weight loss and fatigue were the most common findings. Iron deficiency anemia was found in 63.2% of patients and this became normal after adoption of a gluten-free diet in all patients. Immunoglobulin A, IgG antigliadin antibodies and IgA anti-endomysium antibodies were found in 33 and 48 cases, 78.8% and 85.4% of patients, respectively. Biopsy of the small intestine revealed that 90.4% of patients had typical lesions according to the Marsh classification.

CONCLUSION: Although classical presentation was seen in most of the patients, atypical clinical manifestations of celiac disease should be kept in mind. In particular, patients with uncommon findings, such as short stature, and iron-deficiency anemia, should be screened for celiac disease. Further epidemiological studies in our area in the general population and in high risk groups seem to be indicated.

Celiac disease

Celiac disease is a chronic intestinal disease caused by intolerance to gluten. It is characterized by immune-mediated enteropathy, associated with maldigestion and malabsorption of most nutrients and vitamins. In predisposed individuals, the ingestion of gluten-containing food such as wheat and rye induces a flat jejunal mucosa with infiltration of lymphocytes. The main symptoms are: stomach pain, gas, and bloating, diarrhea, weight loss, anemia, edema, bone or joint pain. Prevalence for clinically overt celiac disease varies from 1:270 in Finland to 1:5000 in North America. Since celiac disease can be asymptomatic, most subjects are not diagnosed or they can present with atypical symptoms. Furthermore, severe inflammation of the small bowel can be present without any gastrointestinal symptoms. The diagnosis should be made early since celiac disease causes growth retardation in untreated children and atypical symptoms like infertility or neurological symptoms. Diagnosis requires endoscopy with jejunal biopsy. In addition, tissue-transglutaminase antibodies are important to confirm the diagnosis since there are other diseases which can mimic celiac disease. The exact cause of celiac disease is unknown but is thought to be primarily immune mediated (tissue-transglutaminase autoantigen); often the disease is inherited. Management consists in life long withdrawal of dietary gluten, which leads to significant clinical and histological improvement. However, complete normalization of histology can take years.

Prevalence of coeliac disease in Italian patients affected by Addison's disease

OBJECTIVE

It is well known that coeliac disease is associated with autoimmune endocrine diseases, such as autoimmune thyroid disease and insulin-dependent diabetes mellitus. Recently, coeliac disease has been shown in approximately 10% of patients with autoimmune Addison's disease. Addison's disease is the most common cause of primary adrenocortical insufficiency and it shares several clinical features with coeliac disease. Although hyperpigmentation and hypotension are the most specific signs, gastrointestinal symptoms are common and can be the first complaints of the patients. The aim of our study was to investigate the prevalence of coeliac disease in Italian patients with Addison's disease.

MATERIAL AND METHODS

Seventeen consecutive patients affected by Addison's disease (14 F, mean age 53.9 years, range 26-79 years) were enrolled in the study. Eleven of them were affected by Addison's disease associated with autoimmune thyroid disease and/or insulin-dependent diabetes mellitus; the other 6 patients were suffering from isolated Addison's disease. Diagnosis had been performed at the age of 40.5 years (range 23-55). Steroid treatment had already been started in 16 of the patients. Endomysial antibodies were tested in all of them and a duodenal biopsy was taken in those found to be positive for antiendomysial antibody (EMA).

RESULTS

One out of 17 patients was found to be EMA positive. Duodenal biopsy confirmed the diagnosis of coeliac disease by showing subtotal villous atrophy.

CONCLUSIONS

Although we studied only a small sample, our preliminary results confirmed that Addison's disease is associated with coeliac disease, being present in 5.9% of patients with Addison's disease. Since the symptoms can be similar and treatment of Addison's disease can mask coeliac disease, this association should always be actively investigated.

[Association between serum markers for celiac and thyroid autoimmune diseases]

Celiac disease (CD) is an autoimmune disease of the small bowel characterized by a strong genetic association with HLA - DQ2 and DQ8. Gluten is the etiological factor and the tissue enzyme transglutaminase (TGase) is its autoantigen. CD is associated with several autoimmune diseases such as type 1 diabetes, systemic lupus erythematous, rheumatoid arthritis, Sjögrens syndrome and autoimmune thyroid diseases. The aim of this study was to investigate the occurrence of serum IgA anti-endomysial and anti-human TGase antibodies in individuals with positive anti-thyroid antibody (ATA). The concordance between these two tests was also evaluated. Anti-endomysial antibodies were positive in 10 out of 456 (2.2%) and anti-human TGase were positive in 14 of 454 (3.1%) individuals with positive ATA. In control subjects they were positive in 1 of 197 (0.5%) and 2 of 198 (1%) for anti-endomysial and anti-human tissue TGase antibodies, respectively. The odds ratio (OR) for the anti-endomysial antibodies was 4.42 and for the anti-human TGase 3.12 in individuals with ATA when compared with controls. An elevated concordance index (k= 0.84) was observed between anti-endomisyal antibodies and anti-human TGase. We conclude that the determination of anti-TGase antibodies is a good test for DC screening.

