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Biopsy Results - No Dh
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18 posts in this topic

I admit I'm kind of disappointed. I really wanted closure to this. It states "antibodies to IgG and IgA are negative . . . level sections do not reveal evidence of dermatitis herpetiformis."

The description for the two other biopsies taken are full of big words which scare the heck out of me. I've searched them all, most I don't understand, all seem to have some sort of reference to cancer in one form or another. (She never mentioned cancer to me I'm a hypochondriac, cancer is my biggest fear, so maybe I'm just reading into things.) On the biopsy report it all points to sclerosis of some sort or an auto-immune disorder or superficial morphea. But that doesn't explain the horrid, itch rash unlike anything I have ever had before.

Now I have to go for blood work to check for lupus and things along that line and follow up with the doctor in a month. Meanwhile I have my yearly check up with my PCP in 3 weeks so I'll ask him what he thinks of all this.

Jane

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Well, at least now you know it is NOT DH, but it does not answer the question of what it IS then. (and I suspect, this test may be invalid as you have been gluten-free for a year!)

And it does not exclude a gluten intolerance.

Jane, did you call and ask for an explanation of the biopsy report?

What do the words say--maybe someone here can help. Many of us have other autoimmune diseases.

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Jane, I'm so sorry. Yep, that sounds weird doesn't it? Sorry you don't have the cursed dh? Well, I'm sure you understand my drift.

Now don't go thinking you have cancer. Find out first. Yes, like IH says, you need to have the biopsies explained to you & not 3 weeks from now.

And I think cancer is the biggest fear for 90% of people. When I was growing up heart attack was the term that struck terror in your heart but now there's so much they can do in that arena & the newest terrorizing thought is the big "C".

Yes, if you post the reports here I bet someone can read them for you.

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No, it doesn't answer at all what my problem is!!! That is still a big question mark. I had an appt this morning and she told me what the report said and then gave me a copy. She (nurse practioner) seemed kind of puzzled by it as she was reading it. It wasn't until I got home after work that I sat down and read it myself.

The main findings are

subtle spongiotic interface dermatitis

papillary dermal sclerosis

suggesive of superficial morphea

C3, C5b-9 and C4D trace granular basement membrane deposits

I wonder if these are a reaction to the rash and the damage I have probably done by scratching so hard as opposed to them being the main problem?? There is no reference as to what the rash itself could be. Later I can write out more of what it said, but right now it is 90 degrees up here where my computer is and I gotta go down where it is cool.

Thank you so much for your help, Jane

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Tomorrow (when clean and on my computer instead of phone) I'll post some links I found. Mostly, I have no idea what they mean...but they are interesting.

I'm pretty sure the fact that you've been gluten-free for 4 months (right?) invalidates the test since they are looking for iga which falls quickly. INTERESTINGLY, it appears other antibodies (subsets? I am so out of my depth here) keep DH active or are present in DH but not in celiac disease (without DH). The test doesn't look for this....if I'm reading correctly.

I had read there's a very high rate of negative results on DH testing. I had read 37%, but presently can't find the link. I'll look tomorrow.

So, don't assume you don't have DH. All you know is the lab read it as negative or perhaps inconclusive. You need to read these links and ask a lot of questions.

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Exactly.

If all the discussion over several years proves anything, it is that tests for DH are notoriously unreliable.

I would not assume that you do not have DH, based on tests, particularly if you have been eating gluten free for a while.

In any case labels are of limited use. If gluten free eating provides relief that is the path to take.

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I would not assume that you do not have DH, based on tests, particularly if you have been eating gluten free for a while.

In any case labels are of limited use. If gluten free eating provides relief that is the path to take.

This raises the point I asked on Jane's other thread. Since gluten is the underlying mechanism of DH, if she has been gluten-free for a year, wouldn't the skin biopsy be invalid?

No one seemed to answer that question, maybe because no one saw it after I wrote it, but you raise it here and Prickly says it too and it does make me wonder. IgA antibodies deposit in the skin. If she has low levels...then????.... :unsure:

Jane,

what did the doctor say about the fact that you have been gluten-free???

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You might find these interesting:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2193738/

http://suphu.medcom.ch/uploads/media/Dermatitis_herpetiformis.pdf

http://onlinelibrary.wiley.com/doi/10.1111/j.1468-3083.2009.03188.x/full

http://www.ncbi.nlm.nih.gov/m/pubmed/12142608/?i=6&from=/12220281/related

http://anagen.ucdavis.edu/141/correspondence/dh/van.html

http://www.arupconsult.com/Topics/DermHerpetiformis.html#tabs=3

I still can't find the link to the negative test rate article. I'll keep looking. Although if you read between the lines its easy to see how there's such a high rate of negatives... medical professionals don't know how to properly biopsy it, must be on a gluten diet, and it's a "judgement" test - meaning it's subject to human error, and it the samples don't always contain the iga in the form needed to id.

