Prevalence of celiac disease in Iranian patients with rheumatologic disorders

Aim: Patients with Systemic Lupus Erythematosus [SLE], Rheumatoid Arthritis [RA], and Fibromyalgia [FM] may have underlying non-diagnosed celiac disease [CD]

Background: The aim of this study was to determine the prevalence of CD in patients with these underlying diseases in Iran

Methods: This cross-sectional study was performed among 300 consecutive patients with SLE, RA, and FM [each group 100 patients] since 2015 to 2017. The blood samples were collected and serum IgA anti-tissue trans-glutaminase [Anti-tTG] level was assessed for all patients. The seropositive patients underwent endoscopy and duodenal/jejunal biopsy according to the Marsh classification

Results: Out of 300 investigated patients with mean age of 41.2 years old, 92% of patients with SLE, RA and fibromyalgia were women. Among 100 patients with SLE, only 1 subject [1%], out of 100 patients with RA 3 subjects [3%], and none of the patients with fibromyalgia were seropositive for CD [with overall prevalence 1.4]. All four patients were female and categorized as Marsh III

Conclusion: The results of the study indicated that patients with lupus have the same prevalence, but subjects with RA had three times higher prevalence rate than normal population for CD. Therefore, CD investigation in these individuals can improve their quality of life

Prevalence of celiac disease serological markers in a cohort of Italian rheumatological patients

Aim: To assess the prevalence of celiac disease [CD] serological markers in a cohort of patients referred to an Italian rheumatological outpatient clinic

Background: Current guidelines do not suggest CD screening in patients with rheumatological diseases and these subjects are not considered to be at high risk for CD

Methods: A total of 230 sera of rheumatological patients referred to the Division of Internal Medicine at the Department of Medical and Surgical Sciences between January 2005 and December 2013 were screened for CD by testing IgA antitransglutaminase [TTG IgA], IgG deamidated gliadin peptides [DGP IgG] and IgA antiendomysium [EMA] antibodies. Of the 230 patients tested, 67 had a diagnosis of rheumatoid arthritis [RA], 52 Sjögren's syndrome [SjS], 42 systemic sclerosis [SCL], 35 systemic lupus erythematosus [SLE], 15 mixed connective tissue disease, 11 polymyositis and 10 dermatomyositis

Results: TTG IgA antibodies were identified in 7/230 cases [3%], 3 in SjS [3/42 - 5.8%], 2 in SCL [2/42 - 4.8%], 1 in RA [1/67 - 1.5%] and 1 in SLE sera [1/35 - 2.8%]. All the seven sera were also positive for DGP IgG and EMA IgA. DGP IgG were the most frequent antibody detected, being found in 16 [7%] sera

Conclusion: This study identified a high prevalence of CD antibodies in adult patients referred to a rheumatology outpatient clinic.These results highlight the importance of CD screening in subjects presenting with rheumatological features

Detection of asymptomatic celiac disease in two siblings from a mother with non-celiac gluten sensitivity

Non-celiac gluten sensitivity and celiac disease are known to be two distinct clinical entities, however, non-celiac gluten sensitivity has been detected in a proportion of first-degree relatives of celiac patients. Herein for the first time we describe the occurrence of asymptomatic celiac disease in two siblings, a girl and a boy, whose mother suffered from a proven non-celiac gluten sensitivity. Both the 12-year old girl and 9-year old boy were positive for anti-endomysial and anti-tissue transglutaminase antibodies of IgA class at a very high and low titer, respectively. Duodenal biopsy confirmed the diagnosis of active celiac disease [severe villous flattening] in the girl, whereas her brother had Marsh 1 lesion consistent with a potential celiac disease. This case report indicates that antibody screening for celiac disease can be recommended in any symptomatic or asymptomatic first-degree relatives of patients with nonceliac gluten sensitivity

Economic burden made celiac disease an expensive and challenging condition for Iranian patients

Aim: The aim of this study was to estimate the economic burden of celiac disease [CD] in Iran

Background: The assessment of burden of CD has become an important primary or secondary outcome measure in clinical and epidemiologic studies

Methods: Information regarding medical costs and gluten free diet [GFD] costs were gathered using questionnaire and checklists offered to the selected patients with CD. The data included the direct medical cost [including Doctor Visit, hospitalization, clinical test examinations, endoscopies, etc.], GFD cost and loss productivity cost [as the indirect cost] for CD patient were estimated. The factors used for cost estimation included frequency of health resource utilization and gluten free diet basket. Purchasing Power Parity Dollar [PPP dollars] was used in order to make inter-country comparisons

Results: Total of 213 celiac patients entered to this study. The mean [standard deviation] of total cost per patient per year was 3377 [1853] PPP dollars. This total cost including direct medical cost, GFD costs and loss productivity cost per patients per year. Also the mean and standard deviation of medical cost and GFD cost were 195 [128] PPP dollars and 932 [734] PPP dollars respectively. The total costs of CD were significantly higher for male. Also GFD cost and total cost were higher for unmarried patients

Conclusion: In conclusion, our estimation of CD economic burden is indicating that CD patients face substantial expense that might not be affordable for a good number of these patients. The estimated economic burden may put these patients at high risk for dietary neglect resulting in increasing the risk of long term complications

