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    Can Understanding Clonal T Cell Receptor Gene Rearrangements Improve Refractory Celiac Diagnosis?


    Jefferson Adams
    • Researchers suspect that better understanding of clonal T cell receptor gene rearrangements may help researchers to improve diagnosis of refractory celiac disease, a rare complication of celiac disease that has high death rates.

    Can Understanding Clonal T Cell Receptor Gene Rearrangements Improve Refractory Celiac Diagnosis?
    Image Caption: Image: CC--NIAID

    Celiac.com 06/14/2018 - Refractory celiac disease type II (RCDII) is a rare complication of celiac disease that has high death rates. To diagnose RCDII, doctors identify a clonal population of phenotypically aberrant intraepithelial lymphocytes (IELs). 

    However, researchers really don’t have much data regarding the frequency and significance of clonal T cell receptor (TCR) gene rearrangements (TCR-GRs) in small bowel (SB) biopsies of patients without RCDII. Such data could provide useful comparison information for patients with RCDII, among other things.

    To that end, a research team recently set out to try to get some information about the frequency and importance of clonal T cell receptor (TCR) gene rearrangements (TCR-GRs) in small bowel (SB) biopsies of patients without RCDII. The research team included Shafinaz Hussein, Tatyana Gindin, Stephen M Lagana, Carolina Arguelles-Grande, Suneeta Krishnareddy, Bachir Alobeid, Suzanne K Lewis, Mahesh M Mansukhani, Peter H R Green, and Govind Bhagat.

    They are variously affiliated with the Department of Pathology and Cell Biology, and the Department of Medicine at the Celiac Disease Center, New York Presbyterian Hospital/Columbia University Medical Center, New York, USA. Their team analyzed results of TCR-GR analyses performed on SB biopsies at our institution over a 3-year period, which were obtained from eight active celiac disease, 172 celiac disease on gluten-free diet, 33 RCDI, and three RCDII patients and 14 patients without celiac disease. 

    Clonal TCR-GRs are not infrequent in cases lacking features of RCDII, while PCPs are frequent in all disease phases. TCR-GR results should be assessed in conjunction with immunophenotypic, histological and clinical findings for appropriate diagnosis and classification of RCD.

    The team divided the TCR-GR patterns into clonal, polyclonal and prominent clonal peaks (PCPs), and correlated these patterns with clinical and pathological features. In all, they detected clonal TCR-GR products in biopsies from 67% of patients with RCDII, 17% of patients with RCDI and 6% of patients with gluten-free diet. They found PCPs in all disease phases, but saw no significant difference in the TCR-GR patterns between the non-RCDII disease categories (p=0.39). 

    They also noted a higher frequency of surface CD3(−) IELs in cases with clonal TCR-GR, but the PCP pattern showed no associations with any clinical or pathological feature. 

    Repeat biopsy showed that the clonal or PCP pattern persisted for up to 2 years with no evidence of RCDII. The study indicates that better understanding of clonal T cell receptor gene rearrangements may help researchers improve refractory celiac diagnosis. 

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  • About Me

    Jefferson Adams earned his B.A. and M.F.A. at Arizona State University, and has authored more than 2,000 articles on celiac disease. His coursework includes studies in biology, anatomy, medicine, and science. He previously served as Health News Examiner for Examiner.com, and provided health and medical content for Sharecare.com.

    Jefferson has spoken about celiac disease to the media, including an appearance on the KQED radio show Forum, and is the editor of the book Dangerous Grains by James Braly, MD and Ron Hoggan, MA.

