Clinical Aspects of Coeliac Disease in Children with Insulin-Dependent Diabetes Mellitus

Abstract

Coeliac disease (CD) is heterogeneous in its clinical presentation and pathological expression. Silent, latent and potential forms represent the submerged part of the so-called "coeliac iceberg". The association of insulin-dependent diabetes mellitus (IDDM) and CD has been widely reported. For the screening of CD in diabetic patients, anti-reticulin R1 (ARA-R1) and anti-endomysium (AEA) antibodies are more reliable markers than anti-gliadin (AGA) antibodies. Recent studies have reported an increased prevalence of CD in children with IDDM. In our experience intestinal biopsy confirmed a diagnosis of CD in 6 out of 172 diabetic patients, with a prevalence of 3.5%. Only occasionally does CD precede the onset of IDDM; more often CD is diagnosed shortly or sometimes years after the onset of diabetes. Typical gastrointestinal complaints of CD (such as diarrhoea, abdominal distension) are rare in IDDM patients, while atypical isolated signs or symptoms of CD are more common, in particular sideropenic anemia, short stature, delayed puberty, epilepsy, hypertransaminasemia, dyspeptic symptoms, herpetiform dermatitis, and recurrent aphthous stomatitis. It is recommended that all diabetic children, even those asymptomatic, should be screened yearly for CD, using a combination of AGA plus ARA-R1 and AEA.

The Temporal Relationship Between the Onset of Type 1 Diabetes and Celiac Disease: A Study Based on Immunoglobulin A Antitransglutaminase Screening

“…Atypical isolated signs or CD symptoms are the most common forms in pa- tients with type 1 diabetes. 5 Most of our 11 patients with type 1 diabetes and a biopsy showing atrophic mucosa had, in fact, evocative symptoms of CD (Table 1). Only 4 of 11 had a typical form associated with gastrointestinal symptoms and weight loss with growth retardation.…”

“…26 Immunoregulatory disturbances in type 1 diabetes could trigger the reaction to gliadin in susceptible individuals. 5 However, we speculate that CD occurs first and that abnormal intestinal mucosa enhances the absorption of foreign antigens, inducing an immune response in patients who are genetically predisposed to type 1 diabetes. Type 1 diabetes could then develop in patients with silent, nontreated CD through gluten-mediated immune activation against other organs.…”

“…More often, CD is diagnosed shortly after or sometimes years after the onset of type 1 diabetes. 5,[21][22][23] To determine the temporal relationship between the onset of type 1 diabetes and CD, we tested for anti-tTG in the initial serum taken at the onset of diabetes using our serum library. The retroactive screening showed that only 1 of 11 patients (patient 11)-the one with a positive jejunal biopsy-was anti-tTG negative at the onset of the type 1 diabetes.…”

“…3 The prevalence of this association is usually ϳ5% (with a range of 2.3%-7%). 4,5 Type 1 diabetes is claimed to occur before CD in nearly all patients. 6 Most patients who have diabetes and CD have nonclassic forms of the disease, with various symptoms such as short stature, sideropenic anemia, or hypertransaminasemia; in many cases, patients are totally symptom-free.…”

Dietary gluten and the development of celiac disease and type 1 diabetes

“…In fact, about 90% of T1DM patients at the time of diagnosis of CD have little or no gastrointestinal symptoms. 53 In the majority of cases, the CD diagnosis follows that of T1DM as a consequence of case-finding at diagnosis or follow-up; thus, CD is found at an early stage in patients with T1DM. On the contrary, there is a paucity of data on the onset of T1DM in patients with treated CD.…”