IgA anti-transglutaminase antibodies as a tool for screening atypical forms of coeliac disease in a French at-risk paediatric population

OBJECTIVE

The diagnosis of coeliac disease (CD) is often delayed because many children are free from the major symptoms characteristic of this enteropathy. The aim of the present study was to determine the efficacy of antibodies directed against tissue transglutaminase (tTG Abs) for early detection of CD in a population with few symptoms of the disease, as well as in children with an autoimmune disorder.

METHODS

This was a prospective study in a paediatric population including 638 patients with clinical symptoms frequently associated with CD, autoimmune diseases such as type 1 diabetes mellitus (DM1), autoimmune thyroiditis or hepatitis, and Turner's syndrome. Anti-endomysium, tTG Abs and antigliadin antibodies were analysed in these patients using an indirect immunofluorescence technique and enzyme-linked immunosorbent assay techniques. Intestinal biopsies were performed for some patients with positive or negative antibodies.

RESULTS

tTG Abs were detected in 2.6% of children with symptoms associated with CD, such as digestive signs and growth failure, and in 5.4% of children with DM1. No other autoimmune disease was positive for tTG Abs. Biopsies performed in the patients with positive tTG Abs showed mucosal atrophy confirming the diagnosis of CD in all cases.

CONCLUSION

Children displaying minimal symptoms frequently associated with CD and children with DM1 should be systematically screened for tTG Abs.

Coeliac disease: the great imitator

Coeliac disease (CD) is caused by a complex immunological response provoked by grain protein in susceptible people. The majority of people with CD are symptom-free adults; the remainder are prone to a bewildering variety of signs and symptoms, ranging from infertility to type 1 diabetes. Many patients with undiagnosed CD spend years seeking help for complaints such as chronic tiredness or mild abdominal symptoms. In primary care, an appropriate target group to test for CD is people with anaemia (especially women), chronic tiredness, non-specific abdominal symptoms (including so-called "irritable bowel syndrome"), or a family history of CD. The response to an appropriate gluten-free diet is often life-transforming for symptomatic patients. Positive serological tests for CD require confirmation by duodenal biopsy and, if confirmed, referral to a dietitian and a coeliac society, followed by a life-long gluten-free diet.

Risk of malignancy in patients with celiac disease

PURPOSE

Studies from Europe have demonstrated an increased risk of malignancy, especially non-Hodgkin's lymphoma, in patients with celiac disease. However, there are no data on the risk for similar patients in the United States. Our aim was to estimate the risk of malignancy in a cohort of patients with celiac disease compared with the general U.S. population and to determine if a gluten-free diet is protective.

METHODS

Patients with celiac disease seen between July 1981 and January 2000 at a referral center were included. Standardized morbidity ratios (SMRs) (ratio of observed to expected) and corresponding 95% confidence intervals (CI) were calculated, using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program.

RESULTS

Forty-three (11%) of 381 celiac disease patients had a diagnosis of cancer; 9 were after the diagnosis of celiac disease, 7 were simultaneous (during same month or admission), and 27 were before the diagnosis. The standardized morbidity ratio for all cancers combined was 1.5 (95% CI: 0.3 to 7.5), with significantly increased values for small bowel cancer (SMR = 34; 95% CI: 24 to 42), esophageal cancer (SMR = 12; 95% CI: 6.5 to 21), non-Hodgkin's lymphoma (SMR = 9.1; 95% CI: 4.7 to 13), and melanoma (SMR = 5.0; 95% CI: 2.1 to 12). Following the diagnosis of celiac disease, patients were at increased risk of non-Hodgkin's lymphoma only (SMR = 6.2; 95% CI: 2.9 to 14), despite adherence to a gluten-free diet. The non-Hodgkin's lymphoma included both T-cell and B-cell types and occurred in both gastrointestinal (n = 5) and extraintestinal sites (n = 4).

CONCLUSION

In this cohort of patients with celiac disease, we observed increased risks of small intestinal adenocarcinoma, esophageal cancer, melanoma, and non-Hodgkin's lymphoma. The risk of non-Hodgkin's lymphoma persisted despite a gluten-free diet.

High frequency of coeliac disease among patients with autoimmune adrenocortical failure

BACKGROUND

Coeliac disease (CD) is an autoimmune disease of the small intestine caused by gluten ingestion in genetically predisposed subjects. It can occur isolated or in combination with other autoimmune diseases. Autoimmune Addison's disease is frequently associated with other organ-specific autoimmune diseases. We have investigated the prevalence of CD among a large cohort of patients with autoimmune Addison's disease.

METHODS

Seventy-six patients (44 women) with Addison's disease, 52% of whom had polyendocrine failure, were recruited from a registry of organ-specific autoimmune diseases in Norway. All sera were analysed for antibodies against gliadin (AGA), endomysium (EMA) and tissue transglutaminase (tTG). Patients with positive EMA and/or anti-tTG were offered endoscopy. The human leucocyte antigen (HLA) class II genotypes were determined.

RESULTS

Five patients had antibodies against both endomysium and tissue transglutaminase. In these five patients, CD was verified by biopsy. One patient had known CD prior to the study. All six patients with CD carried the CD-associated HLA haplotype DR3-DQ2. The total prevalence of CD was 7.9%.

