Autoantibodies related to ataxia and other central nervous system manifestations of gluten enteropathy

Gluten ataxia and other central nervous system disorders could be linked to gluten enteropathy and related autoantibodies.In this narrative review,we focus on the various neuro-logical manifestations in patients with gluten sensitivity/celiac disease,immunological and autoimmune mechanisms of ataxia in connection to gluten sensitivity and the autoantibodies that could be used as a biomarker for diagnosing and following.We focused on the anti-gliadin antibodies,antibodies to different isoforms of tissue transglutaminase(TG)(anti-TG2,3,and 6 antibodies),anti-glycine receptor antibodies,anti-glutamine acid decarboxylase antibodies,anti-deamidated gliadin peptides antibodies,etc.Most studies found a higher prevalence of these antibodies in patients with gluten sensitivity and neurological dysfunction,presented as different neurological disorders.We also discuss the role of a gluten-free diet on the clinical improvement of patients and also on imaging of these disorders.

Autoantibodies in chronic hepatitis C: A clinical perspective

Non-organ-specific autoantibodies and thyroid autoantibodies have been frequently found in chronic carriers of hepatitis C virus(HCV). With respect to endomysial antibodies and tissue transglutaminase, it is controversial whether the prevalence of glutenrelated seromarkers is higher in patients with HCV. In such cases, in addition to acknowledging any currently existing autoimmune disease, recognizing the risk of the patient developing an autoimmune disease during interferon(IFN)-based treatment must be a principle concern. From a clinical point-of-view, the presence of autoantibodies arouses suspicion that an autoimmunedisease may be present or may be precipitated by IFNbased HCV treatment. In this paper, we review the prevalence of autoantibodies in individuals with hepatitis C, the clinical significance of these autoantibodies, and the approach recommended for such situations.

Near-infrared photoimmunotherapy of pancreatic cancer using an indocyanine green-labeled anti-tissue factor antibody

AIM To investigate near-infrared photoimmunotherapeutic effect mediated by an anti-tissue factor(TF) antibody conjugated to indocyanine green(ICG) in a pancreatic cancer model.METHODS Near-infrared photoimmunotherapy(NIR-PIT) is a highly selective tumor treatment that utilizes an antibody-photosensitizer conjugate administration, followed by NIR light exposure. Anti-TF antibody 1849-ICG conjugate was synthesized by labeling of rat IgG2 b anti-TF monoclonal antibody 1849(anti-TF 1849) to a NIR photosensitizer,ICG. The expression levels of TF in two human pancreatic cancer cell lines were examined by western blotting. Specific binding of the 1849-ICG to TF-expressing BxPC-3 cells was examined by fluorescence microscopy. NIR-PITinduced cell death was determined by cell viability imaging assay. In vivo longitudinal fluorescence imaging was used to explore the accumulation of 1849-ICG conjugate in xenograft tumors. To examine the effect of NIRPIT, tumor-bearing mice were separated into 5 groups:(1) 100 μg of 1849-ICG i.v. administration followed by NIR light exposure(50 J/cm2) on two consecutive days(Days 1 and 2);(2) NIR light exposure(50 J/cm2) only on two consecutive days(Days 1 and 2);(3) 100 μg of 1849-ICG i.v. administration;(4) 100 μg of unlabeled antiTF 1849 i.v. administration; and(5) the untreated control. Semiweekly tumor volume measurements, accompanied with histological and immunohistochemical(IHC) analyses of tumors, were performed 3 d after the 2nd irradiation with NIR light to monitor the effect of treatments. RESULTS High TF expression in BxPC-3 cells was observed via western blot analysis, concordant with the observed preferential binding with intracellular localization of 1849-ICG via fluorescence microscopy. NIR-PIT-induced cell death was observed by performing cell viability imaging assay. In contrast to the other test groups, tumor growth was significantly inhibited by NIR-PIT with a statistically significant difference in relative tumor volumes for 27 d after the treatment start date [2.83 ± 0.38(NIR-PIT) vs 5.42 ± 1.61(Untreated), vs 4.90 ± 0.87(NIR), vs 4.28 ±1.87(1849-ICG), vs 4.35 ± 1.42(anti-TF 1849), at Day 27, P < 0.05]. Tumors that received NIR-PIT showed evidence of necrotic cell death-associated features upon hematoxylin-eosin staining accompanied by a decrease in Ki-67-positive cells(a cell proliferation marker) by IHC examination.CONCLUSION The TF-targeted NIR-PIT with the 1849-ICG conjugate can potentially open a new platform for treatment of TF-expressing pancreatic cancer.