  • Popular Contributors

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    Jefferson Adams
    Is Diagnosis for Refractory Celiac Disease on the Rise?
    Celiac.com 01/14/2011 - Researchers recently presented information at the American College of Gastroenterology that indicates that more people with celiac disease might stop responding to gluten-free diets. Their new study, in the form of a retrospective chart review, turned up 17 cases of refractory celiac disease, each of which was eventually treated successfully with thiopurines.
    Researchers Christopher Hammerle, MD, and Sheila Crowe, MD, of the University of Virginia in Charlottesville, reported the results at a meeting at the American College of Gastroenterology. Hammerle called thiopurines her "treatment-of-choice for refractory celiac disease to avoid long-term steroids." The researchers stated that refractory disease appear to be on the rise. Patients with refractory celiac disease have recurrent symptoms such as abdominal pain, severe malabsorption, and intestinal damage.
    While some people note that refractory sprue might be caused by non-compliance to the gluten-free diet, current guidelines for treating refractory sprue call for doctors to review the dietary compliance of their patients, and to press for stricter adherence, and to search for other triggers of non-responsiveness only once dietary adherence issues are ruled out. In order to best understand the natural history of the celiac disease and to establish best practices for treatment, the researchers examined non-responsive celiac patients who had been seen at the University of Virginia Medical Center over the previous 10-year period.
    They found 17 such patients; 16 of whom had intraepithelial lymphocytes, four with the polyclonal phenotype and 12 with the monoclonal phenotype. One patient was untyped, while five patients also suffered autoimmune disease. The average age for diagnosis of a polyclonal phenotype was 45 years, and for the monoclonal phenotype mean age at diagnosis was 59. Overall, patients received a diagnosis of refractive disease an average of 4.7 years after receiving their diagnosis of celiac disease.
    According to the data, diagnosis for refractive celiac disease seems to be happening more recently, with all but one diagnosis happening in the last five years, and 41% diagnosed within six months of the researchers report. Every patient diagnosed with refractive celiac disease showed evidence of malabsorption, while 71% suffered from iron deficiency Anemia, 59% suffered hypo-albuminuria, 47% had osteoporosis and 24% showed elevated liver enzymes.
    According to Dr. Hammerle, steroids are the most common treatment choice for truly refractive disease. Indeed, more than four out of five refractory celiac patients (82%) first received corticosteroid treatment, but two patients went on to become steroid-dependent. Instead, Hammerle prefers to treat refractory celiac disease patients with a thiopurine. Of 14 of patients who received a thiopurine, all but one showed a notable improvement in symptoms.
    Hammerle notes that, while diagnosis for refractory disease seems to be rising, celiac disease itself is still widely underdiagnosed. Brandt concurs, noting that people with undiagnosed celiac disease, or even persistent celiac disease, can develop serious complications, including lymphoma. In people with celiac disease, this can result from increased production of cytokines, including IL-15, Hammerle said, which promote the creation of T-cells that can turn malignant.
    Source:

    American College of Gastroenterology. Hammerle C, Crowe S "Natural history and treatment of refractory celiac disease: Experience with 17 patients at a single center" ACG 2010; Abstract 235.

    Jefferson Adams
    Celiac.com 01/04/2013 - Currently, doctors must still use invasive techniques to distinguish between uncomplicated and complicated forms of celiac disease.
    In an effort to find a non-invasive approach to the issue, a research team recently set out to investigate the potential use of novel serum parameters, including IL-6, IL-8, IL-17, IL-22, sCD25, sCD27, granzyme-B, sMICA and sCTLA-4 in patients diagnosed with active celiac disease, celiac disease on a GFD, Refractory coeliac disease (RCD) type I and II, and enteropathy associated T-cell lymphoma (EATL).
    The research team included Greetje J. Tack, Roy L. van Wanrooij, B. Mary Von Blomberg, Hedayat Amini, Veerle M. Coupe, Petra Bonnet, Chris J. Mulder and Marco W. Schreurs.
    Their investigation revealed elevated levels of the pro-inflammatory IL-8, IL-17 and sCD25 in both active celiac disease and in refractory celiac disease, types I and II.
    They also found that RCDII patients displayed higher serum levels of soluble granzyme-B and IL-6 in comparison to active celiac disease patients. Furthermore, EATL patients showed higher levels of IL-6 as compared to all other groups. Otherwise, the team found no differences between RCDI and active celiac disease or RCDII.
    These novel serum parameters show distinct immunological differences in RCDII and EATL, compared with uncomplicated celiac disease and RCDI.
    Source:
    BMC Gastroenterology 2012, 12:159. doi:10.1186/1471-230X-12-159