CONCLUSION

CD is frequently associated with Addison's disease. The risk of developing CD seems to be higher than can be explained by the common DR3-DQ2 association alone. It is often asymptomatic or associated with unspecific symptoms. Addison patients should be screened for the presence of CD on a regular basis.

Extreme thrombocytosis as a sign of coeliac disease in the elderly: case report

Increase in the number of blood platelets to over 1,000,000/mm3 in elderly patients is generally considered secondary to a myeloproliferative or neoplastic disease. To report the case of an elderly woman hospitalized for extreme thrombocytosis associated with severe anaemia, who was found to be suffering from coeliac disease. The patient, aged 83 years, was hospitalized presenting with fatigue. Laboratory tests showed microcytic hypochromic anaemia (haemoglobin 4 g/dl) and extreme thrombocytosis (platelet count 1,400,000/mm3). Physical examination was normal, with the exception of marked thinness. There was no evidence of macroscopic bleeding from the gastrointestinal or genitourinary tracts. She had never suffered from gastrointestinal problems and had no family history of gastroenterological diseases. Oesophagogastroduodenoscopy and histology of the gastric and duodenal mucosa evidenced atrophic gastritis and an adenomatous polyp. The duodenal mucosa showed total villous atrophy, suggesting the diagnosis of coeliac disease. Antiendomysial IgA and anti-transglutaminase IgA antibodies were also positive. Colonoscopy was negative. An ultrasound examination of the abdomen was normal, and the spleen was within the normal range. A peripheral blood smear showed no alterations in erythrocyte morphology typical of hyposplenism due to coeliac disease. The platelet count decreased rapidly after blood transfusions, when both serum iron and ferritin levels were still below normal limits. Furthermore, we observed a significant inverse correlation between the platelet count and haemoglobin concentration (r = -0.94, P < 0.003). Platelet count and red blood cell count normalized after 2 months of a gluten-free diet; the haemoglobin concentration was also normal at this time. After 1 year of following a gluten-free diet, the patient remained well and had no complaints. There were no gastrointestinal disturbances. All haematological parameters were within normal limits. Intestinal biopsies showed normal villi and crypts without inflammatory infiltration of the lamina propria. This case shows that the association of haematological signs--extreme thrombocytosis and severe anaemia--considered in an elderly patient to be typical of myeloproliferative disorders or neoplastic conditions can be due to coeliac disease; thus, coeliac disease must also be considered among the possible diagnoses.

Endocrinological disorders and celiac disease

Celiac disease is a permanent intolerance to dietary gluten. Its well known features are abdominal symptoms, malabsorption of nutrients, and small-bowel mucosal inflammation with villous atrophy, which recover on a gluten-free diet. Diagnosis is challenging in that patients often suffer from subtle, if any, symptoms. The risk of clinically silent celiac disease is increased in various autoimmune conditions. The endocrinologist, especially, should maintain high suspicion and alertness to celiac disease, which is to be found in 2-5% of patients with insulin-dependent diabetes mellitus or autoimmune thyroid disease. Patients with multiple endocrine disorders, Addison's disease, alopecia, or hypophysitis may also have concomitant celiac disease. Similar heredity and proneness to autoimmune conditions are considered to be explanations for these associations. A gluten-free diet is essential to prevent celiac complications such as anemia, osteoporosis, and infertility. The diet may also be beneficial in the treatment of the underlying endocrinological disease; prolonged gluten exposure may even contribute to the development of autoimmune diseases. The diagnosis of celiac disease requires endoscopic biopsy, but serological screening with antiendomysial and antitissue transglutaminase antibody assays is an easy method for preliminary case finding. Celiac disease will be increasingly detected provided the close association with autoimmune endocrinological diseases is recognized.

Pediatric celiac disease in India is associated with multiple DR3-DQ2 haplotypes

The role of human leukocyte antigen (HLA) DQ2 heterodimer (DQA1*0501-DQB1*0201) in presenting gluten peptides to effector T cells in celiac disease (CD) has been well documented. Because HLA-DQ2 is carried on DR3 haplotypes due to linkage disequilibrium, such haplotypes are encountered more frequently in patients with autoimmune disease. This study analyzed 35 North Indian children below 15 years of age and diagnosed to have CD as per the ESPGAN criteria, which included histopathologic alterations in duodenal biopsies, clinical response to gluten withdrawal, and presence of antiendomysial antibodies. The HLA class I and class II alleles were determined by polymerase chain reaction-sequence-specific primers, sequence-specific oligonucleotide probe, and reverse line strip molecular techniques. A statistically significant positive association of the disease with HLA-DRB1*03 (94.2% versus 22.1% in controls, chi(2) = 73.4, p = 7.54E-11), and a negative association with DRB1*15 (chi(2) = 7.4, p = 6.5E-03) and DRB1*13 alleles was observed. The HLA-DQB1*0201 was observed in all the 35 patients (100%), whereas the DQ2 heterodimer alpha(0)beta(0) occurred in 97.1% of CD patients (31.4% in double dose, 65.7% in single dose) and revealed significant deviation from healthy controls (chi(2) = 102.08, p = 7.56E-11). Further analysis revealed involvement of multiple DR3+ve haplotypes with CD in Indians, of which A26-B8-DR3 was the most common DR3 haplotype among patients (34.28%, chi(2) = 40.57, p = 2.65E-10) followed by Ax-B21-DR3 (11.4%) (chi(2) = 13.8, p = 2E-04) and the classical Caucasian haplotype A1-B8-DR3 (5.7%). The former two haplotypes are characteristic of Asian Indians and are involved in the development of CD. We conclude that the high risk DR3 haplotypes that play a crucial role in the development of CD are unique in Asian Indians. Detailed analysis of these haplotypes in Indian patients with autoimmune diseases may help understand the influence of other intervening genes within the major histocompatibility complex.

