Monkey Esophagus Research Articles

Pemphigus vulgaris presenting in a radiation portal

We report a case of mucocutaneous pemphigus vulgaris in a patient with squamous cell carcinoma of the lung. The cutaneous involvement was limited to the skin within his therapeutic radiation portal. The diagnosis of pemphigus vulgaris was confirmed by histopathology and immunologic studies. Direct immunofluorescence demonstrated IgG and C3 in the intercellular spaces and indirect immunofluorescence was positive on monkey esophagus at a titer of 1:160. Enzyme-linked immunosorbent assay of the patient's serum detected autoantibodies only to desmoglein (Dsg)3, with no reactivity to Dsg1. Immunomapping of perilesional skin from the irradiated field illustrated decreased Dsg1 expression compared with a control sample from an area that was not exposed to radiation. This case provides support for the Dsg compensation hypothesis and may also suggest a mechanism by which irradiation may induce skin lesions.

Prevalence of stratified epithelium-specific antinuclear antibodies in 138 patients with lichen planus

Antibodies to stratified epithelia characterize chronic ulcerative stomatitis, an entity that very closely resembles erosive lichen planus both clinically and histologically. These antibodies are directed against a 70-kd antigen. Our aim was to verify whether antibodies to stratified epithelia are present in patients with common lichen planus. One hundred thirty-eight patients with various forms of lichen planus were studied. Indirect immunofluorescence was performed on both monkey esophagus and HEp2-2000 cells. Immunoblotting was done with cultured keratinocytes used as the source antigen. Nineteen patients had antibodies to stratified epithelia (in 9 directed against an antigen of 70 kd). Forty-eight patients had circulating antibodies detected by indirect immunofluorescence on both monkey esophagus and HEp2-2000 cells (in 7 directed against an antigen of 70 kd). Indirect immunofluorescence was positive only on HEp2-2000 cells in 21 patients. Indirect immunofluorescence was negative in 50 patients on both HEp2-2000 cells and monkey esophagus. None of the last 71 patients had antibodies directed to an antigen of 70 kd. This is a serological study; results from direct immunofluorescence studies would be interesting. Antibodies to stratified epithelia directed to an antigen of 70 kd are not exclusive to chronic ulcerative stomatitis, but are also present in some patients with lichen planus.

Prevalence of IgA-antiendomysial antibody in a patient cohort with idiopathic low bone mineral density

To investigate the frequency of serum IgA-antiendomysial antibody positivity in patients with low bone mineral density and to assess the risk group for screening of celiac disease. One hundred and thirty-five patients (14 male, 121 female) with idiopathic low bone mineral density were evaluated. The median age was 57.2 years (24-81). Antiendomysial antibody was determined by the immunofluorescence method using a commercial kit (INOVA Diagnostics Inc., CA, USA), which employs a 5 microm thin cryostat section of monkey esophagus as a substrate. Of the 135 patients evaluated, 13 were found to have positive IgA antiendomysial antibody test (9.6%) response. None of the patients had IgA deficiency. Endoscopic appearance and histological examination were normal in all of these patients. Seropositive patients had significantly lower age (48.9 +/- 4.3 vs 59.2 +/- 6.2, P < 0.05), higher ratio of male gender (61.5% vs 4.9%, P < 0.01) and pre-menopausal status (8.7% vs 1.3%, P < 0.01). Lumbar spine and femoral neck z-scores, but not t-scores were significantly lower in seropositive patients. Seropositive patients had lower serum 25 (OH) vitamin D, calcium and higher serum parathormone levels than seronegative patients. The screening of celiac disease in idiopathic osteoporosis should be restricted to patients without classical risk factors (younger, pre-menopausal, male gender) for osteoporosis. Bone mineral density measurements using z-scores should be considered for identifying risk groups for celiac disease.

