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CELIAC DISEASE AMONG CHILDREN PRESENTED with UNEXPLAINED SHORT STATURE Mohamed Sayed Hemeda, Ahmed Saad Eldeen Ibrahim, Mohamed Sami Elhakim, Kamel Soliman Hammad

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CELIAC DISEASE AMONG CHILDREN PRESENTED with UNEXPLAINED SHORT STATURE Mohamed Sayed Hemeda, Ahmed Saad Eldeen Ibrahim, Mohamed Sami Elhakim, Kamel Soliman Hammad CELIAC DISEASE AMONG CHILDREN PRESENTED WITH UNEXPLAINED SHORT STATURE Mohamed Sayed Hemeda, Ahmed Saad Eldeen Ibrahim, Mohamed Sami Elhakim, Kamel Soliman Hammad CELIAC DISEASE AMONG CHILDREN PRESENTED WITH UNEXPLAINED SHORT STATURE By Mohamed Sayed Hemeda*, Ahmed Saad Eldeen Ibrahim*, Mohamed Sami Elhakim**, Kamel Soliman Hammad*** Pediatrics*, Pathology** and clinical Pathology*** departments, Faculty of Medicine, Al-Azhar University ABSTRACT Introduction: Celiac disease is a chronic autoimmune condition, in genetically susceptible persons, perpetuated by the ingested gluten from cereals, wheat and barley, its clinical spectrum is broad, varies from absence of symptoms to gastrointestinal (classic) and/or extra intestinal (non-classic) symptoms, patients without symptoms may have latent or silent celiac disease, because celiac disease can be atypical or even clinically silent, many patients remain undiagnosed and at risk for the long-term, sometimes serious complications of untreated celiac disease. Short stature is the most commonly encountered extra-intestinal (non –classical) symptoms of CD in children, being found in roughly one-third of all new pediatric celiac diagnoses, while it can be directly related to malabsorption of nutrients, it should completely reverse once a child is strictly adherent to Gluten free diet. Aim of the work: The goal of this study was to screen for coeliac disease in Egyptian children with unexplained short stature by estimating serum level of total IgA and tissue transglutaminase IgA. Methodology: Cross sectional analytical study for 100 child with short stature (males and females), attended the pediatric out-patient clinics of AL-Sayed Galal and Alhussen university hospitals in Cairo during the period from April 2017 to march 2019, any child aged 2- 18 years with undetectable cause of short stature whose Z score for height was less than -2 SD for the age and sex according to the WHO charts (WHO, 2006), not previously screened for Celiac disease was enrolled in the study, after approval of his care-giver, the medical records of patients evaluated for short stature include a proper detailed history and physical examination, growth analysis, followed by radiological (bone age), and Laboratory screening (including celiac serological screening and Growth hormone evaluation) , chromosomal analysis were performed when appropriate, followed by small intestinal biopsy for celiac seropositive patients and Growth hormone stimulation test was performed in suspected patients. Results: The demographic characteristics of all 100 cases regarding mean age in months was 80.85 ± 33.55 with range 36 – 179, Sex distribution of all cases was 52 (52.0%) female and 48 (48.0%) male, mean height in cm for all cases was 102.04 ± 663 Al-Azhar Journal of Ped. Vol. 23 No. 47 Jan 2020 13.48 with range 84 – 141 and median height Z score for all study group was -3.4 (-3.6 – -3) with range -4.6 - -2.6. The results showed that 11(11%) cases were positive for TTG IgA antibodies with normal level of total IgA Identified celiac cases with mean age in months was 86.91 ± 37.58, female cases were 7 (63.6%) and 4 (36.4%) cases were males, mean Height in cm was 102.18 ± 14 and median height Z score was -3.6 (-4.3 – -3.4). Keywords: Short stature; Celiac disease; Children; Anti-tissue transglutaminase antibody, Idiopathic short stature. INTRODUCTION followed by intestinal biopsy for 3 Celiac disease is a chronic histologic confirmation. autoimmune condition, in Short stature is the most genetically susceptible persons, commonly encountered extra- perpetuated by the ingested gluten intestinal manifestation of CD in from cereals, wheat and barley.1 children, being found in roughly Classic symptoms include one-third of all new pediatric gastrointestinal problems such as celiac diagnoses. While it can be chronic diarrhea, abdominal directly related to malabsorption distension, malabsorption, loss of of nutrients, it should completely appetite, and among children reverse once a child is strictly failure to grow normally. This adherent to a Gluten free diet 4 often begins between six months (GFD). and two years of age. Non-classic Around 2.5-3% of the children symptoms (eg, short stature, worldwide are short, 5 The delayed puberty, epilepsy, Egyptian Demographic and Health peripheral neuritis and iron Survey of 2008 (EDHS 2008) defiency anemia) are the most revealed that the prevalence of common, especially in people stunting among children under 5 older than two years.2 was 28.9%2, while that of the The standard method of EDHS 2014 was found to be 21% diagnosing celiac disease in while the prevalence of stunting symptomatic persons older than 2 among children aged 1-12 years years is the tissue attending the outpatient Pediatric transglutaminase (tTG) IgA test, clinic of Al-Azhar University 664 CELIAC DISEASE AMONG CHILDREN PRESENTED WITH UNEXPLAINED SHORT STATURE Mohamed Sayed