Diagnosis of celiac sprue

Celiac sprue is a common lifelong disorder affecting 0.3-1% of the Western world and causing considerable ill health and increased mortality, particularly from lymphoma and other malignancies. Although high prevalence rates have been reported in Western Europe, celiac sprue remains a rare diagnosis in North America. Whether celiac sprue is truly rare among North Americans or is simply underdiagnosed is unclear, although serological screening of healthy American blood donors suggests that a large number of American celiacs go undiagnosed. Celiac sprue is an elusive diagnosis, and often its only clue is the presence of iron or folate deficiency anemia or extraintestinal manifestations, such as osteoporosis, infertility, and neurological disturbances. The challenge for gastroenterologists and other physicians is to identify the large population of undiagnosed patients that probably exists in the community and offer them treatment with a gluten-free diet that will restore the great majority to full health and prevent the development of complications. The advent of highly sensitive and specific antiendomysium and tissue transglutaminase serological tests has modified our current approach to diagnosis and made fecal fat and D-xylose absorption testing obsolete. A single small bowel biopsy that demonstrates histological findings compatible with celiac sprue followed by a favorable clinical and serological response to gluten-free diet is now considered sufficient to definitely confirm the diagnosis. We review the wide spectrum of celiac sprue, its variable clinical manifestations, and the current approach to diagnosis.

Antiendomysium antibodies in Brazilian patients with celiac disease and their first-degree relatives

BACKGROUND

Literature data have shown high specificity of antiendomysial antibodies (EmA IgA) in celiac disease. The scarcity of Brazilian reports concerning this subject motivated the present study.

OBJECTIVES

To determine the sensitivity and specificity of antiendomysial IgA antibodies in Brazilian celiac patients at diagnosis and after treatment, to confirm patient adherence to a gluten-free diet and to screen first-degree relatives.

METHODS

An extensive clinical and serological study was performed by investigating the presence of these antibodies in 392 individuals from Southern Brazil. Indirect immunofluorescence using human umbilical cord as substrate was employed and the total levels of IgA were determined by turbidimetry in all groups. The study was conducted on 57 celiac patients (18 at diagnosis, 24 who adhered to a gluten-free diet and 15 with marked or slight transgression of the diet), 115 relatives of celiac patients (39 families), 94 patients with other gastrointestinal diseases, and 126 healthy individuals from the general population.

RESULTS

The results demonstrated 100% positivity for the recently diagnosed patients and for those consuming gluten, in contrast to the patients who complied with the diet (0%). In the control group one individual was positive, but refused to undergo a biopsy. In the group of other gastrointestinal diseases, one positive patient presented ulcerative colitis, Down's syndrome and epilepsy, and the intestinal biopsy was diagnostic for celiac disease. These data showed 99.3% specificity for the test. Eighteen relatives were positive for antiendomysial antibodies IgA (15.65%), and comparison with the healthy population revealed a significant difference. An intestinal biopsy was obtained from seven subjects (one with total villous atrophy and six without alterations in the mucosal architecture, but all with a high number of intra-epithelial lymphocytes).

CONCLUSIONS

The method revealed 100% sensitivity and 99.3% specificity. Because it is not an invasive method it can be used for the screening of atypical and latent forms of celiac disease to avoid serial biopsies and to control adherence to a gluten-free diet with implications in the prevention of malignancy in celiac disease.

Characteristics of adult celiac disease in the USA: results of a national survey

OBJECTIVE

The clinical spectrum of adults with celiac disease in the United States, where the disease is considered rare, is not known. We sought this information by distributing a survey.

METHODS

A questionnaire was distributed by way of a celiac newsletter, directly to celiac support groups, and through the Internet.

RESULTS

Respondents (1,612) were from all United States except one. Seventy-five percent (1,138) were biopsy proven. Women predominated (2.9:1). The majority of respondents were diagnosed in their fourth to sixth decades. Symptoms were present a mean of 11 yr before diagnosis. Diarrhea was present in 85%. Diagnosis was considered prompt by only 52% and 31% had consulted two or more gastroenterologists. Improved quality of life after diagnosis was reported by 77%. Those diagnosed at age > or = 60 yr also reported improved quality of life. Five respondents had small intestinal malignancies (carcinoma 2, lymphoma 3) accounting for a relative risk of 300 (60-876) for the development of lymphoma and 67 (7-240) for adenocarcinoma.

CONCLUSIONS

Patients with celiac disease in the United States have a long duration of symptoms and consider their diagnosis delayed. Improved quality of life after diagnosis is common. An increased risk of developing small intestine malignancies is present.