Antigen Specificity in Subsets of Mucous Membrane Pemphigoid

Mucous membrane pemphigoid (MMP) has several subsets based on target antigens recognized by their sera. MMP and ocular cicatricial pemphigoid (OCP) sera recognize beta4 integrin subunit, oral pemphigoid sera recognize alpha6 integrin subunit, and anti-epiligrin cicatricial pemphigoid sera recognize laminin 5. Our aim is to determine if autoantibodies in the sera of patients with MMP, OCP, and oral pemphigoid (OP) recognize only their target antigens, and to see if this specificity is maintained throughout the clinical course. An immunoblot assay using bovine gingival lysate was used as substrate. Fifteen MMP patients, eight with OCP, and 15 OP patients were studied before therapy and at multiple intervals during the clinical course. Absorption and blocking studies were performed to determine binding specificity. Sera of patients with MMP and OCP recognize only beta4 integrin subunit, and sera of OP patients recognize alpha6 integrin throughout the clinical course. The sera of patients in the subsets of MMP described in this report show adherence and selectivity to target antigen during the entire clinical course, without crossover, interaction, or change. Hence, these subsets of MMP provide an excellent model to study clinical correlation with antigen and antibody specificity, in autoimmunity.

A complicated blistering disease case demonstrating the usefulness of immunoblotting and ELISA for the diagnosis of immunobullous diseases

A 51 year old female was referred for evaluation of a transient pruritic blistering eruption located on the trunk and extremities. She had a complicated medical background including rheumatoid arthritis and drug‐induced lupus erythematosus from the TNF blocker adalimubab. Her medications included prednisone 4 mg/day and hydroxychloroquine 400 mg/day. On examination a few large tense blisters were noted and the Nikolsky sign was negative.A routine skin biopsy showed intraepidermal vesicles, eosinophilic spongiosis and significant subepidermal oedema, but no acantholysis. Direct immunofluorescence (DIF) showed IgG depositions in an intercellular pattern in the upper epidermis, and IgM depositions in a granular pattern at the dermo‐epidermal junction. Indirect immunofluorescence on monkey oesophagus and rat bladder was negative, whereas salt‐split skin showed positive staining for IgG in the roof of the blister.As it was difficult to establish a unifying diagnosis given these clinical and histopathological features, the auto‐antigenic targets were studied by ELISA and immunoblotting techniques. ELISA showed IgG reactivity to the 165 kd desmoglein 1 antigen, but not to desmoglein 3. Immunoblotting to basement membrane components was negative. These results supported a unifying final diagnosis of pemphigus foliaceus. She has been treated with minomycin and topical corticosteroids and has had a benign course.This case demonstrates the concurrence of multiple serious autoimmune diseases, which represent an ongoing diagnostic and management challenge. Although the molecular pathogenesis of autoimmune blistering diseases is well understood, clinico‐pathological correlation may not always be achieved with routine dermatohistopathology and immunofluorescence examination. This case demonstrates the utility of additional molecular techniques in differentiating blistering diseases, which has important implications for management and prognosis.

Bullous pemphigoid in a patient with psoriasis during the course of PUVA therapy: study by ELISA test

A 65-year-old woman had a history of deep vein thrombosis and depression. Psoriasis was diagnosed in 1986 and various topical and systemic therapies, singly or in combination, were prescribed: tar, topical corticosteroids, cyclosporine, etretinate, and methotrexate. Two courses of oral and one course of bath psoralen plus UVA (PUVA) therapy (cumulative dose, 467 J/cm(2)) and UVB (2.96 J/cm(2)) had been given. In January 1999, she developed a flare of generalized psoriasis. In May 1999, therapy with PUVA (8-methoxypsoralen) plus topical acetonide triamcinolone 0.1% was initiated. At the time, she was taking acenocoumarol, lorazepam, and hydroxyzine chlorhydrate. In August 1999, at session 30, when the dose of UVA was 9 J/cm(2), and the total dose was 205 J/cm(2), a bulla appeared on the dorsum of the toe and was controlled with topical antibiotics. Five further sessions of PUVA were given and a generalized itching bullous eruption appeared all over the body. PUVA was stopped and the patient was hospitalized. On physical examination, extensive psoriatic plaques plus vesicles and bullae on the normal skin and on psoriatic lesions were observed all over the body (Fig. 1). Histopathologic study of a lesion showed a subepidermal vesicle containing fibrin, neutrophils, and a few eosinophils. No sunburn cells were observed (Fig. 2). The direct immunofluorescence (DIF) test of perilesional uninvolved skin revealed immunoglobulin G (IgG) (Fig. 3) and C3 at the dermal-epidermal junction. The DIF study using the patient's skin, previously treated with 1 m NaCl, localized the IgG at both the epidermal and dermal sides of the basement membrane zone (Fig. 4). Bullous pemphigoid (BP) was diagnosed and therapy with prednisone (60 mg/day) was started. The disease was well controlled in 3 weeks. The dose of prednisone was tapered and stopped 20 months later, without any recurrence. Study of the antibodies by the indirect immunofluorescence (IIF) test, using monkey esophagus and guinea pig as substrate, was positive at a titer of 1/160 in September 1999. The titer decreased to 1/10 in January 2000, and was negative in July 2000. An enzyme-linked immunosorbent assay (ELISA) test, performed using the commercial kit MBL, which identifies antibodies directed against epitopes of the extracellular fragment NC16 of antigen 2 of BP, was positive at 15 U/mL (normal value, < 9 U/mL) in September 1999, and negative in July 2000 (Table 1).

