Celiac Disease and Sensitization to Wheat, Rye, and Barley: Should We Be Concerned?

BACKGROUND: Concomitance of celiac disease (CD) and IgE-mediated wheat allergy is described in some case reports. The objective was to evaluate the frequency of sensitization to wheat, rye, barley, and malt in children and adolescents with CD. METHODS: Measurement of serum levels of specific IgE to wheat, rye, barley, and malt (ImmunoCAP; sensitization IgE ≥0.35 kUA/L) in CD patients followed in specialized clinics to verify allergy history, general characteristics, small bowel biopsy characteristics, compliance with gluten-free diet (GFD), and occurrence of symptoms in case of noncompliance. RESULTS: We evaluated 74 patients; the median of age and age at diagnosis of CD were 8.6 years (5.0-12.8) and 3.6 years (1.6-7.0), respectively. Median time of GFD was 3.5 years (1.4-5.8). History of asthma occurred in 17.3% of subjects, allergic rhinitis in 13.5%, and AD in 5.4%. Frequency of sensitization was 4% for wheat, 10.8% for rye, 5.4% for barley, and 2.7% for malt. There was no association between wheat sensitization and age at diagnosis, time of GFD, small bowel biopsy characteristics, allergy history, and gluten consumption. There was no relationship between sensitization to wheat and occurrence of immediate symptoms when not complying with GFD. CONCLUSION: In conclusion, the frequency of sensitization to wheat, rye, barley, and malt in CD patients was 4, 10.8, 5.4, and 2.7%, respectively. Therefore, to ensure that cutaneous and respiratory contact with wheat is safe, we advise patients with CD to investigate their sensitivity to wheat, rye, and barley because not all patients with CD are allergic to these cereals.

Surgical treatment of awn aspiration causing bronchopleural fistula and bronchiectasis: case reports.

BACKGROUND: Aspiration of grass inflorescences is an extremely rare phenomenon with potential diagnostic difficulties. Due to its special shape, each coughing and respiratory action helps its migration towards the periphery of lung, resulting late-onset, life-threatening complications. The diagnosis has some difficulties for the reason that soon after the aspiration initial symptoms, such as coughing, wheezing or vomiting disappear and bronchoscopy is mostly negative. At least serious complications such as tension pneumothorax, bronchopleurocutaneous fistula or even spontaneous percutan elimination may develope. CASE PRESENTATION: We present two cases of pleuropneumonia resulting from aspiration of the head of barley grass. Soon after the accidents initial symptoms diminished, inflammatory markers improved and bronchoscopy was unable to confirm the presence of awn. Despite of conservative treatment (antibiotics, physiotherapy, bronchodilators, expectorants, and inhalation) localized pulmonary inflammation developed after 1 and 9 months showed up on chest computed tomography. After ineffective conservative treatment, surgical resections became inevitable in order to remove chronically inflamed parts (lobectomy, segmentectomy) and foreign bodies. Both patients recovered and were discharged home after successful interventions. CONCLUSIONS: Due to its peculiar shape and behaviour, awn inhalation is a special and atypical form of aspiration, thus great care and awareness is needed in its treatment. Negative bronchoscopic result does not exclude the presence of bronchial grass head. Symptomless child with negative bronchoscopy and improved inflammatory markers should be followed up thoroughly to recognize late complications in time. Regular diagnostic steps (chest ultrasound/X-ray) should be performed to localize potential chronic lung inflammation. Chest computed tomography is a valuable diagnostic tool for identifying and localising the foreign body. In cases with localized inflammation and peripheric localisation, segmentectomy can be a successful and safe alternative of lobectomy.

Significant differences in coeliac immunotoxicity of barley varieties.

SCOPE: The only treatment available for coeliac disease (CD) is a strict diet in which the intake of wheat, barley, rye, or oats is avoided. Barley is a major cereal crop, grown mainly for its use in brewing, and it has high nutritional value. The identification of varieties with a reduced toxicity profile may contribute to improve the diet, the quality of life and health of CD patients. METHODS AND RESULTS: Searching for harmless barleys, we investigated accessions of malting and wild barley, used for developing new cultivated cereals. The CD toxicity profile of barleys was screened using G12 antibody and cell proliferation and IFN-γ release from peripheral blood mononuclear cells and intestinal biopsies from CD patients. We found a direct correlation between the reactivity with G12 and the immunogenicity of the different barleys. CONCLUSION: The malting barleys were less immunogenic, with reduced levels of toxic gluten, and were possibly less harmful to CD patients. Our findings could raise the prospect of breeding barley species with low levels of harmful gluten, and the attractive goal of developing nontoxic barley cultivars, always taking into account the Codex standard for foods for special dietary use for persons intolerant to gluten.

Mouse barley awn (Hordeum murinum) migration induced cystolithiasis in 2 male dogs.

Two male dogs were presented with cystic uroliths composed of magnesium ammonium phosphate (struvite). Each had an atypical nidus, a mouse barley awn (Hordeum murinum). To our knowledge, this is the first report of grass awns located in the bladder lumen of dogs. The composition of uroliths and the pathophysiology of grass awn migration to the urinary bladder are discussed.