    Jefferson Adams
    Celiac.com 10/27/2014 - There have been a few reports tying cortical myoclonus with ataxia to celiac disease. Such reports also suggest that the former is unresponsive to a gluten-free diet.
    A team of researchers recently set out to determine if there is any significant connection between the two conditions. The research team included Ptolemaios G. Sarrigiannis, Nigel Hoggard, Daniel Aeschlimann, David S. Sanders, Richard A. Grünewald, Zoe C. Unwin, and Marios Hadjivassiliou.
    They are variously associated with the Departments of Gastroenterology, Neurology, Neurophysiology and Neuroradiology at Royal Hallamshire Hospital, in Sheffield, UK, and with the College of Biomedical and Life Sciences at Cardiff University in Cardiff, UK.
    The team presented detailed electro-clinical characteristics of a new syndrome of progressive cortical hyperexcitability with ataxia and refractory celiac disease. Regular follow ups of over 600 patients with neurological manifestations due to gluten sensitivity revealed 9 patients with this syndrome.
    They found that all nine patients, six men and three women, experienced asymmetrical irregular myoclonus involving one or more limbs and sometimes face. This was often stimulus sensitive and became more widespread over time. Three patients had a history of Jacksonian march, and five had at least one secondarily generalized seizure. Electrophysiology showed evidence of cortical myoclonus. Three showed a phenotype of epilepsia partialis continua at onset.
    All patients showed clinical, imaging and/or pathological evidence of cerebellar involvement. All patients followed a strict gluten-free diet, and most successfully eliminated gluten-related antibodies. However, all patients still showed evidence of enteropathy, suggests that refractory celiac disease is to blame.
    During the study, two patients died from enteropathy-associated lymphoma and one from status epilepticus. Five patients were treated with mycophenolate and one in addition with rituximab and IV immunoglobulins. These patients showed improvement of ataxia and enteropathy, but continued to suffer the effects of myoclonus.
    These results indicate that myoclonus ataxia might be the most common neurological manifestation of refractory celiac disease.
    The clinical involvement, apart from ataxia, covers the whole clinical spectrum of cortical myoclonus.
    Source:
    Cerebellum & Ataxias 2014, 1:11. doi:10.1186/2053-8871-1-11

    Jefferson Adams
    Celiac.com 08/16/2016 - Celiac disease changes the composition and differentiation potential of the duodenal intraepithelial innate lymphocyte compartment, specifically, the composition and function of duodenal intraepithelial T cells.
    The intestinal tract is also home to four types of CD3-negative intraepithelial lymphocytes (IELs) with largely unknown function: CD56(-)CD127(-); CD56(-)CD127(+); CD56(+)CD127(-) and CD56(+)CD127(+).
    A team of researchers wanted to gain insight into the potential function of these innate IELs in health and disease. Specifically, they wanted to assess how the composition and differentiation potential of the duodenal intraepithelial innate lymphocyte compartment is altered in celiac disease.
    The research team included F Schmitz, Y Kooy-Winkelaar, AS Wiekmeijer, MH Brugman, ML Mearin, C Mulder, S Chuva de Sousa Lopes, CL Mummery, FJ Staal, J van Bergen, F Koning. They are variously affiliated with the Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands, the Department of Immunohematology and Blood Transfusion at Leiden University Medical Center in Leiden, The Netherlands, the Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands, the Department of Gastroenterology at the Free University Medical Center, Amsterdam, The Netherlands, and with the Department of Anatomy and Embryology at Leiden University Medical Center in Leiden, The Netherlands.
    For their study, the team measured the phenotypes, relative abundance and differentiation potential of these innate IEL subsets in duodenal biopsies from controls and patients with celiac disease or patients with refractory celiac disease type II (RCDII).
    Hierarchical clustering analysis of the expression of 15 natural killer and T cell surface markers showed that innate IELs differed markedly from innate peripheral blood lymphocytes and divided innate IEL subsets into two main branches: a CD127(-) branch expressing high levels of interleukin (IL) 2/15Rβ but no IL-21R, and a CD127(+) branch with the opposite phenotype. While celiac disease was characterized by the contraction of all four innate IEL subsets, a selective expansion of CD56(-)CD127(-) and CD56(-)CD127(+) innate IEL was detected in RCDII.
    In vitro, in the presence of IL-15, CD56(-)CD127(-) IEL from controls and patients with celiac disease differentiated into functional natural killer and T cells, the latter largely dependent on notch-signaling. This did not occur in patients with RCDII. Furthermore, compared with non-celiac controls, CD56(-)CD127(-) IEL from patients with celiac disease expressed more intracellular CD3ε and CD3γ and gave more pronounced T cell differentiation.
    RCDII changes the normally diverse and plastic innate IEL compartment, and encourages a loss of differentiation potential.
    Source:
    Gut. 2016 Aug;65(8):1269-78. doi: 10.1136/gutjnl-2014-308153.

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