High prevalence of coeliac disease: need for increasing awareness among physicians.

BACKGROUND: Coeliac disease is a wheat gluten and related prolamines-induced disease with a prevalence that may be underestimated in many geographical regions and populations. AIM: To investigate the prevalence of coeliac disease in a population of schoolchildren of Estonia using tissue transglutaminase antibodies for screening. SUBJECTS AND METHODS: The study was designed as cross-sectional. Serum samples from 1160 randomly selected schoolchildren (636 female and 564 male, aged 9 or 15 years) were studied using a novel tissue transglutaminase antibody immunoassay (EliA Celikey IgA assay). Antibody-positive subjects were investigated for coeliac disease. RESULTS: A total of five subjects had antibodies. Four of them agreed for further investigations. By small-bowel biopsy they all were confirmed to have active coeliac disease, including three subjects with symptoms that were not considered by their family doctors. The prevalence of coeliac disease is at least 1 case per 290 (0.34% with CI 0.09-0.88%) in Estonia. It is much higher than that in our previous screening studies but is comparable with data from other European countries. CONCLUSION: The prevalence of coeliac disease might have increased during the last decade in Estonia. This study clearly shows that the awareness of coeliac disease among physicians is low. Thus, there is a need for more epidemiological studies and education related to coeliac disease.

Three patients with 9p deletions including DMRT1 and DMRT2: a girl with XY complement, bilateral ovotestes, and extreme growth retardation, and two XX females with normal pubertal development.

It is well documented that distal 9p monosomy can be associated with XY sex reversal. Recently, the possibility of DMRT1 and/or DMRT2 (the genes for doublesex and mab-3 related transcription factor 1 and 2) being the sex determining genes(s) at 9p has been raised. DMRT1 and DMRT2 map near the 9p telomere, distal of marker D9S1779. We describe here three unrelated females with distal 9p monosomy, one with XY complement and two with XX complements. In each individual, fluorescent in situ hybridization predicted the loss of the DMRT genes. Patient 1, an XY individual with monosomy 9pter --> p24.1 approximately 24.2 and trisomy 7q32 --> qter had normal female external genitalia, a blind ending vagina, no uterus, a Fallopian tube on the right, and bilateral ovotestes with primitive ovarian tissue. She also had extreme growth retardation. Around 80 cases of distal 9p monosomy have been reported previously, but there has been no report of ovotestes or gonads comprising ovarian tissue in a XY patient with 9p deletion. Findings in Patient 1 suggest that the phenotypic spectrum of the heterozygous DMRT deletion may include true hermaphroditism. Patients 2 and 3 were 12- and 14-year-old females with XX complements, normal external genitalia, and normal pubertal development. Patient 2 had pure monosomy 9pter --> p23 and Patient 3 had monosomy 9pter --> p22.3 approximately 23 combined with trisomy 3pter --> p23 approximately 24. To date, detailed reports on the gonadal status of XX 9p-females have been limited to prepubertal girls. Patients 2 and 3 are the first females reported to have distal 9p monosomy and a normal puberty.

Increased levels of IgA antibodies against desmin in children with coeliac disease.

BACKGROUND: In addition to IgA anti-endomysial antibodies, IgA anti-smooth muscle antibodies have been observed in a number of patients with coeliac disease (CoD), but only limited data exist on the frequency and antigen specificity of IgA against cytoskeletal proteins in CoD. METHODS: We evaluated the sera of 42 untreated CoD patients, follow-up sera of 26 CoD patients after treatment, and 116 control sera for IgA reactivity to cytoskeletal proteins from the human umbilical cord (HUC) by immunoblotting, and compared the results with anti-tissue transglutaminase IgA (anti-tTG IgA) ELISA and immunofluorescence results. RESULTS: Serum IgA from CoD patients most frequently recognized a 57-kD antigen in HUC cytoskeletal extract, identified as desmin using mass spectrometry and internal peptide sequencing. Increased IgA reactivity to the human desmin band was detected in 22 children with untreated CoD (52.4%), in 4 treated CoD patients (15.4%), and in 12 control subjects (10.3%) (p < 0.01); similar results were obtained with anti-chicken desmin IgA ELISA. Anti-tTG IgA levels (increased in 71.4% of untreated CoD patients) correlated significantly with anti-desmin IgA levels in untreated CoD, and both autoantibody reactivities decreased in response to a gluten-free diet. Pre-adsorption experiments and affinity purification of anti-desmin IgA antibodies further confirmed that desmin is an IgA autoantigen in CoD and is recognized by antibodies which are not cross-reactive with tTG. CONCLUSIONS: Anti-desmin IgA antibodies are frequently occurring if not the predominant cytoskeletal antibodies in children with untreated CoD and could be related to the disease process in the small intestine.

