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Re: The Confusing Clinical Diagnosis of Celiac Disease
Submit responseI have read with interest the comments made by Dr Daniel G. Arkfeld. In particular the application of HLA-DQ typing to clinical practice. I like to stress another valuable addition of HLA-DQ typing in patients who have been following a gluten-free diet for years and then decide to eat normally or patients in whom for another reason have been typed and found to be negative for HLA-DQ2 and/or HLA-DQ8. I have observed a nurse and a teacher who after following the diet for 15 and 12 years respectively were found to be not carriers of these HLA-DQ specific alleles associated with celiac disease. I let them continue with the new normal diet and followed the evolution with specific serological tests (anti-endomysium antibodies, at the time human tissue transgutaminase test was not available) and after some years repeated the duodenal biopsy. They proved not to have celiac disease. The original abnormal intestinal biopsy had obviously a different etiology. Also HLA-DQ typing can be particularly important in patients who already have started a gluten-free diet without confirmation of an abnormal small intestinal biopsy. This will help to confirm or exclude the diagnosis. This is important because celiac disease patients should follow the gluten -free diet for life (so long as no other proven therapies are available) to avoid the risk of the development of malignancy later in their lives. In practice to follow a strict gluten-free diet is not only difficult but it requires discipline and constant vigilance for the patients.
Conflict of Interest:
None declared
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The Confusing Clinical Diagnosis of Celiac Disease
Submit responseIt is with great interest that I read the article entitled "Accuracy of Serologic Tests and HLA-DQ Typing for Diagnosing Celiac Disease" by Hadithi et al. As a university based rheumatologist who sees many patients where celiac disease enters the differential diagnosis, I appreciated the effort to delineate the sensitivity and specificity of antibody testing, HLA typing, and small bowel biopsy. It is surprising to see the very low number of patients referred for small bowel biopsy who actually had celiac disease. Many fibromyalgia and irritable bowel patients are worried about celiac disease which may relate to access to clinical information via the internet, support groups as well as other sources. I often check for celiac disease but rarely find it, much like the data presented in this paper. Elimination of gluten in diets can be difficult for patients and they always think that they have not done this accurately. This is an area where HLA typing can be essential to "rule out" sprue in a patient without celiac antibodies, especially those with irritable bowel symptomatolgy.
On the other hand, I did recently see a patient with antibodies to sprue who did not improve despite aggressive dietary change. It turned out that he was eating sushi regularly with soy sauce which is high in gluten content. With restriction of soy sauce, he is now normal from a GI perspective. After reviewing this article, it would have been helpful to do HLA typing in his case. In summary, I feel that the data presented will help me clinically assess patients with GI complaints.
Conflict of Interest:
None declared