Erythrocytic transglutaminase inhibition hemolysis at presentation of celiac disease

Celiac disease (CD) is a common autoimmune condition.Previously it was considered to be a rare childhood disorder,but is actually considered a relatively common condition,present at any age,which may have multiple complications and manifestations.Hematological disorders of the disease are not uncommon.Among these disorders,the most frequently reported are anemias as a result of iron deficiency,often associated with folate and/or B12 deficiency.Anemias caused by hemolysis are very rarely reported in celiac patients.An 11-year-old girl with a previous uneventful medical history presented with severe hemolytic anemia.Hemolysis was Coombs negative,accompanied by inappropriate low reticulocyte count,despite exaggerated bone marrow hyperplasia of the erythroid precursors which showed normal maturation.Serology for recent infections,including EpsteinBarr virus,parvovirus B19,cytomegalovirus and mycoplasma,were all negative.Levels of serum IgA,IgG and IgM,were all within normal ranges for age.Screeningfor anti-DNA,antinuclear,antineutrophil cytoplasmic,antimicrosomal,antithyroglobulin,and antimitochondrial antibodies and lupus anticoagulants,was negative.She was also negative for human immunodeficiency virus.Conventional therapy with corticosteroids and intravenous immunoglobulin failed.CD was serendipitously discovered upon screening for anti-tissue transglutaminase autoantibodies.The disease was confirmed by biopsy of the small intestine mucosa.The patient recovered with gluten-free diet.A unique case of CD is presented.CD should be serologically screened in each patient with Coombs negative "immune"hemolytic anemia,particularly if accompanied by "reticulocytopenia".A new hemolytic mechanism and very speculative explanation for "reticulocytopenia"are discussed.

Endomysial antibodies predict celiac disease irrespective of the titers or clinical presentation

AIM:To investigate the association between serum antibody levels and a subsequent celiac disease diag-nosis in a large series of children and adults. METHODS:Besides subjects with classical gastrointestinal presentation of celiac disease,the study cohort included a substantial number of individuals with extraintestinal symptoms and those found by screening in at-risk groups.Altogether 405 patients underwent clinical,serological and histological evaluations.After collection of data,the antibody values were further graded as low[endomysial(EmA)1:5-200,transglutaminase 2 antibodies(TG2-ab)5.0-30.0 U/L]and high (EmA 1:≥500,TG2-ab≥30.0 U/L),and the serological results were compared with the small intestinal mucosal histology and clinical presentation. RESULTS:In total,79%of the subjects with low and 94%of those with high serum EmA titers showed small-bowel mucosal villous atrophy.Furthermore, 96%of the 47 EmA positive subjects who had normal mucosal villi and remained on follow-up either subsequently developed mucosal atrophy while on a glutencontaining diet,or responded positively to a glutenfree diet. CONCLUSION:Irrespective of the initial serum titers or clinical presentation,EmA positivity as such is a very strong predictor of a subsequent celiac disease diagnosis.

慢性丙型肝炎患者血清抗组织谷氨酰胺转移酶抗体的检测及临床研究

目的了解抗组织谷氨酰胺转移酶(tTG)抗体在慢性丙型肝炎患者中的表达。方法选取56例慢性丙型肝炎患者,采用ELISA法检测血清Ig-A型抗tTG抗体,采用间接免疫荧光法测定血清自身抗体ANA、AMA和SMA,采用BECKMAN全自动生化分析仪测定ALT和球蛋白。结果 23例肝硬化患者中IgA-抗tTG抗体阳性9例,与IgA-抗tTG抗体阴性肝硬化患者相比,ALT、自身抗体、免疫球蛋白均无明显差异。结论丙肝后肝硬化患者体内存在较高的IgA-抗tTG抗体表达水平,可能与肝硬化引起的门脉高压有关。

