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Re: The change in haematological presentation of iron deficiency is also an issue

Dear Editor,

Notwithstanding the fact that iron deficiency anaemia is the commonest extraintestinal manifestation of subclinical coeliac disease(CD)(1)(2), in ordinary clinical practice diagnostic strategies for early detection of iron deficient erythropoiesis have not been optimised to the same extent as diagnostic strategies for early recognition of CD. For example, when serological testing is the chosen parameter for evaluation of the co-existence of CD and iron deficiency the use of parameters such as the reticulocyte haemoglobin content(CHr), which reflect the earlier phases of iron deficient eryhtropoiesis, does not seem to have supplanted reliance on parameters such as mean cell volume(MCV), mean cell haemoglobin(MCH), and total blood haemoglobin(Hb), respectively, for characterising the co-existence of iron deficieny(3)(4). All this in spite of the fact that diagnostic accuracy of CHr, as judged by its receiver operator characteristic(ROC) curve, is superior to the diagnostic accuracy of MCV, and MCH, and Hb, respectively, for predicting depletion of bone marrow iron stores or a transferrin saturation of < 10%(5)(6). Reliance on subnormal Hb or subnormal MCV has the potential to distort the prevalence of the association of CD and iron deficiency as shown by the study where four out of the twelve patients with this association had normal values for MCV and Hb is spite of having subnormal levels of serum ferritin(3). Accordingly, the recognition of the change in the clinical presentation of CD(7) ought to be accompanied by a change in the use of parameters for early recognition of iron deficiency.

References:

(1) Bottaro G., Cataldo F., Rotolo N., Spina M., Corazza GR The clinical pattern of subclinical/silent celiac disease: an analysis of 1026 consecutive cases American Journal of Gastroenterology 1999:94:691-6.

(2) Tursi A., Giorgetti G., Brandimarte G., et al Prevalence and clinical presentation of subclinical/silent celiac disease in adults: an analysis on a 12-year observation Hepatogastroenterology 2001:48:462-4.

(3) Howard MR., Turnbull AJ., Morley P., et al A prospective study of the prevalence of undiagnosed coeliac disease in laboratory defined iron and folate deficiency Journal of Clinical Pathology 2002:55:754-7.

(4) Kalayci AG., Kanber Y., Birinci A., Yildiz L., Albayrak D The prevalence of coeliac disease as detected by screening in children with iro deficiency anaemia Acta Paediatrica 2005:94:678-81.

(5) Mast AE., Blinder MA., Flax S., Dietzen DJ Clinical utility of reticulocyte hemoglobin content in the diagnosis of iron deficiency Blood 2002:99:1489-91.

(6) Ullrich C., Wu A., Armsby C., et al Screening healthy infants for iron deficiency using reticulocyte hemoglobin content Journal of the American Medical Association 2005:294:924-30.

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Re: Changing faces of coeliac disease - DGH Perspective.

Dear Editor,

The paper from Cardiff by Ravi kumara et al and the comprehensive summary by Beattie is timely and to a great extent serve to remind professionals who deal with patients with Coeliac disease(CD) of the current thinking on this subject. In my experience in caring for patients with gastroenterological ailments in a DGH, the spectrum of the cases I have been exposed to are clearly highlighted in these papers. The patients I have managed, commonly fall into the following groups;-

•Those children who typically fail to thrive after weaning to wheat containing solids

•The Caucasian or mostly non-Caucasian child who present with profound anaemia – mostly nutritional (so called). A number of these cases have been noted with CD.

•The child who presents with growth failure

•The child with conditions usually associated with CD e.g. Down’s, William’s and Turner syndrome respectively, type 1 diabetes and auto immune thyroid disease.

•The patient with symptoms and with negative serology but positive biopsy. Serology testing is generally available and I still use the Crosby capsule to obtain Jejunal biopsy. I do however encounter occasional problem with sedation in a few patients. Those patients referred for endoscopic duodenal biopsy do have to ‘compete’ for theatre time which is increasingly proving difficult to secure. Nice has directed that patients with type 1 diabetes should be screened every 3 years instead of a yearly program. I am not clear of the evidence base as I have seen patients on my list who had negative result one year and becoming positive the next year. In such cases the 3 year rule would have resulted in some delay with diagnosis. There is a place for flexibility and vigilance here. Is the incidence of CD truly increasing or just an increased awareness and improved diagnostic methods?

References:

•Ravikumara M, Tuthill DP, Jenkins HR; Arch Dis child; 2006 ;91; 969-971

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Re: Coeliac disease: Crossing racial boundaries

Dear Editor,

We read with interest, the paper from Cardiff by Ravi Kumara et al (1) on the presentation of Paediatric coeliac disease.

We did a similar retrospective study in the Wolverhampton region in midlands, looking at children diagnosed with coeliac disease from 1992 - 2005. The total number of children diagnosed was 25. (4 children diagnosed from 1992-1998 and 21 from 1999-2005).The ratio of boys to girls was 14:11. Six out of twenty-five children (24%) were of asian origin.

The median age at diagnosis was 43 months. Median age of diagnosis of asian children was102 months as compared to 30 months in Caucasian children.

Coeliac serology was positive in all children. Antiendomysial antibodies were done in all children; Anti-tissue transglutaminase done in 9, while Antigliandin antibodies were done in 15 children.

Biopsy was positive in 18 children and is awaited in 7. All the children who did not have biopsy done had presented with typical gastrointestinal symptoms with positive serology.

Presenting features of the children were similar to Ravi kumara et al study (1). Only 15 (60 %) presented with typical gastrointestinal symptoms while 10 (40%) of the children had atypical symptoms at presentation. The typical presentation included diarrhoea, failure to thrive, anorexia & abdominal distention. The atypical presentation included short stature, recurrent abdominal pain, irritable bowel syndrome, constipation and persistent iron deficiency anaemia.

In four children (16%), persistent iron deficiency anaemia was the presenting complaint, while iron deficiency anaemia was also noted in eighteen (72%) of the children at initial investigation. Persistent iron deficiency anaemia as a presenting feature is higher than Ravi kumara et al (1 in 50).

Conclusion

Results are similar to the study by Ravi kumara et al (1). The sample size is smaller as it represents population of a smaller city.

Iron deficiency anaemia was the most common finding in the children and might be the only clue to diagnosis.

The study by Ravi kumara et al does not specify the ethnicity of children. Our study has shown that 24% of the children in the study had asian origins. This might be a reflection of ethnic composition of local population. All these children had atypical presentations and were diagnosed later.

Coeliac disease has been described in children from Asian countries (2, 3) , however it has not been described in studies from UK. This may be explained by paucity of knowledge of presentation of coeliac disease in asian children, which may have atypical presentation. (3)

References:

1. Ravikumara M, Tuthill DP, Jenkins HR. The changing clinical presentation of coeliac disease. Arch Dis Child 2006;91:969–71.

2. Amrinder Singh Puri, Sanjay Garg, Rajnish Monga, Pankaj Tyagi , Manoj Kumar Saraswat. Spectrum of atypical celiac disease in North Indian children. Indian Pediatrics : Aug 2004;41:822 – 827