*******

I was asked to add this additional info about having a rash and having a gluten issue. These are my personal observations based on my readings and experience.

1) If your rash responds to gluten, it is a gluten-related rash.

2) You can try to biopsy it, but a negative result does not mean it isn't DH or a gluten related rash.

3) Most gluten rashes have a related component: salicylates, amines, iodine, msg's, etc.

4) A gluten rash can pop up at any time.

5) Gluten rashes are trending on this board to being the FIRST sign or a LATTER sign (or both).

6) You can have more than one type gluten related rash (judging by the varying dx's on the board).

7) DH does "morph" over time. I saw it , as have many others, and this makes it very hard to dx.

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I'm not 100% convinced I don't have DH (and I'm probably way in the minority in wishing I had tested positive). I've been gluten-free for a little over 2 years. The only gluten I have eaten is from cc and 3 or 4 times when I have snitched a little cookie or something (and nothing was snitched in weeks before I broke out in a rash). I've been extremely compliant. So if I do have DH I am totally perplexed as to where it could have come from so based on my diet. It makes no sense. On the other hand my symptoms match it quite nicely, bilateral, symmetric, looks like chicken pox, itches like the dickens, elbows, knees, lower back, shoulders, prickles and burns like a sunburn.

If I've been gluten-free then naturally my skin biopsy would be negative but also, if I've been gluten-free, I shouldn't even have had a dh rash. I've read as an aside the gluten-free pathology should also show neurtophiles and my report didn't mention that but did mention lymphocytes, two different things.

Tne NP never thought I had DH and wouldn't even have tested me had I not asked her to. I don't know how accurate her testing mode was. I read the specimin taken should be 3-8 mm deep, mine was 3 mm, just barely making what it should be. Even she said that she hoped she took a big enough sample. And I don't know for sure if she took it from a clean piece of skin. At my appt yesterday I didn't get into my gluten-free diet with her, I felt it was useless since she is sure I don't have it.

I'm seeing my PCP in a couple of weeks and will go all over this with him and get his take of the biopsy report. And I might do a little testing this weekend with an oreo cookie, yum-yum.

Jane

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You might find these interesting:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2193738/

http://suphu.medcom.ch/uploads/media/Dermatitis_herpetiformis.pdf

http://onlinelibrary.wiley.com/doi/10.1111/j.1468-3083.2009.03188.x/full

http://www.ncbi.nlm.nih.gov/m/pubmed/12142608/?i=6&from=/12220281/related

http://anagen.ucdavis.edu/141/correspondence/dh/van.html

http://www.arupconsult.com/Topics/DermHerpetiformis.html#tabs=3

I still can't find the link to the negative test rate article. I'll keep looking. Although if you read between the lines its easy to see how there's such a high rate of negatives... medical professionals don't know how to properly biopsy it, must be on a gluten diet, and it's a "judgement" test - meaning it's subject to human error, and it the samples don't always contain the iga in the form needed to id.

*******

I was asked to add this additional info about having a rash and having a gluten issue. These are my personal observations based on my readings and experience.

1) If your rash responds to gluten, it is a gluten-related rash.

2) You can try to biopsy it, but a negative result does not mean it isn't DH or a gluten related rash.

3) Most gluten rashes have a related component: salicylates, amines, iodine, msg's, etc.

4) A gluten rash can pop up at any time.

5) Gluten rashes are trending on this board to being the FIRST sign or a LATTER sign (or both).

6) You can have more than one type gluten related rash (judging by the varying dx's on the board).

7) DH does "morph" over time. I saw it , as have many others, and this makes it very hard to dx.

Prickly - thank you so much for the links. I am going to print them out and read them. And thank you for added info, all vere interesting.

As you said, very often pathology results are one person's opinon. Someone else may read them differenlty. It's not always black and white. Considering all that I am reading between the lines of the report I think DH would be a piece of cake.

Thank you again for the info, it's very helpful

Jane

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Prickly - thank you so much for the links. I am going to print them out and read them. And thank you for added info, all vere interesting.

As you said, very often pathology results are one person's opinon. Someone else may read them differenlty. It's not always black and white. Considering all that I am reading between the lines of the report I think DH would be a piece of cake.

Thank you again for the info, it's very helpful

Jane

In one of those links you'll find a doctor saying the antibodies can stay in your skin up to 10 years.

Yeah.

TEN YEARS.

I almost choked.

And the IgA, which is what they test for may not be all that is causing the DH. One of those studies details other antibodies present in DH Celiacs, in the skin, that are thought to be what differentiates us from regular celiac disease. And THOSE are probably what they should be testing for. But of course, they don't have a test for it for dx.