乳糜泻患者血清tTG-IgA水平测定及临床研究

目的:通过乳糜泻特异性血清抗体组织转谷氨酰胺酶抗体(tTG-IgA)筛查符合肠易激综合征ROME Ⅲ诊断标准患者中乳糜泻的患病率。方法:采用ELISA方法行血清学tTG-IgA检测,对抗体阳性患者行内镜检查,取十二指肠组织活检,病理检查确诊乳糜泻。结果:136例肠易激综合征患者,tTG-IgA阳性5例,病理检查结果显示,3例疑似乳糜泻者的病理分级为Marsh 3b,为典型的乳糜泻病理特征。结论:乳糜泻患者中的血清抗体特别是tTG-IgA检测检出率较高,结合消化道内镜及小肠病理学诊断,可有助于临床诊断。

Celiac disease markers in patients with liver diseases: A single center large scale screening study

AIM:To study the coincidence of celiac disease, we tested its serological markers in patients with various liver diseases.METHODS:Large-scale screening of serum antibodies against tissue transglutaminase (tTG), and deamidated gliadin using enzyme-linked immunosorbent assay and serum antibodies against endomysium using immunohistochemistry, in patients with various liver diseases (n = 962) and patients who underwent liver transplantation (OLTx, n = 523) was performed. The expression of tTG in liver tissue samples of patients simultaneously suffering from celiac disease and from various liver diseases using immunohistochemistry was carried out. The final diagnosis of celiac disease was confirmed by histological analysis of small-intestinal biopsy. RESULTS:We found that 29 of 962 patients (3%) with liver diseases and 5 of 523 patients (0.8%) who underwent OLTx were seropositive for IgA and IgG anti-tTG antibodies. However, celiac disease was biopsy-diagnosed in 16 patients:4 with autoimmune hepatitis type Ⅰ, 3 with Wilson's disease, 3 with celiac hepatitis, 2 with primary sclerosing cholangitis, 1 with primary biliary cirrhosis, 1 with Budd-Chiari syndrome, 1 with toxic hepatitis, and 1 with non-alcoholic steatohepatitis. Unexpectedly, the highest prevalence of celiac disease was found in patients with Wilson's disease (9.7%), with which it is only rarely associated. On the other hand, no OLTx patients were diagnosed with celiac disease in our study. A pilot study of the expression of tTG in liver tissue using immunohistochemistry documented the overexpression of this molecule in endothelial cells and periportal hepatocytes of patients simultaneously suffering from celiac disease and toxic hepatitis, primary sclerosing cholangitis or autoimmune hepatitis type Ⅰ. CONCLUSION:We suggest that screening for celiac disease may be beneficial not only in patients with associated liver diseases, but also in patients with Wilson's disease.

腹泻型肠易激综合征脾虚患者乳糜泻血清标志物初步筛查

目的:初步筛查腹泻型肠易激综合征脾虚患者乳糜泻血清标志物,调查其发病状况。方法:自2002年12月～2008年8月搜集73例腹泻型肠易激综合征脾虚证患者血清,其中女性28例,男性45例,平均年龄(50±15)岁,均为江苏汉族人,进食米面食品。分别测定乳糜泻血清标志物抗麦胶抗体(IgG-AGAs)、抗组织转谷氨酰胺酶抗体(IgA-tTGs)以及血清免疫球蛋白水平(IgG、IgA、IgM)。结果:73例病患中有6例乳糜泻抗体阳性(8.2%),其中5例IgG-AGAs阳性(6.8%),2例IgA-tTGs阳性(2.7%),两种抗体均为阳性者1例,6例患者均无IgA缺乏。随访发现6例血清标志物阳性患者均婉拒十二指肠活检进一步确诊检查,而选择去麦胶饮食(GFD)治疗。病例3和病例4于1年后腹泻停止,病例3开始生长发育,而病例4体重不再减轻。结论:腹泻型肠易激综合征脾虚证患者乳糜泻血清标志物筛查结果显示,江苏地区可能存在乳糜泻患者,对麦胶敏感可能是我国慢性腹泻患者的病因之一。