Gliadin antibodies in adult insulin-dependent diabetes--autoimmune and immunogenetic correlates

Gliadin antibody (GA) tests used in screening for coeliac disease (CD) frequently yield positive GA results without accompanying CD in cases of diabetes mellitus type 1 (DM-1). To enlighten this phenomenon we screened 848 DM-1 patients for IgA- and IgG-GA. Subsequently, 16 out of 19 high titre GA patients (6 with CD) were compared with 37 low titre DM-1 patients matched for sex, age and disease duration, for autoimmune and immunogenetic markers. Chronic thyroiditis and thyroid peroxidase (TPO) antibody positivity were more frequent in the GA-positive than in the GA-negative sub-group (38 vs. 2.7%, p = 0.003, and 69 vs. 27%, p < 0.00, respectively). The tissue transglutaminase (tTg) IgA titres correlated with CD but not with GA. tTg IgG titres were lower in GA-positive individuals (p = 0.0012). GA-positivity correlated with a higher titre of factor XIII IgA antibodies (p < 0.001). GA-positive DM-I patients were characterised by a distinct immunogenetic profile; the risk of HLA DQB1*02 was lower among GA-positive patients than among GA-negatives (OR 0.4, preventive fraction 0.43). All CD patients were HLA DRB1*03-DQB1* 02-positive, but none of the five patients with normal biopsies. GA-positive patients instead had HLA DRB1*13 in 37.5% as compared to 8.6% in GA-negative (OR 6.4, etiologic fraction 0.32). Thus, the occurrence of positive GA in DM-1 is correlated to TPO antibody positivity, thyroiditis and factor XIII IgA antibodies, but inversely correlated to tTg IgG, and seems to be associated with another HLA haplotype than that previously found to be associated with CD.

Modulation of immune function by dietary lectins in rheumatoid arthritis

Despite the almost universal clinical observation that inflammation of the gut is frequently associated with inflammation of the joints and vice versa, the nature of this relationship remains elusive. In the present review, we provide evidence for how the interaction of dietary lectins with enterocytes and lymphocytes may facilitate the translocation of both dietary and gut-derived pathogenic antigens to peripheral tissues, which in turn causes persistent peripheral antigenic stimulation. In genetically susceptible individuals, this antigenic stimulation may ultimately result in the expression of overt rheumatoid arthritis (RA) via molecular mimicry, a process whereby foreign peptides, similar in structure to endogenous peptides, may cause antibodies or T-lymphocytes to cross-react with both foreign and endogenous peptides and thereby break immunological tolerance. By eliminating dietary elements, particularly lectins, which adversely influence both enterocyte and lymphocyte structure and function, it is proposed that the peripheral antigenic stimulus (both pathogenic and dietary) will be reduced and thereby result in a diminution of disease symptoms in certain patients with RA.

Increased density of jejunal gammadelta+ T cells in patients having normal mucosa--marker of operative autoimmune mechanisms?

Both from a clinical and a biological point of view, coeliac disease can be classified among the autoimmune diseases, or one could suspect autoimmune mechanisms to be operative in the disease. The aim of the present study was to find evidence for mucosal markers of coeliac disease latency in patients clinically suspected but on routine biopsy excluded for the disease. Monoclonal antibodies were used to stain jejunal intraepithelial lymphocytes and mucosal HLA-DR. Serum IgA-class reticulin autoantibodies were measured by an indirect immunofluorescence and gliadin antibodies by an enzyme-linked immunosorbent assay method. The DQA1*0501 and DQB1*0201 alleles were determined. Twenty-seven of 107 consecutive patients had coeliac disease. Altogether 39 of 79 (49%) children with normal jejunal mucosa had an increased density of intraepithelial gammadelta+ T cells (> or = 4.4 cells/mm). IgA-class reticulin autoantibodies were positive in 18 (23%) of the children excluded for coeliac disease. The antibody positivity was mostly seen in patients carrying the DQAI 0501 and DQB1*0201 alleles. Also, reticulin autoantibody-positive children having normal jejunal mucosal morphology had significantly higher densities of intraepithelial gammadelta+ T cells than antibody negative ones. On 1.5-4.5 year follow-up four out of 18 (22%) children primarily excluded for coeliac disease showed mucosal deterioration and coeliac disease. Many patients clinically suspected of coeliac disease but having normal jejunal mucosa show markers of coeliac disease latency which may be gluten-induced indicating autoimmune mechanisms to be operative in the gut.

Duration of exposure to gluten and risk for autoimmune disorders in patients with celiac disease. SIGEP Study Group for Autoimmune Disorders in Celiac Disease

BACKGROUND & AIMS

The relationship between celiac disease and many autoimmune disorders has been explained by the sharing of a common genetic factor. In a multicenter national study, we examined the relationship between the prevalence of autoimmune disorders in celiac disease and the duration of exposure to gluten.

METHODS

Over a 6-month period, 909 patients with celiac disease (group A; mean age, 16.1 +/- 3.8 years; grouped according to age at diagnosis into three subgroups [group A1, <2 years; group A2, 2-10 years; and group A3, >10 years]), 1268 healthy controls (group B; mean age, 20.8 +/- 4.5 years), and 163 patients with Crohn's disease (group C; mean age, 28.8 +/- 10 years) were evaluated for the presence of autoimmune disorders.