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Okay, this has been driving me crazy too b/c I have read at least a dozen times what Prickly is saying about needing to be eating gluten for the dh biopsy AND the reason I read that is b/c Prickly posted the links & I bookmarked them. Funny how you can miss things right in front of your eyes. I have been going through my bookmarks for hours & hours & reading & then going through them again & reading everything again. FINALLY I found them. Compliments of Prickly:

Read especially "Diagnosis of dh" AND "Diagnosis of celiac"

http://www.coeliac.org.uk/healthcare-professionals/associated-conditions-and-complications/dermatitis-herpetiformis

You will find the relevant text under "diagnosis"

http://en.wikipedia.org/wiki/Dermatitis_herpetiformis

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Okay, this has been driving me crazy too b/c I have read at least a dozen times what Prickly is saying about needing to be eating gluten for the dh biopsy AND the reason I read that is b/c Prickly posted the links & I bookmarked them. Funny how you can miss things right in front of your eyes. I have been going through my bookmarks for hours & hours & reading & then going through them again & reading everything again. FINALLY I found them. Compliments of Prickly:

Read especially "Diagnosis of dh" AND "Diagnosis of celiac"

http://www.coeliac.org.uk/healthcare-professionals/associated-conditions-and-complications/dermatitis-herpetiformis

You will find the relevant text under "diagnosis"

http://en.wikipedia.org/wiki/Dermatitis_herpetiformis

Doesn't that drive you nuts?

That's ok, the first time I heard gluten-free would make a biopsy negative I didn't believe it because everything I remembered reading didn't mention it. But if you read enough, you start to find it. You don't see it mentioned a lot, but I'm noticing it more now. Maybe I'm finding better reading material?

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One of the problems with the wiki article is it says "there is a strong relationship between DH and celiac" and NO citation is provided. IMHO--There is more than a "strong relationship". DH IS the skin manifestation of CELIAC.

From Celiac Disease: The Hidden Epidemic. Dr. Peter H. R. Green and Rory Jones

"DH was first described by Dr Louis Duhring in 1884, four years before Samuel Gee made sense of the "coeliac affliction". In 1967 Janet Marks of England discovered the link between intestinal biopsy and skin biopsy results of DH patients.

It is a chronic, permanent condition if not treated with a gluten-free diet.

Blood tests for celiac disease--notably endomysial antibodies (EM) and antitissue transglutaminase (tTG) may be positive or even negative in patients with DH.

The biopsy is tested for granular IgA deposits in the dermal papillae (under the top layer of skin) using direct immunoflorescence. The term granular refers to the pattern of immunoflorescence, a very specific appearance that differentiates DH from another, almost identical disease Linear IgA disease.

If you have a positive DX of DH, you have celiac disease.

Since no tests in medicine are 100% , not everyone with DH will have a positive skin biopsy. A negative biopsy should not necessarily be used to exclude the DX if the lesions look and act like DH and occur after the ingestion of gluten.

Patients should be retested.

DH biopsies for IgA are usually positive for a long time after gluten has been stopped--and become positive again within a few months of ingesting gluten. But it is unclear what dose of gluten is necessary.

Pathogenesis

It has a mutlifactorial derivation:

-a genetic predisposition

-prolonged exposure to gluten

-an immunological response

In susceptible individuals, the chronic stimulation of the immune system by gluten produces IgA antibodies that bind to the skin and CAUSE DH.

Patients with DH have a higher incidence of non-Hodgkins lymphoma but the gluten-free diet reduces the risk. They also have a higher risk of anemia, type 1 diabetes, lupus, Sjogren's, and vitiglio.

BUT -- this is also similar in patients with celiac disease--even in the absence of DH.

More than one skin condition can occur, making it confusing. There are forms of eczema that look and itch just like DH lesions and the blistering can be confused without biopsy confirmation.

DH is very erratic. Since the skin may not be rid of IgA deposits for more than 2 years after starting a gluten-free diet, flare- ups occur without obvious gluten ingestion. It may take patients a substantial amount of time to erase years of IgA buildup in the skin.

A flare could also be due to inadvertent gluten ingestion, iodine, NSAIDS. Opinions vary as to whether topical lotions and creams have ingredients that might trigger a reaction and stress may exacerbate the flares, although there is no science behind the stress link.

If the patient has DH, it may take years for it to get better."

************ Note:

If there are any typos, I apologize. (bad English Prof. :lol: ). It is very late and I am tired, but I wanted to provide this "in plain English" explanation. I have been reading some PubMed stuff that requires a medical dictionary and as Prickly and I decided earlier, there is still much to be learned from all this. My eyes are pooped. :lol:

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One of the problems with the wiki article is it says "there is a strong relationship between DH and celiac" and NO citation is provided. IMHO--There is more than a "strong relationship". DH IS the skin manifestation of CELIAC.