Comparison of the prevalence of glutamic acid decarboxylase (GAD65) and gliadin antibodies (AGA) in a randomly selected adult estonian population.

We aimed to test the hypothesis that gluten might be associated with the development of islet cell autoimmunity. A random sample of 200 persons (87 males, mean age 42.4 years) from Estonia including one patient with type I diabetes mellitus was studied. IgG-type glutamic acid decarboxylase (GAD65) antibodies were determined using radioligand-binding assay and IgG/IgA-type gliadin antibodies (AGA) by enzyme-linked immunosorbent assay. Generic HLA-DRB1* alleles were analyzed using a polymerase chain reaction. Although our results revealed the highest GAD65Ab index and a high IgA-type AGA in a person with diabetes, no correlation between GAD65Ab and AGA values was revealed among the other 199 persons (p > 0.05). There were also no differences between test values among persons with and without different HLA-DRB1* alleles (p > 0.05). In the GAD65Ab assay, one person (0.5 %; 95 % CI: 0 - 1.5) out of 199 exceeded the 99(th) centile of the GAD65Ab index. In summary, the present study does not confirm the possibility that there is a relationship between the immune reactivity against GAD65 and gliadin, at least in persons without type I DM.

Boy with celiac disease, malformations, and ring chromosome 13 with deletion 13q32-->qter.

We describe a 2(1/2)-year-old boy with a ring chromosome 13 with distal deletion of 13q32-->qter and celiac disease.

Coeliac disease in spondyloarthropathy: usefulness of serological screening.

The aim of our study was to find unidentified or neglected cases of coeliac disease by using serological screening in a group of patients with spondyloarthropathies. Altogether, 74 consecutively hospitalised patients (28 females, 46 males, from 15 to 72 years of age, mean age 40.4+/-1.6 years) with spondyloarthropathies were investigated by serological screening tests for coeliac disease. IgA- and IgG-type antigliadin antibodies were determined using an enzyme-linked immunosorbent assay, and IgA- and IgG-type antireticulin and IgA-type antiendomysium antibodies were measured by an indirect immunofluorescence method. An increased level of antigliadin antibodies was found in nine (12%) of the studied patients and in one of them, antiendomysium antibodies were revealed. In this HLA B8-positive patient, typical villous atrophy with crypt hyperplasia was found in the small bowel biopsy specimen, which confirmed the diagnosis of coeliac disease. None of the patients had IgA- and IgG-type antireticulin antibodies. We found an association of spondyloarthropathy with coeliac disease in one patient out of 74. Clinicians need to be aware of this association, which has important implications for the correct management of patients.

The high frequency of coeliac disease among children with neurological disorders.

In the present study we have explored antigliadin (AGA) and antireticulin (ARA) antibody tests for the serological screening for coeliac disease (CD) of 206 children with neurological disorders. IgA- or/and IgG-type AGA was discovered in 17 (8.3%) patients and IgA-type ARA in one (0.5%) patient. A small intestinal biopsy was performed in all 18 antibody-positive patients, and villous atrophy compatible with CD was revealed in three cases (patients with either epilepsy, retardation of psychomotor development or Down's syndrome). The CD prevalence rate of 14.6 per 1000 (95% CI 7.0-22.2) found in the present study was higher than could have been anticipated on the basis of the results of our previous population studies, which indicate that CD occurs more frequently among children with neurological disorders (OR = 37.6; 95% CI 9.7-146.9). Whether this finding reflects certain immunopathogenic links between CD and particular neurological diseases needs to be studied further. In this study, we were unable, using indirect immunofluorescence testing, to demonstrate the presence of autoantibodies against brain tissue in CD and AGA-positive patients.