Paraneoplastic pemphigus resembling linear IgA bullous dermatosis

A 69-year-old Chinese man presented in 2001 with a blistering eruption over the upper and lower limbs associated with oral ulceration for 1 month. He had stage IIIA follicular small cell cleaved non-Hodgkin's lymphoma diagnosed 5 years previously, and had received several lines of palliative chemotherapy, including two courses of chlorambucil, six cycles of cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP), and two four-cycle courses of rituximab, with disease stabilization at the time of presentation. Examination revealed erythematous, annular plaques with raised, urticarial borders studded with tense bullae and vesicles over the thighs. Some lesions were arciform and annular, with vesicles arranged in a ring at the border (Fig. 1). There was involvement of the feet with desquamation at the tips of the toes (Fig. 2). Severe erosions with hemorrhagic crusts on the lips, tongue, and buccal mucosa were seen. Herpes simplex virus serology was negative. A biopsy specimen from a vesicle on the left thigh showed suprabasal acantholysis (Fig. 3), some apoptotic keratinocytes (Fig. 4), satellite cell necrosis in the epidermis, and a superficial perivascular infiltrate of lymphocytes and eosinophils. Direct immunofluorescence showed intercellular immunoglobulin G (IgG) and C3 within the epidermis and along the basement membrane zone. Indirect immunofluorescence on monkey esophagus was positive for anti-intercellular antibody at a titre of 1/160 and positive on rat bladder at a titre of 1/80. A presumptive diagnosis of paraneoplastic pemphigus was made. This was later confirmed by the presence of antibodies against envoplakin (210 kDa), periplakin (190 kDa), and desmoglein 1 on immunoprecipitation studies. He was started on prednisolone 60 mg/day (1 mg/kg/day), with complete resolution of skin lesions within 1 week, but persistence of oral ulcers. Cyclophosphamide was added at a low dose of 1 mg/kg/day as he had baseline leukopenia. Cyclosporine was later added to a maximum of 4 mg/kg/day with only mild improvement of the oral lesions. He declined rituximab therapy. He died 2 months later from fulminant pneumonia.

Thymoma, myasthenia gravis, eruptions of pemphigus vulgaris and a favourable course of relapsing melanoma: an immunological puzzle

Conflicts of interest: none declared. Sir, The paraneoplastic appearance of pemphigus vegetans, pemphigus vulgaris (PV), pemphigus foliaceus and pemphigus erythematosus with thymoma and/or myasthenia gravis is well documented.1, 2 However, cases of pemphigus associated with malignant melanoma (MM) are very unusual. We report a woman with a history of thymoma/myasthenia gravis who had recurring episodes of PV triggered by local relapses of the MM with an otherwise remarkably favourable course. A 57‐year‐old white woman was referred to our outpatient clinic for excision of an acral lentiginous MM on the sole of the left foot with a 2‐cm safety margin (Clark level IV, Breslow thickness 1·2 mm, pT2). The excision site was grafted and further staging was performed (N0, M0). Apart from this, physical examination revealed areas of figurate erythema resembling ‘timber grain’ on the trunk and blisters in the centre of those areas. Oral manifestations were not found. There was no history of medical problems or drugs which may have caused a bullous drug reaction. Histology of a corresponding skin specimen revealed intraepithelial blistering with acantholysis and focal eosinophilic spongiosis. The upper dermis was infiltrated by lymphocytes and eosinophils. Direct immunofluorescence revealed intercellular deposition of IgG; indirect immunofluorescence was positive for pemphigus antibodies on monkey oesophagus, but negative on rat bladder. Immunoblotting did not show the specific autoantibody spectrum of paraneoplastic pemphigus such as antibodies to desmoplakin 1 (250 kDa), bullous pemphigoid antigen 1 (230 kDa), envoplakin and desmoplakin 2 (210 kDa) and periplakin (190 kDa).2 Instead, autoantibodies against desmoglein 1 and 3 were detected, indicating PV. In addition, due to muscle weakness and a high titre of antiacetylcholine receptor (AChR) antibodies thoracic computed tomographic (CT) scans were performed and a mediastinal tumour bioptically classified as benign mixed‐type thymoma was diagnosed.