Review article: The diagnosis of coeliac disease.

Coeliac disease is a chronic inflammatory condition associated with small intestinal injury that results in the malabsorption of different nutrients. The damaging factor is gluten present in wheat, barley and rye. The diagnosis relies on the clinical picture of the patient, serological markers for coeliac disease, characteristic findings of small intestinal biopsy and, eventually, clinical improvement on a gluten-free diet. Our strategies for the diagnosis of coeliac disease have changed dramatically within the last 10 years. The advent of serological markers with high sensitivity and specificity is changing our understanding of the disease and its prevalence. Treatment includes a life-long gluten-free diet to prevent the recurrence of symptoms and other potential consequences. Most coeliac disease remains under-diagnosed; the utilization of more accurate serological tests and a greater awareness of its many presentations will aid its identification.

Inhalation of wild barley into the airways: two different outcomes.

OBJECTIVE: There are only two previous reports of wild barley inhalation into the tracheobronchial tree in the literature. Our aim is to describe the effects, outcome and management of wild barely inhalation into the airways. METHODS: In a retrospective study, 18 patients with inhalation of spike of wild barley into the tracheobronchial tree were divided into 2 groups according to their clinical presentation. RESULTS: Eighteen children below 5 years of age presented between 1989 and 1994 inclusive. Fourteen patients presented with a short duration of choking and cough. The wild barley spike was removed by laryngoscopy (12 patients) or rigid bronchoscopy (2 patients). Four patients presented with a longer history of cough, dyspnea and fever and had serious respiratory disease such as pneumothorax, lobar pneumonia and pleural empyema requiring surgical intervention. All patients made a satisfactory recovery. CONCLUSION: Wild barley is a common grass in our area and we should be aware that children are exposed to the risk of inhalation into the airways.

Chronic respiratory disorders related to farming and exposure to grain dust in a rural adult community.

In a survey of chronic respiratory symptoms and airflow obstruction of a rural population aged 20-65 years, the effects of both farming and, in particular, the exposure to grain dust on the respiratory health of the people was examined. Of the 1,892 subjects (82% of the eligible population) studied, 924 were males and 968 females, with half living in the town. Three groups were identified: current, former, and never farmers. Almost all current farmers were exposed to grain for, on average, 2 months a year. There was no difference in atopic status between the groups. While there was a strong association between most symptoms and smoking, there was no association between symptoms and exposure to grain and farming category once age and smoking had been taken into account. Results of this study suggest that farmers do not have chronic respiratory symptoms or impairment of lung function because of their exposure to grain dust. Lung function of former farmers might have been affected by farming, and this may reflect more involvement with livestock in the past.

Lung function after exposure to barley dust.

Six men handling barley were followed up over two working days and their flow volume curves were measured every two hours. All experienced falls in ventilatory capacity of up to 800 ml with changes in the shape of the flow volume curve in five men. Five volunteers not previously exposed to barley dust sat in a silo for two hours. Decreases in ventilatory capacity ranging from 200 ml to 800 ml were found, with recovery taking up to 72 hours. All subjects had decreases in flow at 50% vital capacity but little or no change in flow at 75% vital capacity. In three subjects there was a drop in specific conductance that lasted for less than 24 hours. Two subjects were similarly exposed on a second occasion when transfer factor for carbon monoxide was measured in addition to flow volume curves. There was a decrease in transfer factor but no change in transfer factor per unit volume (Kco).

Grain exposure--symptoms and lung function.

Eighty dock workers handling grains and other cargoes were surveyed by respiratory and occupational questionnaires, spirometry, skin tests with common allergens and grain extracts, and serological tests. Sixty-nine of the men reported chest symptoms during exposure to barley dust and 13 men reported evening feverish episodes after handling barley. Symptoms were not related to smoking or atopic status. No gross deficits in lung function were detected. Six men handling barley and four handling non-dusty cargoes had their lung function measured over two working days. Falls in ventilatory capacity occurred in the six workers handling barley but not in the four handling non-dusty cargoes. Six previously unexposed subjects spent 2 h in a barley dust atmosphere of a silo and had lung function measured before and after the exposure. All subjects had falls in ventilatory capacity. In four these lasted 24 h or more and were associated with systemic symptoms. As with cotton dust the agent(s) responsible for symptoms from grain dust exposure remains uncertain. Our findings on the dock workers suggest that specific immunological responses are not involved.

The role of various cereals in coeliac disease.

It is well established that the consumption of wheat gluten will produce the characteristic mucosal lesion of coeliac disease in subjects who are predisposed to it. The role of other cereals in the pathogenesis of this disease is less certain. In the present study, four different cereals (rye, barley, maize and rice) have been tested by feeding them to volunteer coeliac subjects who had shown good mucosal recovery on a gluten free diet and assessing the effect by serial jejunal biopsy. The biopsy specimens obtained before and after challenge were compared in terms of histology and disaccharidase activity. The results indicate that rye and barley are harmful but that maize and rice are harmless.