Correspondence
Case 30-1994: Antiendomysial Antibodies and Celiac Disease
N Engl J Med 1994; 331:1776December 29, 1994
- Article
To the Editor:
With respect to the case report regarding a 74-year-old woman with diarrhea, dehydration, and weight loss (Aug. 11 issue),1 we believe the discussants left us tantalizingly short of important clinical and laboratory information that would boost the reader's confidence in the final diagnosis. We were surprised that there was no mention of the estimation of antibodies such as antigliadin antibody or, more particularly, antiendomysial antibody in the investigation of small-bowel diarrhea, tests that in our experience have a specificity approaching 100 percent.2 Indeed, a positive test for endomysial antibodies would substantially increase the probability that a gluten-sensitive enteropathy was present.
We were also unaware that diffuse macroscopic abnormalities in the stomach such as “erythema, edema, and small raised dots of reddened mucosa” were recognized abnormalities in celiac disease. The authors have not informed us of the results of the endoscopic biopsies of specimens taken from this area or of the serum gastrin levels, information we assume was available. Could this patient have had a concomitant hypersecretory state?
Although we are informed in the Addendum that this patient showed clinical improvement after gluten was withdrawn from her diet, this would be unusual in ulcerative jejunoileitis, which we presume was the alternative diagnosis. Surely histologic confirmation of the morphologic improvement in small-bowel mucosa is required for a diagnosis of “celiac sprue.”
2 ReferencesS.E. Patchett, M.D.
E.M. Alstead, M.D.
P.J. Kumar, M.D.
St. Bartholomew's Hospital, London EC1A 7BE, United Kingdom1
Case Records of the Massachusetts General Hospital (Case 30-1994)
Full Text | Web of Science | Medline2
Ferreira M ,Davies SL ,Butler M ,Scott D ,Clark M ,Kumar P . Endomysial antibody: is it the best screening test for coeliac disease? Gut 1992;33:1633-1637
CrossRef | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Measurements of serum antigliadin or antiendomysial antibody are useful in screening for celiac disease, in following a patient's response to a gluten-free diet. In the case discussed, however, there was a clear indication for an immediate biopsy of the small intestine -- a need that would not be obviated by the performance of a serologic screening test. Histologic examination of the small intestine remains the gold standard for the diagnosis of celiac disease. Thus, endoscopic distal duodenal biopsy was the initial investigation of choice in this critically ill patient.
Supportive laboratory data became available after the diagnosis. The serum gastrin concentration was less than 10 pg per milliliter, and the titers of serum antigliadin IgG and IgA antibodies were normal, but the antiendomysial IgA antibody titer was markedly elevated at 1:2560. No gastric-biopsy specimens were obtained during the initial endoscopy since the gastritis appeared mild.
Classically, to confirm villous recovery, patients should undergo another biopsy after the initiation of the appropriate diet. This point was made when celiac disease was discussed as part of the differential diagnosis and was reiterated in the pathological discussion.
One year after diagnosis, the patient was robust and had regained the weight she had lost and recovered her sense of well-being. She had not yet undergone a second biopsy.
Ciaran P. Kelly, M.D.
Boston University Medical Center, Boston, MA 02118Peter B. Kelsey, M.D.
Fiona Graeme-Cook, M.D.
Massachusetts General Hospital, Boston, MA 02114