Prevalence of celiac disease in Tunisian blood donors

Prevalence of adult celiac disease is unknown in Tunisia. Symptomatic forms are less frequent than silent forms, which, according to recent serological screening in Europe and the United States, have an estimated prevalence of 1/100 to 1/500. We aimed to determine the prevalence of celiac disease in healthy blood donors in Tunisia. Between November 2002 and March 2004, 1 418 sera from blood donors were tested for IgA anti-endomysium antibodies (EMA) by indirect immuno-fluorescence on monkey esophagus cryosections. The sample population included 1090 men and 328 women: mean age 29 and 26 years respectively. Three sera from two men and one woman were positive for IgA EMA. ELISA search for anti-tissue tranglutaminase antibodies (ATG) in these three sera was positive in two. Upper gastrointestinal endoscopy with proximal intestinal biopsies was performed in the three patients. Subtotal or total villous atrophy was observed in the two ATG-positive patients, confirming the diagnosis of celiac disease. In the third patient, histologic examination did not show any abnormality. Adult celiac disease is considered relatively rare in Tunisia. In fact, our study revealed a prevalence of about 1/700 among blood donors.

Autoimmune bullous disorders

Bullous skin diseases represent a group of organ-specific autoimmune disorders characterised by binding of circulating autoantibodies to adhesion molecules of the epidermis and the dermo-epidermal basement membrane zone. Binding of these autoantibodies to their antigenic targets results in loss of adhesion between epidermal keratinocytes and at the level of the basement membrane zone. Chronic blisters and secondary painful erosions are the clinical hallmark of autoimmune bullous disorders. Histopathology reveals the location of blister formation and helps to classify the subtype of the bullous skin disorder. Immunofluorescence is crucial for diagnosing autoimmune bullous skin disorders. Tissue-bound autoantibodies are detected by direct immunofluorescence of perilesional skin. Circulating autoantibodies can be visualised by indirect immunofluorescence using tissue substrates such as monkey oesophagus and sodium chloride-split human skin. Most of the autoantigens are available as recombinant proteins, which allows for autoantibody screening by ELISA or immunoblot analysis to confirm the primary diagnosis and, importantly, for immunoserological follow-up of patients.

Establishment of the Mouse Model by Rabbit Antiserum Specific to EC1-2 or EC3-4 Epitopes for Studying the Pathogenesis of Pemphigus Vulgaris

The research goal was to establish the neonatal mouse model by specific rabbit anti EC1-2 or EC3-4 antiserum for the purpose of studying pemphigus vulgaris (PV) pathogenesis. RNA was extracted from human keratinocytes. The cDNAs was synthesized by reverse transcription. Amplified EC1-2 or EC3-4 genes were inserted into pGEX-4T expression plasmids to constitute the recombinant plasmids, and transformed into E.coli. for the expression of the fusion proteins. The purified fusion proteins were used to immunize New Zealand white rabbits to obtain the specific anti EC1-2 or EC3-4 antisera. IgG fractions from the antisera were purified and passively transferred intradermally into the upper back skin of neonatal BALB/c mice. Histologic, ultrastructural, and immunofluorescence features of PV were evaluated in these mice. PV features were shown in the mice injected with anti EC1-2 antibody, erythema on the flanks and positive Nikolsky sign. The histology showed intraepidermal vesicle formation and acantholytic cells within. Acantholysis, but no clinical symptoms, was seen in the mice treated with the antibody specific to EC3-4. Additionally, skin sections from the abdomen from these neonatal mice were cryo-sectioned for direct-immunofluorescence. FITC-conjugated IgG antibody deposit between the keratinocytes throughout the epidermis. The indirect immunofluorescence with monkey esophagus showed the presence of anti-intracellular antibody with a titer of 1:40. On electronic microscopy, intercellular spaces (ICS) were widened and the desmosomes were split or dissolved. A novel PV mouse model was established by treatment with the specific rabbit antiserum. These data confirmed that both EC1-2 and EC3-4 are pathogenic epitopes in PVA, but EC1-2 is more dominant.