Non-invasive prediction of persistent villous atrophy in celiac disease

BACKGROUND Celiac disease(CD)is an immune-mediated enteropathy that is primarily treated with a gluten-free diet(GFD).Mucosal healing is the main target of the therapy.Currently,duodenal biopsy is the only way to evaluate mucosal healing,and noninvasive markers are challenging.Persistent elevation of anti-tissue transglutaminase antibodies(aTTG)is not an ideal predictor of persistent villous atrophy(VA).Data regarding prediction of atrophy using anti-deamidated gliadin peptide antibodies(aDGP)and abdominal ultrasonography are lacking.AIM To evaluate the ability of aTTG,aDGP,small bowel ultrasonography,and clinical and laboratory parameters in predicting persistent VA determined using histology.METHODS Patients with CD at least 1 year on a GFD and available follow-up duodenal biopsy,levels of aTTG and aDGP,and underwent small bowel ultrasonography were included in this retrospective cohort study.We evaluated the sensitivity,specificity,and positive and negative predictive values of aTTG,aDGP,small bowel ultrasonography,laboratory and clinical parameters to predict persistent VA.A receiver operating characteristic(ROC)curve analysis of antibody levels was used to calculate cut off values with the highest accuracy for atrophy prediction.RESULTS Complete data were available for 82 patients who were followed up over a period of four years(2014-2018).Among patients included in the analysis,women(67,81.7%)were predominant and the mean age at diagnosis was 33.8 years.Followup biopsy revealed persistent VA in 19 patients(23.2%).The sensitivity and specificity of aTTG using the manufacturer’s diagnostic cutoff value to predict atrophy was 50%and 85.7%,respectively,while the sensitivity and specificity of aDGP(using the diagnostic cutoff value)was 77.8%and 75%,respectively.Calculation of an optimal cutoff value using ROC analysis(13.4 U/mL for aTTG IgA and 22.6 U/mL for aDGP IgA)increased the accuracy and reached 72.2%[95%confidence interval(CI):46.5-90.3]sensitivity and 90%(95%CI:79.5-96.2)specificity for aDGP IgA and 66.7%(95%CI:41.0-86.7)sensitivity and 93.7%(95%CI:84.5-98.2)specificity for aTTG IgA.The sensitivity and specificity of small bowel ultrasonography was 64.7%and 73.5%,respectively.A combination of serology with ultrasound imaging to predict persistent atrophy increased the positive predictive value and specificity to 88.9%and 98%for aTTG IgA and to 90.0%and 97.8%for aDGP IgA.Laboratory and clinical parameters had poor predictive values.CONCLUSION The sensitivity,specificity,and negative predictive value of aTTG and aDGP for predicting persistent VA improved by calculating the best cutoff values.The combination of serology and experienced bowel ultrasound examination may achieve better accuracy for the detection of atrophy.

儿童无腹泻症状乳糜泻1例报道并文献复习

本文报道1例儿童乳糜泻患者,其临床表现为腹痛、头痛,无明显腹泻症状,完善肠道黏膜病理诊断为乳糜泻,检索并总结国内儿童乳糜泻患者的临床特点,为儿科医师提供诊疗思路,以加强对该病的认识。

IgA-抗组织转谷氨酰胺酶抗体在慢性肝病患者中的表达

目的了解IgA抗组织转谷氨酰胺酶(tTG)抗体在慢性肝病患者中的表达。方法以ELISA法检测26例慢性肝病患者(16例慢性肝炎,10例肝硬化)血清IgA抗tTG抗体水平,结果>10AU为阳性。结果26例慢性肝病患者中有4例IgA抗tTG抗体阳性(15.4%),且该4例患者均为乙型肝炎肝硬化病例。ChildPughB级患者的抗体阳性水平略高于ChildPughA级。结论慢性肝病患者中存在较高的IgA抗tTG抗体表达水平,且与门脉高压密切相关。

血清特异性抗体对乳糜泻疾病诊断价值的研究

目的:评价血清中抗组织转谷氨酰胺酶(t TG)抗体与抗麦胶蛋白抗体(AGA)在乳糜泻(Celiac Disease,CD)中的诊断价值。方法:对198例慢性腹泻患者进行血清特异性抗体检测,并结合胃肠镜及病理学检查进行疾病诊断。结果:在15例经胃肠镜和病理学确诊的CD患者中,Anti-t TG阳性14例,AGA阳性15例;在183例非CD患者中,t TG阳性5例,AGA阳性38例。结论:通过ROC曲线分析,血清抗组织转谷氨酰胺酶(t TG)抗体的阳性预测值PPV及阴性预测值NPV都较为理想,可作为CD筛查与诊断的重要指标。