RESULTS

Prevalence of autoimmune disorders in group A was significantly higher than in group B (14% vs. 2.8%; P < 0.000001) but not higher than in group C (12.9%). Prevalence of autoimmune disorders in celiac disease increased with increasing age at diagnosis: 5.1% in group A1, 17% in group A2, and 23.6% in group A3 (P = 0.000001). In group A3, the prevalence of autoimmune disorders was significantly higher than in group C. In a logistic regression model, age at diagnosis was the only significant predictor variable of the odds of developing an autoimmune disorder (r = 0.3; P < 0.000001).

CONCLUSIONS

Our data show for the first time that the prevalence of autoimmune disorders in celiac disease is related to the duration of exposure to gluten.

Salivary SIgA and SIgA 1 in coeliac disease, inflammatory bowel disease and controls

Levels of secretory IgA1 (SIgA1) in the saliva have not been measured previously in either coeliac disease (CD) or inflammatory bowel disease (IBD). Saliva was collected from coeliacs, IBD patients and controls. The concentration of total SIgA in saliva was measured by enzyme linked immunosorbent assay (ELISA) with an anti-human SIgA antibody as the bound phase and human SIgA isolated from colostrum as the standard. The concentration of SIgA1 was determined using an ELISA with a lectin with a high affinity for human SIgA1. The IBD patients have a significantly higher concentration of SIgA1 than the controls. The rate of secretion of saliva and %SIgA1 was significantly lower in coeliacs than in the control and IBD groups. The rate of secretion of SIgA1 was significantly higher in the IBD than in the coeliacs. We describe hitherto unreported levels of SIgA1 in CD and IBD.

Neurology and the gastrointestinal system

Both achalasia and Hirchsprung's disease arise from defects of innervation of the oesophagus and distal large bowel respectively. Their consequences are confined to disorders of motility in the relevant part of the gastrointestinal tract. Many neurogenic and primary muscle disorders are associated with abnormalities of gut motility. Stroke, even when unilateral, is commonly associated with dysphagia. Transcranial magnetoelectric stimulation has established that the pharyngeal phase of swallowing tends to receive its innervation principally from one hemisphere. In many neurological disorders, dysphagia is only one part of the clinical picture but in some--for example, the Chiari malformation--dysphagia may be the sole or major feature. Disturbances of small and large bowel motility, when seen in neurogenic disorders, are associated with autonomic neuropathy and are particularly common in diabetes mellitus. Primary muscle disorders can lead to dysphagia (for example, with polymyositis or oculopharyngeal dystrophy) or defects of large bowel motility (for example, with Duchenne's muscular dystrophy). Primary gut disorders particularly associated with neurological disease include pernicious anaemia, nicotinamide and thiamine deficiencies, selective vitamin E deficiency, and coeliac disease. Inflammatory bowel disease is associated with thromboembolic complications which may include the CNS, inflammatory muscle disease, and abnormalities on MRI of the brain of uncertain relevance. Whipple's disease is a rare condition which sometimes is largely or entirely confined to the CNS. In such cases, a particular neurological presentation can indicate the diagnosis.

Celiac disease risk in the USA: high prevalence of antiendomysium antibodies in healthy blood donors

BACKGROUND

Recent epidemiologic studies in Europe using antigliadin (AGA) and anti-endomysium antibodies (AEA) for initial screening have shown that the overall prevalence of celiac disease (CD) is about 1:300. There are no comparable scientific data for the USA, where CD is considered rare. The main aim of this study was to determine the prevalence of increased AEA in healthy blood donors in the USA.

METHODS

Sera from 2000 healthy blood donors were screened for IgG AGA and IgA AGA with an enzyme-linked immunosorbent assay test. All those with increased AGA levels, those with intermediate levels, and random samples with low levels were tested for AEA, using both monkey esophagus (ME) and human umbilical cord (HUC) cryosections as substrates.

RESULTS

The mean age of the blood donors was 39 years, with 52% being men, 85.2% being Caucasian, 11.8% African-American, 1.5% Asian, and 1.5% Hispanic. Eight healthy blood donors had positive AEA tests on both monkey esophagus and human umbilical cord. Among the eight subjects with increased AEA levels seven were Caucasian and one was African-American. All the four examined AEA-positive donors carried the known susceptibility alleles for CD.

CONCLUSIONS

The prevalence of increased AEA levels in healthy blood donors in the USA is 1:250 (8:2000). This is similar to that reported in countries in Europe, where subsequent small-intestinal biopsies have confirmed CD in all those with AEA positivity. On the basis of a high positive predictive value of the AEA antibody test, it is likely that the eight blood donors identified in this study have CD. These data suggest that CD is not rare in the USA and that there is need for a large-scale epidemiologic study to determine the precise prevalence of the disease in the USA.

IgA- and IgG-class antihuman umbilical cord antibody tests in adult coeliac disease

BACKGROUND

An antiendomysium antibody test using human umbilical cord as antigen has recently been introduced.