Hemeda, Ahmed Saad Eldeen Ibrahim, Mohamed Sami Elhakim, Kamel Soliman Hammad Hospital (Al-Hussein), Cairo was recommendations or 15.8%.6 prescriptions. Endocrinological causes of 4- The aim of the study & all short stature accounted for 26% investigations as well as the while celiac disease (CD) risks & benefits of study have constituted 6.6% of children with been explained to parents of short stature in Egypt.7 the patients. In Egypt celiac disease is a 5- The authors declared no frequent disorder among children, potential conflicts of interest both in the general population with respect to the research, (0.53%) and in at-risk groups authorship and/or publication (6.4%).8 of this article. The only known effective 6- All data of patients & results of treatment is a strict lifelong study are confidential & gluten-free diet, which leads to patients have the right to keep recovery of the intestinal mucosa, it. improves symptoms, and reduced 7- The patient has the right to risk of developing complications withdraw from the study at 9 in most people, If untreated it any time. may result in cancers such as intestinal lymphoma and a slight increased risk of early death.10 Financial Disclosure/Funding: Ethical consideration: The authors received no 1- The ethical committees of Al- financial support for research, Azhar faculty of medicine & authorship, & or publication of pediatric department approved this article. the study. PATIENTS AND METHODS 2- Informed consent was obtained This study is a cross sectional from parents of all included study that was carried out on 100 children. children with short stature (males 3- The research protocol did not and females), The cases were interfere with any medical attending the pediatric out-patient clinic off AL-Sayed Galal and Alhussen university hospitals in 665 Al-Azhar Journal of Ped. Vol. 23 No. 47 Jan 2020 Cairo, any child fulfilled the Each child enrolled in the study inclusion criteria was enrolled in was subjected to the following:- the study after obtaining a written 1) Prestructured questionnaire. consent from the care giver during the period from April 2017 to 2) Anthropometric measurements. march 2019. 3) Detailed history (eg: personal, Inclusion criteria: dietetic, familial, gastrointestinal symptoms). 1- Age 2 - 18 years with undetectable case of short 4) Complete physical examination. stature whose Z score for 5) Radiological investigation: height was < -2 SD for the age Antero-posterior plain X-ray and sex according to the WHO film of left wrist was taken, and charts.11 bone age was determined 2. Not previously screened for according to Greulich and Pyle 12 Celiac disease. atlas. Exclusion criteria: 6) Laboratory investigations Short children with • Complete blood count by demonstrable cause such as; using cell counter (Diagon D cell 60, Hungary). 1) Familial and constitutional short stature. • Liver ((SGOT, SGPT) and renal (Blood urea and 2) Chronic illness. creatine) using biochemical 3) Disproportionate short stature. auto-analyzer (BT 1500, 4) Short stature of endocrinal Rome, Italy origin (eg, growth hormone • Total serum IgA by deficiency). nephlometry using a Behring 5) Turner syndrome. BNII nephelometer (Dade Behring, Milton Keynes, 6) Short stature with significant UK).level below10mg/dl congenital anomalies. considered deficient.13 7) Patients on gluten free diet. • IgA class serum human tissue transglutaminase antibody 666 CELIAC DISEASE AMONG CHILDREN PRESENTED WITH UNEXPLAINED SHORT STATURE Mohamed Sayed Hemeda, Ahmed Saad Eldeen Ibrahim, Mohamed Sami Elhakim, Kamel Soliman Hammad (IgA-TTGA) by enzyme deficient when the peak GH linked immunosorpant assay value during the stimulation (ELISA): test was equal to or higher Used kits: Enzyme-linked than 7 ng/ml Immunosorbent Assay Kit • KARYOTYPING for all for Tissue transglutaminase female patients with IgA (INOVA Diagnositics undetectable cause of short Inc., USA). stature to exclude turner Results: The result was syndrome considered weak positive if 7) Upper gastrointestinal the sample demonstrates 20– endoscopy for duodenal biopsy: 30U/ml or moderate to was done for the study group strong positive if the sample subjects who will have positive demonstrates >30U/ml.14 values on anti-tissue • Thyroid profile: TSH was transglutaminase (IgA) antibody estimated by estimation, Four to six biopsy immunoradiometric assay specimens were taken from the (IRMA), while FT3 and FT4 bulb and second parts of the were estimated by duodenum. Formalin-fixed biopsy radioimmunoassay kits from specimens stained with Diagnosis Product hematoxylin and eosin will be Corporation (Los Angeles, studied with the use of light CA, USA).15 microscopy, mucosal lesions were classified according to the criteria • Growth hormone of modified Marsh (Dr. Michael evaluation (IGF-1 and Marsh introduced the growth hormone provocation classification system to describe test for cases with low level the stages of damage in the small of IGF-1), IGF-1 was intestine as seen under a determined at diagnosis microscope).16 using solid phase IRMA, using kits from Diagnostic Statistical analysis: System Laboratories Inc., Data were analyzed using Texas, USA., Patients were IBM© SPSS© Statistics version considered not to be GH 23 (IBM© Corp., Armonk, NY, 667 Al-Azhar Journal of Ped.
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