IgA-antigliadin antibodies in patients with IgA nephropathy: the secondary phenomenon?

Circulating IgA-antigliadin antibodies (IgA-AGA) are often found in patients with IgA nephropathy (NP). IgA-AGA are sensitive markers of an abnormal immune system reaction to gluten, seen particularly in patients with celiac disease. However, a lack of IgA-antireticulin and IgA-antiendomysium antibodies and often jejunal mucosal atrophy of patients with IgA NP suggest that most patients do not have latent celiac disease. To examine the relationship between IgA-AGA and clinical data, enzyme-linked immunosorbent assays for IgA-AGA were performed in 28 patients with IgA NP and in 50 healthy persons. The results were calculated in arbitrary units (AU). The cutoff level for a negative or a positive test was found to be 60 AU, calculated according to the AGA test result (mean + 3 SD) in 50 healthy persons. The following clinical data were assessed: age, gender, disease duration, daily proteinuria, blood pressure, serum creatinine, and creatinine clearance. Control sera were negative for IgA-AGA. Positive IgA-AGA tests were observed in 14 of the 28 patients (p < 0.0001 vs. controls) and high levels of IgA-AGA (AU >90) in 6 of the 28 patients (p < 0.001 vs. controls). The mean duration of the disease of the patients with positive IgA-AGA was significantly longer as compared with the patients who had a negative antibody test. IgA-AGA correlated with age (p < 0.05, r = 0. 56), disease duration (p < 0.05, r = 0.40), and blood pressure (p < 0.05, r = 0.48). Antireticulin and antiendomysium antibody tests were negative in all patient and control sera. We conclude that IgA-AGA are associated with the progression of IgA NP. Our findings support the current concept about the pathogenesis of IgA NP, where the defective IgA production itself may be the primary and intestinal lesions as well as the production of IgA-AGA the secondary phenomenon.

Comparison of enterovirus-specific cellular immunity in two populations of young children vaccinated with inactivated or live poliovirus vaccines.

Enterovirus-specific cellular immunity was studied in Estonian and in Finnish children at the age of 9 months. The aim was to evaluate the level of responsiveness in two neighbouring countries with different poliovirus immunization practices and striking differences in the incidence of insulin-dependent diabetes mellitus (IDDM), a disease in which early enterovirus infections are an aetiological risk factor. The Estonian children immunized with live attenuated polio vaccine had stronger T cell responses to coxsackievirus B4 and poliovirus type 1 when compared with Finnish children immunized with inactivated polio vaccine (median stimulation indices 10.4 and 6.3 in Estonian children and 1.9 and 2.9 in Finnish children, respectively; P < 0.05). Lymphocytes stimulated by poliovirus type 1 antigen expressed interferon-gamma (IFN-gamma) mRNAs, which strongly correlated with the level of proliferation responses. Lymphocytes of Estonian children had a tendency towards stronger expression of IFN-gamma upon poliovirus challenge when compared with Finnish children. The number of children who had experienced coxsackievirus B infections, as determined by the presence of neutralizing antibodies, did not differ between Estonian and Finnish children. The results show that Finnish children have weaker cellular immunity against enteroviruses at the age of 9 months compared with Estonian children at the same age. This is most probably due to the difference in polio vaccination schedules; in Estonia live poliovirus vaccine is used and given at earlier ages than the inactivated vaccines in Finland. This leads to stronger T cell immunity which cross-reacts with other enterovirus serotypes. This may explain the lower incidence of IDDM in Estonia by providing effective protection against diabetogenic enterovirus strains in Estonian children.