Autoimmune enteropathy: not all flat mucosa mean coeliac disease

A 62-year-old woman complaining of severe malabsorption was diagnosed with celiac disease based on the findings of flat, small intestinal mucosa and HLA-DQ2 positivity, although celiac serology was negative. This diagnosis was questioned due to the lack of clinical and histological improvement after a long period of strict gluten-free diet. The detection of enterocyte autoantibodies guided to the correct diagnosis of autoimmune enteropathy, leading to a complete recovery of the patient following an appropriate immunosuppressive treatment. Autoimmune enteropathy should be considered in the differential diagnosis of malabsorption with severe villous atrophy, including those cases with negative celiac-related serology

Dietary Triggers in Irritable Bowel Syndrome: Is There a Role for Gluten?

A tight link exists between dietary factors and irritable bowel syndrome (IBS), one of the most common functional syndromes, characterized by abdominal pain/discomfort, bloating and alternating bowel habits. Amongst the variety of foods potentially evoking "food sensitivity", gluten and other wheat proteins including amylase trypsin inhibitors represent the culprits that recently have drawn the attention of the scientific community. Therefore, a newly emerging condition termed non-celiac gluten sensitivity (NCGS) or non-celiac wheat sensitivity (NCWS) is now well established in the clinical practice. Notably, patients with NCGS/NCWS have symptoms that mimic those present in IBS. The mechanisms by which gluten or other wheat proteins trigger symptoms are poorly understood and the lack of specific biomarkers hampers diagnosis of this condition. The present review aimed at providing an update to physicians and scientists regarding the following main topics: the experimental and clinical evidence on the role of gluten/wheat in IBS; how to diagnose patients with functional symptoms attributable to gluten/wheat sensitivity; the importance of double-blind placebo controlled cross-over trials as confirmatory assays of gluten/wheat sensitivity; and finally, dietary measures for gluten/wheat sensitive patients. The analysis of current evidence proposes that gluten/wheat sensitivity can indeed represent a subset of the broad spectrum of patients with a clinical presentation of IBS.

Clinical and immunological relevance of anti-neuronal antibodies in celiac disease with neurological manifestations

To assess anti-neuronal antibodies [NA] prevalence and their correlation with neurological disorders and bowel habits in celiac disease [CD] patients. Neurological manifestations are estimated to occur in about 10% of celiac disease patients and NA to central nervous system [CNS] and enteric nervous system [ENS] are found in a significant proportion of them. Little is known about the clinical and immunological features in CD patients with neurological manifestations. NA to CNS and ENS were investigated in 106 CD patients and in 60 controls with autoimmune disorders by indirect immunofluorescence on rat / primate cerebellar cortex and intestinal [small and large bowel] sections. IgG NA to CNS [titer 1:50 - 1:400] were positive in 23 celiacs [21%], being more frequently detected in those with neurological disorders that in those without neurological dysfunction [49% vs. 8%, P< 0.0001]. Of the 26 celiacs [24%] with IgG NA to ENS, 11 out of 12 with an antibody titer > 1:200 had severe constipation. Only one patient with cerebellar ataxia and intestinal sub-occlusion was positive for NA to CNS and ENS. NA to CNS and ENS were found in 7% and 5% of controls, respectively. In CD the positivity of NA to CNS can be regarded as a marker of neurological manifestations. High titer NA to ENS are associated with severe constipation. The demonstration of NA to CNS and ENS suggests an immune-mediated pathogenesis leading to central neural impairment as well as gut dysfunction [hence constipation], respectively

Gastrointestinal and non-gastrointestinal presentation in patients with celiac disease

Celiac disease [CD] may have a variety of different presentations. This study has aimed to explore the prevalence of gastrointestinal [GI] and non-GI symptoms in patients with CD according to data collected in Italy and Romania [Europe] and Iran [Middle East]. This is a retrospective cross-sectional study conducted in Iran, Romania and Italy with data collection during the period from May 2009 - May 2011. For each center we included only patients with CD that was confirmed by endoscopy, small bowel biopsies and positive serology. GI symptoms such as abdominal pain, diarrhea, constipation, nausea and vomiting, weight loss and flatulence, as well as additional signs and symptoms of iron deficiency anemia [IDA], osteoporosis, hypertransaminasemia, and other related abnormalities were collected. Overall, 323 women and 127 men, whose mean age at diagnosis was 34.2 +/- 16.47 years were included in this study. Of these, 157 subjects [34.9%] reported at least one GI symptom. The majority of cases had the following primary presenting GI symptoms: diarrhea [13.6%], dyspepsia and constipation [4.0%]. Other disease symptoms were reported by 168 [37.3%] patients. The most presenting non-GI symptoms in the majority of cases were anemia [20.7%] and osteopenia [6%]. There were statistically significant differences between the majority of symptoms when we compared the reported clinical symptoms from different countries. This study indicated that upper abdominal disorders such as abdominal pain and dyspepsia were the most common primary complaints among European patients, whereas Iranian patients had complaints of diarrhea and bloating as the classic presentations of CD. For non-GI symptoms, anemia was the most frequent complaint for both Iranian and Italian patients; however it was significantly higher in Iranians