Patient Care - Allergy & Immunology - October 2007 - (Page 9)

Celiac disease I cers, including oropharyngeal, intesTABLE 1 tinal, hepatobiliary, and pancreatic Celiac disease and associated disorders cancers.9,10 T-cell non-Hodgkin’s lymphomas occur more often than other lymAutoimmune Cancer Other phoproliferative cancers.11 Evidence diseases Hepatobiliary Dermatitis suggests that after 5 years on a glutenherpetiformis Autoimmune Intestinal myocarditis free diet, much of the increased cancer Down syndrome Non-Hodgkin’s risk is ameliorated. Neuropathy lymphoma IgA deficiency As many as 85% of patients with Primary biliary cirrhosis Oropharyngeal Infertility dermatitis herpetiformis also have celiType 1 diabetes Pancreatic ac disease; both conditions have the same disease-producing HLA-DQ molecule, and both respond to a gluten-free diet, may rarely progress to end-stage liver disease.15,16 although dapsone therapy may be required initially Patients with low gluten intake, those on for dermatitis herpetiformis. immunosuppressant therapy, and patients with partial villous atrophy may have negative serology Making the diagnosis results. It is noteworthy that about 30% of individThe diagnosis of celiac disease first requires clinical uals with celiac disease have negative antibodies at suspicion and then serologic testing and duodenal diagnosis.17 In this scenario, multiple small bowel biopsy, with HLA typing reserved for equivocal biopsies are necessary to ascertain whether celiac biopsy results.12,13 Serologic screening has improved disease is present. the rate of diagnosis in both symptomatic and cliniFor patients with IgA deficiency, testing for IgAcally silent disease. Serologic testing for endomysial EMA and IgA-tTG alone is insufficient: The total antibodies IgA-EMA and IgG-EMA has a 100% posIgA titer must be measured in conjunction with IgGitive predictive value for celiac disease, and tissue EMA and IgG antigliadin antibodies.18 Patients with transglutaminase antibody (IgA-tTG) testing has both IgA deficiency and celiac disease have high 95% sensitivity and specificity. Both tests should be titers of IgG-EMA and IgG antigliadin antibodies included in the panel and performed in patients and a low titer of total IgA antibody. with symptoms of celiac disease, in family members Small intestine biopsy remains the gold standard of those who have the disease, and in those who in diagnosing celiac disease. Biopsies should be present with associated conditions such as dermatimultiple, from the second part of the duodenum tis herpetiformis. Antigliadin antibody testing is no and beyond. Endoscopic evaluation without biopsy longer recommended because of low sensitivity and is insufficient for diagnosis. Indications for biopsy specificity.14 include serology results that suggest celiac disease, Screening should also be considered in patients high clinical suspicion despite negative serology with autoimmune disorders, such as type 1 diabetes results, unexplained anemia or folic acid deficiency, and primary biliary cirrhosis, as well as in those and the presence of an associated condition such as with unexplained anemia, osteoporosis, or weight dermatitis herpetiformis. (An exception to the need loss. Mildly abnormal liver biochemistry is frequent for an intestinal biopsy occurs in a patient with in untreated celiac disease and warrants tissue transbiopsy-proven dermatitis herpetiformis.14) glutaminase antibody screening. Once diagnosed, Biopsy specimens may be classified as type 0 to celiac-induced hepatitis should be treated, since it type 4. A type 0 lesion refers to a normal-appearing OCTOBER 2007 PATIENT CARE ALLERGY & IMMUNOLOGY 9

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Patient Care - Allergy & Immunology - October 2007 Research Digest Contents Medicine in the News When to Suspect Celiac Disease and How to Proceed From There Averting Angioedema’s Potentially Dire Consequences Is There a Role for Leukotriene Receptor Antagonists in Treating Allergic rhinitis? Clinical Clips Dermatology Case Challenge Classified Advertising

Patient Care - Allergy & Immunology - October 2007

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