High frequency of antigliadin antibodies and absence of antireticulin and antiendomysium antibodies in patients with ulcerative colitis.

Several authors have described an association between celiac disease (CD) and ulcerative colitis (UC), but this has not yet been established. The aim of our study was to examine the frequency of antigliadin antibodies (AGA), antireticulin antibodies (ARA) and antiendomysium (AEM) antibodies in the sera of patients with UC (n = 50), and to evaluate their correlation with clinical variables. Sixteen patients with irritable bowel syndrome (IBS) and 37 healthy individuals served as controls. An enzyme-linked immunosorbent assay was used for the detection of IgA- and IgG-type AGA. IgG-type ARA were determined by an indirect immunofluorescence assay (IIF) using rat kidney, liver, and stomach as antigen substrates. IgA-type AEM antibodies were measured by IIF, using cryostat sections from human umbilical cord. Seventeen of the 50 patients with UC (34%) were positive for IgA- or/and IgG-type AGA. There was no correlation between the presence of AGA and the duration or extent of the disease, or disease activity. However, 5 patients with both IgA- and IgG-types of AGA had extensive colitis. Only 2 controls (4%) were positive for IgG-AGA. ARA and AEM were not detected in any individuals studied. Since the ARA and AEM test results were negative, we conclude that none of the UC patients in this series had CD.

Low cereal intake in Estonian infants: the possible explanation for the low frequency of coeliac disease in Estonia.

OBJECTIVE: The aim of this study was to analyse the intake of coeliac disease (CD) inducing, gluten containing cereals (wheat, rye, barley and oats) in Estonian infants diet and compare these results with neighbouring countries with different CD incidence rate. DESIGN: Study group consisted of 32 healthy full term infants of Estonian origin. SETTINGS: Study was carried out in Tartu University Women's Hospital and in Tartu University Children's Hospital. These are both primary care facilities. SUBJECTS: Infants were recruited to the study group according to their health parameters and parents agreement to take part of this study. Material of this article is based on one part of Estonian infants dietary habits investigation. RESULTS: The total amount of gluten containing cereals in Estonian infants diet was lower than in Sweden and Finland. We found that there is a certain parallelism between CD incidence and cereal intake. Wheat intake of Estonian infants was very close to Finnish infants, but almost twice lower than in Swedish infants. CONCLUSION: Data from the study is consistent with the hypothesis that gluten intake during infancy play role in development of CD. The quality of gluten-containing cereals may have important part in the development of the disease.

Results of coeliac disease screening in Estonia in 1990-1994.

In the period of 1990-94, 2895 individuals (629 children with suspicion of coeliac disease selected throughout Estonia; 700 consecutively hospitalized children; 105 children with atopic dermatitis; 1461 inhabitants of a small Estonian town) were serologically screened for coeliac disease. The enzyme-linked immunosorbent assay was used for antigliadin antibody determinations and R1-type antireticulin antibodies were detected using an indirect immunofluorescence method. Coeliac disease was diagnosed according to recent criteria recommended by the European Society for Paediatric Gastroenterology and Nutrition. Antigliadin antibody testing was positive in 44 (3.1%) of 1434 children studied, and in 33 of whom coeliac disease was confirmed. In all the coeliac patients R1-type antireticulin antibody test was positive. However, 52 (3.5%) of 1461 adults studied who did not have coeliac disease had positive antigliadin antibody test but negative antireticulin antibody test. Thus, in Estonia, the antigliadin antibody test can be used in screening for coeliac disease in children but not in adults.

Human oesophagus: a convenient antigenic substrate for the determination of anti-endomysium antibodies in the serological diagnosis of coeliac disease.