From Celiac Disease: The Hidden Epidemic. Dr. Peter H. R. Green and Rory Jones

"DH was first described by Dr Louis Duhring in 1884, four years before Samuel Gee made sense of the "coeliac affliction". In 1967 Janet Marks of England discovered the link between intestinal biopsy and skin biopsy results of DH patients.

It is a chronic, permanent condition if not treated with a gluten-free diet.

Blood tests for celiac disease--notably endomysial antibodies (EM) and antitissue transglutaminase (tTG) may be positive or even negative in patients with DH.

The biopsy is tested for granular IgA deposits in the dermal papillae (under the top layer of skin) using direct immunoflorescence. The term granular refers to the pattern of immunoflorescence, a very specific appearance that differentiates DH from another, almost identical disease Linear IgA disease.

If you have a positive DX of DH, you have celiac disease.

Since no tests in medicine are 100% , not everyone with DH will have a positive skin biopsy. A negative biopsy should not necessarily be used to exclude the DX if the lesions look and act like DH and occur after the ingestion of gluten.

Patients should be retested.

DH biopsies for IgA are usually positive for a long time after gluten has been stopped--and become positive again within a few months of ingesting gluten. But it is unclear what dose of gluten is necessary.

Pathogenesis

It has a mutlifactorial derivation:

-a genetic predisposition

-prolonged exposure to gluten

-an immunological response

In susceptible individuals, the chronic stimulation of the immune system by gluten produces IgA antibodies that bind to the skin and CAUSE DH.

Patients with DH have a higher incidence of non-Hodgkins lymphoma but the gluten-free diet reduces the risk. They also have a higher risk of anemia, type 1 diabetes, lupus, Sjogren's, and vitiglio.

BUT -- this is also similar in patients with celiac disease--even in the absence of DH.

More than one skin condition can occur, making it confusing. There are forms of eczema that look and itch just like DH lesions and the blistering can be confused without biopsy confirmation.

DH is very erratic. Since the skin may not be rid of IgA deposits for more than 2 years after starting a gluten-free diet, flare- ups occur without obvious gluten ingestion. It may take patients a substantial amount of time to erase years of IgA buildup in the skin.

A flare could also be due to inadvertent gluten ingestion, iodine, NSAIDS. Opinions vary as to whether topical lotions and creams have ingredients that might trigger a reaction and stress may exacerbate the flares, although there is no science behind the stress link.

If the patient has DH, it may take years for it to get better."

************ Note:

If there are any typos, I apologize. (bad English Prof. :lol: ). It is very late and I am tired, but I wanted to provide this "in plain English" explanation. I have been reading some PubMed stuff that requires a medical dictionary and as Prickly and I decided earlier, there is still much to be learned from all this. My eyes are pooped. :lol:

You've done a great job so far! Are you rewriting or copying?

The medical lingo makes my eyes cross. Sometimes I read a sentence and have to look up every word.

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Great stuff folks. Thanks for the list pricklypear.

I would add, Jane--you talked about occasional 'nibbling'.

My experience is that any gluten consumption at all will be enough to keep the DH going.

I was a 'gluten-free nibbler' for years before the DH broke out, and it was only after I eliminated all the little gluten sources that I started to make progress.

And finally, we've had a couple of threads here talking about how some of us have developed new areas of DH, long AFTER we were almost certainly gluten free. There seems to be a 'momentum' to the condition.

In other words, you cause the condition by eating gluten, but stopping eating gluten is only part of the 'cure'.

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I wrote (somewhat paraphrasing, but mostly that is directly from Chapter 11 ) all of that to explain even small doses of gluten by nibbling/cheating or even trace CC sparks the immune response all over again.

If the antibodies stay in the skin for more than 2 years, a strict gluten-free diet is necessary.

Dapsone helps, according to the materials I read and the people on here.

But as you all point out, iodine, NSAIDS, and for some folks, salicylates can all trigger something in the immune system that also exacerbates the problem.

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It has taken a couple of months of 'testing' buts sals is definitely a problem for me. Corn, raisins etc are all my 'avoid' list now. It has been a difficult but worthy journey for me. In the early days iodine caused a very temporary and very instant effect. Eating prawns caused a reaction within minutes. Now, gluten free strictly since Oct11 these don't seem to trigger at all. I haven't tested the prawns again though :(

Sals seem to trigger a DH outbreak not so temporary ((but not like gluten intake)) and are definitely accumulative. If I have to much sals over time the DH kicks in temporary but longer than those iodine intacts.

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