Gluten sensitive enteropathy in patients with iron deficiency anemia of unknown origin

AIM: To determine the prevalence of gluten sensitive enteropathy (GSE) in a large group of patients with iron deficiency anemia (IDA) of obscure origin. METHODS: In this cross-sectional study, patients with IDA of obscure origin were screened for GSE. Anti- endomysial antibody (EMA) and tissue transglutamin- ase antibody (tTG) levels were evaluated and duodenal biopsies were taken and scored according to the Marsh classification. The diagnosis of GSE was based on a positive serological test and abnormal duodenal histol- ogy. Gluten free diet (GFD) was advised for all the GSE patients. RESULTS: Of the 4120 IDA patients referred to our Hematology departments, 206 (95 male) patients were found to have IDA of obscure origin. Thirty out of 206 patients (14.6%) had GSE. The mean age of GSE pa- tients was 34.6 ± 17.03 (range 10-72 years). The female to male ratio was 1.3:1. Sixteen patients had Marsh 3,12 had Marsh 2, and 2 had Marsh 1 lesions. The sever- ity of anemia was in parallel with the severity of duode- nal lesions. Twenty-two GSE patients (73.3%) had no gastrointestinal symptoms. Fourteen GSE patients who adhered to GFD without receiving iron supplementation agreed to undergo follow up visits. After 6 mo of GFD, their mean hemoglobin levels (Hb) increased from 9.9 ± 1.6 to 12.8 ± 1.0 g/dL (P < 0.01). Interestingly, in 6 out of 14 patients who had Marsh 1/2 lesions (e.g. no villous atrophy) on duodenal biopsy, mean Hb increased from 11.0 ± 1.1 to 13.1 ± 1.0 g/dL (P < 0.01) while they did not receive any iron supplementation. CONCLUSION: There is a high prevalence (e.g. 14.6%) of GSE in patients with IDA of obscure origin. Gluten free diet can improve anemia in GSE patients who have mild duodenal lesions without villous atrophy.

Celiac disease serology in patients with different pretest probabilities: Is biopsy avoidable?

AIM: To establish the diagnostic performance of sev-eral serological tests, individually and in combination, for diagnosing celiac disease (CD) in patients with different pretest probabilities, and to explore potential se- rological algorithms to reduce the necessity for biopsy. METHODS: We prospectively performed duodenal biopsy and serology in 679 adults who had either high risk (n = 161) or low risk (n = 518) for CD. Blood samples were tested using six assays (enzyme-linked immunosorbent assay) that detected antibodies to tissue transglutaminase (tTG) and deamidated gliadin peptide (DGP). RESULTS: CD prevalence was 39.1% in the high-risk population and 3.3% in the low-risk group. In high-risk patients, all individual assays had a high diagnostic efficacy [area under receiving operator characteristic curves (AU ROC): 0.968 to 0.999]. In contrast, assays had a lower diagnostic efficacy (AU ROC: 0.835 to 0.972) in the low-risk group. Using assay combinations, it would be possible to reach or rule out diagnosis of CD without biopsy in 92% of cases in both pretest populations. We observed that the new DGP/tTG Screen assay resulted in a surplus compared to more conventional assays in any clinical situation. CONCLUSION: The DGP/tTG Screen assay could be considered as the best initial test for CD. Combinations of two tests, including a DGP/tTG Screen, might be able to diagnose CD accurately in different clinical scenarios making biopsy avoidable in a high proportion of subjects.

Celiac disease

Celiac disease （CD） is a common autoimmune disorder, induced by the intake of gluten proteins present in wheat, barley and rye. Contrary to common belief, this disorder is a protean systemic disease, rather than merely a pure digestive alteration. CD is closely associated with genes that code HLA-Ⅱ antigens, mainly of DQ2 and DQ8 classes. Previously, it was considered to be a rare childhood disorder, but is actually considered a frequent condition, present at any age, which may have multiple complications. Tissue transglutaminase-2 （tTG）, appears to be an important component of this disease, both, in its pathogenesis and diagnosis. Active CD is characterized by intestinal and/or extra-intestinal symptoms, villous atrophy and crypt hyperplasia, and strongly positive tTG auto-antibodies. The duodenal biopsy is considered to be the ＂gold standard＂ for diagnosis, but its practice has significant limitations in its interpretation, especially in adults. Occasionally, it results in a false-negative because of patchy mucosal changes and the presence of mucosal villous atrophy is often more severe in the proximal jejunum, usually not reached by endoscopic biopsies. CD is associated with increased rates of several diseases, such as iron deficiency anemia, osteoporosis, dermatitis herpetiformis, several neurologic and endocrine diseases, persistent chronic hypertransami-nasemia of unknown origin, various types of cancer and other autoimmune disorders. Treatment of CD dictates a strict, life-long gluten-free diet, which results in remission for most individuals, although its effect on some associated extraintestinal manifestations remains to be established.