OBJECTIVE: Immunoglobulin (Ig) A-class anti-endomysium antibodies are superior to other current antibody tests for detecting coeliac disease. We aimed to evaluate the suitability of human oesophagus for the determination of anti-endomysium antibodies. DESIGN: The specificity of monkey and human oesophageal tissue as antigenic substrate were compared using indirect immunofluorescence analysis. PATIENTS AND METHODS: Overall, 159 individuals were studied: 56 patients with biopsy-proven coeliac disease (39 with active disease) and 103 controls. The patients' IgA-class anti-endomysium antibodies were compared using unfixed cryostat sections of human and monkey oesophagus. Indirect immunofluorescence analysis was performed with an initial serum sample dilution of 1:5, and if positive, the highest dilution yielding a positive reaction was reported. RESULTS: The anti-endomysium antibody test was positive in 38 out of 39 patients with active coeliac disease using monkey oesophagus (sensitivity 97%) and in all 39 patients with active coeliac disease using human oesophagus (sensitivity 100%). Ten out of 17 coeliac patients on a gluten-free diet had positive anti-endomysium antibodies using monkey oesophagus and 12 using human oesophagus as the antigenic substrate. This test was negative in all 103 controls using both substrates. CONCLUSIONS: Our study shows that human oesophageal tissue can be used instead of monkey tissue for determining anti-endomysium antibodies. Human tissue is a more sensitive antigenic substrate than monkey oesophagus and can be used to determine low titres of antibodies. Improving the diagnostic sensitivity of the anti-endomysium antibody test would make an important contribution to screening for coeliac disease.

Childhood celiac disease in Estonia: efficacy of the IgA-class antigliadin antibody test in the search for new cases.

The incidence of celiac disease (CD) and the role of IgA-class antigliadin antibody (AGA) determination in revealing new CD cases were studied in Estonia. Altogether 36 cases of CD in Estonian children were diagnosed from January 1976 through June 1992 by criteria recommended by the European Society for Paediatric Gastroenterology and Nutrition. A significant increase was observed in the incidence of CD in Estonia (from 1:25, 130 live births during 1976-1989 to about 1:2,700 live births during 1990-1992), due mainly to the introduction of IgA-class AGA determinations in an active search for celiac patients since 1990. A total of 29 IgA-class AGA-positive cases was revealed among 1,048 children screened, and 23 of them had CD. Thus, the results show a relatively low incidence of CD in Estonia compared to the figures in neighboring countries. However, the incidence will probably increase if a larger pediatric population can be screened for CD using IgA-class AGA enzyme-linked immunosorbent assay.

Serum IgA anti-gliadin antibodies in an adult population sample. High prevalence without celiac disease.

IgA-class anti-gliadin antibodies (AGA) and IgA-, IgG-, IgM-class anti-reticulin antibodies (ARA) were determined in 1461 persons, representing 84% of a population from the village of Karksi-Nuia. AGA were detected by enzyme-linked immunosorbent assay (ELISA) and ARA by indirect immunofluorescence. Fifty-two (3.5%) persons had IgA-class AGA, of whom 48 and an additional three of four persons with diarrhea were biopsied. All biopsies showed normal small intestinal mucosal architecture. All 1461 persons were negative for ARA. Our results demonstrate that AGA are frequently detected in an adult Estonian population and positivity increases with age in persons with normal small intestinal mucosa. Positivity for AGA does not predict silent undetected celiac disease but rather represents a normal response to dietary antigens in the elderly. Inability to detect ARA suggests that celiac disease does not exist in this population. As none of the AGA-positive but ARA-negative biopsied persons had celiac disease, ARA might be a more specific serologic marker for celiac disease than AGA.

Hospital screening of coeliac disease in Estonian children by anti-gliadin antibodies of IgA class.

Seven hundred consecutive patients from Tartu Children's Clinic were screened for coeliac disease by IgA class anti-gliadin antibody enzyme-linked immunosorbent test during January 1 to May 31, 1991. A positive anti-gliadin antibody test result was revealed in 11 children and in 8 coeliac disease was diagnosed according to the criteria of the European Society for Paediatric Gastroenterology and Nutrition. There was no suspicion of coeliac disease before anti-gliadin antibody determinations in five children and two were asymptomatic. In five children, no suspicion of coeliac disease was raised beforehand. The present study shows that coeliac disease is underdiagnosed in Estonia.