METHODS

We determined IgA- and IgG-class antihuman umbilical cord (HUC-ab), antireticulin (ARA), and antigliadin antibodies (AGA) in 92 untreated adult coeliac patients, in 95 non-coeliac subjects, and in 4 coeliac patients with selective IgA deficiency. Tissue antibodies were measured with an indirect immunofluorescence method and AGA with an enzyme-linked immunosorbent assay.

RESULTS

Of adult coeliac patients 85% were positive for IgA-class HUC-ab, 78% were positive for ARA, and 80% for AGA; the specificity for HUC-ab and ARA was 100%, and for AGA 86%. Combination of HUC-ab, ARA, and high-titre AGA increased the sensitivity to 96% without loss of specificity. IgG-class HUC-ab was positive in 12% of coeliac patients, in all four coeliac patients with IgA deficiency, and in none of the controls.

CONCLUSIONS

The HUC-ab test is highly specific but not 100% sensitive for detecting adult coeliac disease. A combination of the IgA-class HUC-ab, ARA, and high-titre AGA tests is recommended. In selective IgA deficiency the IgG-class HUC-ab test seems to work well.

[Common variable immunodeficiency and total villous atrophy regressive after gluten-free diet]

A patient with a commun variable immunodeficiency (CVID) is hospitalized for chronic symptoms of malabsorption (weigh loss and diarrhea). The duodenal histology show a total villous atrophy. Investigations are negative and a gluten free diet is given. Symptoms of malabsorption disappear and improvement is histologically confirmed. Our observation suggest that the coincidence of gluten sensitive enteropathy and CVID is possible and clinicians should be aware of this association and should consider giving a gluten free diet. The sensitivity of serologic testing in this conditions is unknown.

High incidence and prevalence of adult coeliac disease. Augmented diagnostic approach

BACKGROUND

The diagnosis of coeliac disease is easily overlooked as patients can present with mild or atypical symptoms, or the condition can even be clinically silent. Our aim was to detect coeliac disease patients with such atypical or no symptoms as well as those with typical features.

METHODS

The incidence of adult coeliac disease in Tampere was calculated from 1975 to 1994 and the prevalence as of 31 December 1994. Open-access endoscopy was available for general practitioners, and small-bowel biopsy was done routinely. Serologic screening was applied to patients with an increased risk of coeliac disease.

RESULTS

The incidence of coeliac disease increased tenfold, and the prevalence was 270 per 100,000 inhabitants in 1994. Twenty per cent were found by serologic screening and 10% as a result of routine biopsy; 24% had dermatitis herpetiformis.

CONCLUSIONS

Our diagnostic approach gave a coeliac prevalence similar to that found in population screening studies. One-third had silent coeliac disease.

The spectrum of coeliac disease in children

Coeliac disease is the life-long intolerance to dietary gluten, usually characterized by severe damage to the small-intestinal mucosa. The widespread use of sensitive diagnostic tools, such as the serum anti-gliadin and the anti-endomysial antibodies, has shown not only that coeliac disease is one of the commonest disorders in Western countries but also that this condition is characterized by a higher degree of clinical variability than previously thought (typical, atypical and silent forms). The existence of a latent-potential coeliac disease and even a gluten-sensitive disease with immunological activation of an otherwise normal small-intestinal mucosa has recently been postulated. An increased prevalence of coeliac disease in a number of other disorders has also been reported in both children and adults. The reasons for such a wide clinical heterogeneity are still poorly understood but are likely to depend on both genetic and environmental factors. Further investigations are required to evaluate the impact of undiagnosed, clinically milder forms of coeliac disease on the well-being of the population.

High prevalence of celiac sprue among patients with primary biliary cirrhosis

Although coexisting primary biliary cirrhosis (PBC) and celiac sprue have been described, celiac sprue is sufficiently common in western Europe for chance to explain isolated cases. We screened our patients with PBC for celiac sprue using serum immunoglobulin A endomysial antibody (EmA), with confirmation by duodenal biopsy in EmA-positive patients. Of 57 patients, 6 (11%) had EmA. Four agreed to have a biopsy taken, and all had villous atrophy, yielding a minimum prevalence of 1:14 (7%). Apart from anemia in one patient, none of the four had symptoms or routine laboratory abnormalities suggestive of celiac sprue. None had improvement in liver biochemical tests after 12 to 24 months on gluten-free diets despite the disappearance of EmA. Celiac sprue is common among patients with PBC and they should be routinely screened for this condition. Symptoms wrongly attributed to PBC may respond to gluten exclusion, and both conditions are potent risk factors for osteoporosis.

Celiac disease

Celiac disease, or gluten-sensitive enteropathy, classically presents as diarrhea and weight loss in childhood, but it may also have protean manifestations and appear well into adult life. The increasing availability of noninvasive blood tests that are highly sensitive and specific for celiac disease enables primary care physicians to recognize the disorder in a wide variety of clinical situations. The authors believe that the disease is more common than supposed and thus offer this diagnostic review to increase awareness.

