Children with celiac disease and high tTGA are genetically and phenotypically different

AIM:To investigate whether celiac disease(CD)patients with tissue-transglutaminase antibody(tTGA)≥100 U/mL are different from patients with lower tTGA levels.METHODS:Biopsy-proven(MarshⅢ)pediatric CD patients(n=116)were prospectively included between March 2009 and October 2012.The biopsies were evaluated by a single pathologist who was blinded to all of the patients’clinical data.The patients were distributed into 2 groups according to their tTGA level,which was measured using enzyme-linked immunoassay:tTGA≥100 U/mL and Ttga<100 U/mL.The patients’characteristics,symptoms,human leukocyte antigen(HLA)genotype and degree of histological involvement were compared between the 2 groups.RESULTS:A total of 34(29.3%)children had tTGA values<100 U/mL and 82(70.7%)tTGA levels of≥100 U/mL.Patients with high tTGA levels had lower average body weight-for-height standard deviation scores(SDS)than did patients with tTGA<100 U/mL(-0.20±1.19 SDS vs 0.23±1.03 SDS,P=0.025).In the low tTGA group,gastrointestinal symptoms were more common(97.1%vs 75.6%,P=0.006).More specifically,abdominal pain(76.5%vs 51.2%;P=0.012)and nausea(17.6%vs 3.7%,P=0.018)were more frequent among patients with low tTGA.In contrast,patients with solely extraintestinal manifestations were only present in the high tTGA group(18.3%,P=0.005).These patients more commonly presented with aphthous stomatitis(15.9%vs 0.0%,P=0.010)and anemia(32.9%vs 11.8%,P=0.019).In addition,when evaluating the number of CD-associated HLA-DQ heterodimers(HLA-DQ2.5,HLA-DQ2.2 and HLA-DQ8),patients with low tTGA levels more commonly had only1 disease-associated heterodimer(61.8%vs 31.7%,P=0.005),while patients with high tTGA more commonly had multiple heterodimers.Finally,patients with tTGA≥100 U/mL more often had a MarshⅢc lesion(73.2%vs 20.6%,P≤0.001)while in patients with low tTGA patchy lesions were more common(42.4%vs6.8%,P≤0.001).CONCLUSION:Patients with tTGA≥100 U/mL show several signs of more advanced disease.They also carry a larger number of CD associated HLA-DQ heterodimers.

Immunohistochemical CD3 staining detects additional patients with celiac disease

AIM: To investigate whether performing immuno-histochemical CD3 staining, in order to improve the detection of intra-epithelial lymphocytosis, has an additional value in the histological diagnosis of celiac disease.METHODS: Biopsies obtained from 159 children were stained by hematoxylin and eosin(HE) and evaluated using the Marsh classification. CD3 staining was subsequently evaluated separately and independently.RESULTS: Differences in evaluation between the routine HE sections and CD3 staining were present in 20(12.6%) cases. In 10(6.3%) patients the diagnosis of celiac disease(Marsh Ⅱ and Ⅲ) changed on examination of CD3 staining: in 9 cases, celiac disease had initially been missed on the HE sections, while 1 patient had been over-diagnosed on the routine sections. In all patients, the final diagnosis based on CD3 staining, was concordant with serological results, which was not found previously. In the other 10(12.3%) patients, the detection of sole intra-epithelial lymphocytosis(Marsh Ⅰ) improved. Nine patients were found to have Marsh Ⅰ on CD3 sections, which had been missed on routine sections. Interestingly, the only patient with negative serology had Giardiasis. Finally, in 1 patient with negative serology, in whom Marsh Ⅰ was suspected on HE sections, this diagnosis was withdrawn after evaluation of the CD3 sections.CONCLUSION: Staining for CD3 has an additional value in the histological detection of celiac disease lesions, and CD3 staining should be performed when there is a discrepancy between serology and the diagnosis made on HE sections.

Tissue transglutaminase levels above 100 U/mL and celiac disease:A prospective study

AIM:To investigate whether a tissue-transglutaminase antibody(tTGA) level ≥ 100 U/mL is sufficient for the diagnosis of celiac disease(CD).METHODS:Children suspected of having CD were prospectively included in our study between March 2009 and September 2011.All patients with immune globulin A deficiency and all patients on a gluten-free diet were excluded from the study.Anti-endomysium antibodies(EMA) were detected by means of immunofluorescence using sections of distal monkey esophagus(EUROIMMUN,Luebeck,Germany).Serum anti-tTGA were measured by means of enzyme-linked immunosorbent assay using human recombinant tissue transglutaminase(ELiA Celikey IgA kit Phadia AB,Uppsala,Sweden).The histological slides were graded by a single experienced pathologist using the Marsh classification as modified by Oberhuber.Marsh Ⅱ and Ⅲ lesions were considered to be diagnostic for the disease.The positive predictive values(PPVs),negative predictive values(NPVs),sensitivity and specificity of EMA and tTGA along with their 95% CI(for the cut off values > 10 and ≥ 100 U/mL) were calculated using histology as the gold standard for CD.RESULTS:A total of 183 children were included in the study.A total of 70(38.3%) were male,while 113(61.7%) were female.The age range was between 1.0 and 17.6 years,and the mean age was 6.2 years.One hundred twenty(65.6%) patients had a small intestinal biopsy diagnostic for the disease;3 patients had a Marsh Ⅱ lesion,and 117 patients had a Marsh Ⅲ lesion.Of the patients without CD,only 4 patients had a MarshⅠlesion.Of the 183 patients,136 patients were positive for EMA,of whom 20 did not have CD,yielding a PPV for EMA of 85%(95% CI:78%-90%) and a corresponding specificity of 68%(95% CI:55%-79%).The NPV and specificity for EMA were 91%(95% CI:79%-97%) and 97%(95% CI:91%-99%),respectively.Increased levels of tTGA were found in 130 patients,although only 116 patients truly had histological evidence of the disease.The PPV for tTGA was 89%(95% CI:82%-94%),and the corresponding specificity was 78%(95% CI:65%-87%).The NPV and sensitivity were 92%(95% CI:81%-98%) and 97%(95% CI:91%-99%),respectively.A tTGA level ≥ 100 U/mL was found in 87(47.5%) patients,all of whom were also positive for EMA.In all these 87 patients,epithelial lesions confirming CD were found,giving a PPV of 100%(95%CI:95%-100%).The corresponding specificity for this cutoff value was also 100%(95% CI:93%-100%).Within this group,a total of 83 patients had symptoms,at least gastrointestinal and/or growth retardation.Three patients were asymptomatic but were screened because they belonged to a group at risk for CD(diabetes mellitus type 1 or positive family history).The fourth patient who lacked CD-symptoms was detected by coincidence during an endoscopy performed for gastro-intestinal bleeding.CONCLUSION:This study confirms based on prospective data that a small intestinal biopsy is not necessary for the diagnosis of CD in symptomatic patients with tTGA ≥ 100 U/mL.