Celiac disease in patients with presumed irritable bowel syndrome:A case-finding study

AIM:To estimate the prevalence of celiac disease(CD) in adult patients with presumed irritable bowel syndrome(IBS) .METHODS:Between March 2005 and December 2008,742 consecutive patients(293 male,median age 43 years,range 18-69 years) fulfilling the Rome Ⅱ criteria for IBS were prospectively enrolled in the study.IBS was diagnosed via self-completed Rome Ⅱ modular questionnaires.Anti-tissue transglutaminase(anti-tTG) serology was checked to initially recognize possible CD cases.Patients with a positive test were offered endoscopic duodenal biopsy to confirm the diagnosis of CD.RESULTS:Thirty two patients(15 male,median age 41 years,range 19-59 years) were found to have organic diseases other than CD.Twenty four patients tested positive for anti-tTG antibodies,and duodenal biopsies confirmed the diagnosis in all of them.Thus,in this patient population with presumed IBS,3.23% actually had CD.CONCLUSION:CD is common in patients with presumed IBS.Routine screening for CD in patients with symptoms of IBS is recommended.

Adult celiac disease with acetylcholine receptor antibody positive myasthenia gravis

Celiac disease has been associated with some autoimmune disorders. A 40-year-old competitive strongman with celiac disease responded to a gluten-free diet, but developed profound and generalized motor weakness with acetylcholine receptor antibody positive myasthenia gravis, a disorder reported to occur in about 1 in 5000. This possible relationship between myasthenia gravis and celiac disease was further explored in serological studies. Frozen stored serum samples from 23 acetylcholine receptor antibody positive myasthenia gravis patients with no intestinal symptoms were used to screen for celiac disease. Both endomysial and tissue transglutaminase antibodies were examined. One of 23 (or, about 4.3%) was positive for both IgA-endomysial and IgA tissue transglutaminase antibodies. Endoscopic studies subsequently showed duodenal mucosal scalloping and biopsies confirmed the histopathological changes of celiac disease. Celiac disease and myasthenia gravis may occur together more often than is currently appreciated. The presence of motor weakness in celiac disease may be a clue to occult myasthenia gravis, even in the absence of intestinal symptoms.

Pathogenesis of coeliac disease:implications for treatment

INTRODUCTIONCoeliac disease(CD)is an enteropathy ,characterised by villous atrohy ,which occurs in genetically susceptible individuals .It affects mainly the proximal small intestine,and is caused by an intolerance to cereal storage proteins found in wheat ,barley and rye .

Effect of the timing of gluten introduction on the development of celiac disease

Celiac disease(CD) is a permanent auto-immune enteropathy,triggered in genetically predisposed individuals by the ingestion of dietary gluten.Gluten is the alcohol-soluble protein component of the cereals wheat,rye and barley.CD is a multifactorial condition,originating from the interplay of genetic and environmental factors.The necessary environmental trigger is gluten,while the genetic predisposition has been identified in the major histocompatibility complex region on chromosome 6p21,with over 90% of CD patients expressing HLA DQ2 and the remaining celiac patients express DQ8.The fact that only about 4% of DQ2/8positive individuals exposed to gluten develop CD,has led to the recognition that other genetic and environmental factors are also necessary.In the last few years,several epidemiological studies have suggested that the timing of the introduction of gluten,as well as the pattern of breastfeeding,may play an important role in the subsequent development of CD.Here,we present and review the most recent evidences regarding the effect of timing of gluten introduction during weaning,the amount of gluten introduced and simultaneous breastfeeding,on the development of CD.