Urine patterns, peptide levels and IgA/IgG antibodies to food proteins in children with dyslexia

There is an association between psychiatric disorders and dyslexia. In some psychiatric disorders abnormal urinary peptide patterns and peptide levels, and elevated levels of IgA antibodies to food proteins have been detected. These abnormalities are probably due to insufficient breakdown of the proteins gluten and casein. The aim of this study was to discover whether such abnormalities could be found in urine samples and serum of children with dyslexia. After screening 291 pupils in the fourth grade, 15 dyslexics and 15 controls were pairwise matched by gender, age, and cognitive level. Word decoding, spelling, and short-term memory tests were carried out, and information on handedness, immune and other disorders was obtained. Analyses of 24-h urine samples and of serum were performed. The reading abilities significantly differentiated the groups, and significant differences were found in frequency of left-handedness, immune disorders and other disorders. Three dyslexic children had elevated IgA antibodies. Two of these had positive endomycium tests, and coeliac disease was confirmed by biopsy. One had antibodies to proteins in milk. Our findings may suggest weak urinary peptide abnormalities in the dyslexic children, and they show significant differences in levels of IgA of antibodies to food proteins.

Prevalence of celiac disease in patients with juvenile chronic arthritis

We estimated the prevalence of celiac disease in children with juvenile chronic arthritis (JCA), using antiendomysium antibodies as the screening test to select patients for intestinal biopsy. We studied 119 children with JCA and found four patients with antiendomysium antibodies. In three of these patients (2.5%), intestinal biopsy revealed villous atrophy; in the fourth the intestinal mucosa was normal. We conclude that the prevalence of celiac disease is increased in patients with JCA.

Prevalence of coeliac disease in type I diabetes: a multicentre study

The aim of this study was to point out the prevalence ratio and the clinical presentation of coeliac disease (CD) in a large group of insulin-dependent diabetes mellitus (IDDM) patients.

PATIENTS AND METHODS

1114 patients affected by IDDM were screened for CD using antigliadin and antiendomysium antibodies. Patients who were positive for at least one test underwent an endoscopic biopsy of the descending duodenum in order to verify the presence of villous atrophy. Subjects with CD started a gluten-free diet and underwent a clinical follow up.

RESULTS

Villous atrophy was found in 63 patients (5.6%). Among the Italian population, the rate was 7%. Twenty-four percent of coeliac patients presented with diarrhoea, while 22% were completely symptom-free. A significant correlation was found between the presence of villous atrophy and the duration and onset of diabetes.

CONCLUSIONS

The prevalence of CD in IDDM is higher than previously reported, although the ratio range in different centres from 1.7 to 10%, probably due to both environmental and genetic factors. Twenty-two percent of coeliac patients were completely symptom-free. The prevalence seems to be significantly related to the duration and onset of IDDM.

Celiac disease and hypoparathyroidism: cross-reaction of endomysial antibodies with parathyroid tissue

Celiac disease (CD) is a gluten-sensitive enteropathy characterized by the presence of serum antibodies to endomysial reticulin and gliadin antigens. CD has been associated with various autoimmune endocrine disorders, such as diabetes. We report a rare case of idiopathic hypoparathyroidism with coexistent CD characterized by the presence of serum autoantibodies. Studies were conducted to determine the specificities of these autoantibodies and to localize the antibody binding sites by indirect immunofluorescence and immunoelectron microscopy. Sera from a patient with idiopathic hypoparathyroidism and CD and from two patients with CD alone were tested by indirect immunofluorescence for autoantibodies to parathyroid and endomysial antigens. The specificities of the antibody reactions were determined by testing the sera before and after absorption with monkey stomach tissue. In addition, immunoelectron microscopic studies were performed to determine the localization of the endomysial antigen. Indirect-immunofluorescence studies on the patient's serum were positive with the parathyroid as well as the endomysial substrate. Similar reactions were also observed with the sera of endomysial antibody-positive patients with CD. Absorption of the sera with monkey stomach powder, which is known to have the endomysial antigen, abolished the antibody activities on both the endomysial substrate and the parathyroid tissue. Immunoelectron microscopic studies showed that endomysial antibody activity was associated with antigens localized on the myocyte plasma membrane and in the intercellular spaces. Thus, reactions of the patient's serum with the parathyroid tissue were due to endomysial antibodies and were not parathyroid specific as in patients with idiopathic hypoparathyroidism who did not have coexistent CD. In conclusion, indirect-immunofluorescence tests on parathyroid tissue detect not only tissue-specific antibodies but also cross-reactive antibodies, and this should be taken into consideration when these tests are performed.

Coeliac-type permanent-tooth enamel defects

Systematic and chronologically distributed permanent-tooth so-called coeliac-type enamel defects are highly prevalent both in children and adults with coeliac disease (gluten-sensitive enteropathy) and dermatitis herpetiformis. Coeliac-type enamel defects were also found in healthy first-degree family members of coeliac disease patients. Our family study showed that these persons with the typical defected enamel were genetically similar to coeliac disease patients (A1;B8;DR3). As coeliac disease patients are often clinically silent with no gastrointestinal symptoms, or they complain only of minimal abdominal discomfort, both dentists and physicians could select patients with coeliac-type enamel defects for gastroenterological and dermatological consultations, including serological screening tests and later jejunal mucosal biopsy.