Celiac disease in South-West of Iran

Celiac disease is characterized by life-long gluten intolerance. Clinical features of patients with celiac disease are variable. Studies about the prevalence of celiac disease in our country are scarce and there is no study on the prevalence of celiac disease in southern Iran. In the current study, clinical, laboratory and histo-logical features of 52 patients with celiac disease were evaluated. In a cross sectional study we retrospectively studied the characteristics of 52 celiac patients at Ahwaz JundiShapour University Hospitals (AJSUH) from November 1, 1999 to 1st Sep 2004. Intestinal biopsy and serum antigliadin and anti-endomysium antibodies were used for the diagnosis of patients. Mucosal lesions were classified according to the criteria of Marsh. Antigliadin antibodies were measured with a commercial enzyme-linked immunosorbent assay. Anti-endomysium antibodies were analyzed by indirect immunofluorescence with the use of a section of monkey esophagus. Routine hematological and biochemical analyses and measurement of immunoglobulin levels were undertaken. Male: female ratio was 1.08. The mean +/- SD patient age was 21 +/- 4.5 years (range 10-70 years) and the most common symptoms were diarrhea and weight loss (78.8%) followed by fatigue (73.1%), pallor (65.4%), anorexia (40.4%), abdominal distention (32.7%), and failure to thrive (23.1%). Diarrhea and weight loss and fatigue were the most common findings. Iron deficiency anemia was found in 63.2% of patients and this became normal after adoption of a gluten-free diet in all patients. Immunoglobulin A, IgG antigliadin antibodies and IgA anti-endomysium antibodies were found in 33 and 48 cases, 78.8% and 85.4% of patients, respectively. Biopsy of the small intestine revealed that 90.4% of patients had typical lesions according to the Marsh classification. Although classical presentation was seen in most of the patients, atypical clinical manifestations of celiac disease should be kept in mind. In particular, patients with uncommon findings, such as short stature, and iron-deficiency anemia, should be screened for celiac disease. Further epidemiological studies in our area in the general population and in high risk groups seem to be indicated.

Antibodies to recombinant human tissue-transglutaminase in coeliac disease: Diagnostic effectiveness and decline pattern after gluten-free diet

Background/aims To assess the sensitivity and specificity of IgA and IgG tissue-transglutaminase antibodies assay, the pattern of antibody decline after gluten withdrawal and their modifications with reference to dietary compliance. Subjects We studied sera from 143 untreated coeliac children and adolescents (8.8 ± 6.1 years), 212 sera from 97 of those patients after gluten withdrawal, and 64 control subjects with non-coeliac intestinal disorders (6.8 ± 4.8 years). Methods Samples were tested for IgA and IgG class tissue-transglutaminase antibodies by radiobinding assay, using human-derived tissue-transglutaminase, and for IgA anti-endomysium antibodies by indirect immunofluorescence on monkey oesophagus. Results Untreated coeliac patients had significantly higher titres of IgA and IgG tissue-transglutaminase antibodies than controls ( p < 0.00001); the diagnostic sensitivity was 95.8% and 99.3%, respectively, and the specificity was 95.3%. Three patients with selective IgA deficiency were positive for IgG tissue-transglutaminase antibodies. The concordance rate between IgA tissue-transglutaminase antibodies and anti-endomysium antibodies was 98.1%. Patients on gluten-free diet showed a significant decrease in IgA and IgG tissue-transglutaminase antibodies with respect to untreated patients ( p < 0.0001). Tissue-transglutaminase was more sensible than anti-endomysium antibodies to detect small amounts of gluten intake when the compliance was poor. Conclusions The recombinant human tissue-transglutaminase antibodies assay is a highly sensitive and specific test for diagnosis of coeliac disease, and it is useful in monitoring the compliance to gluten-free diet.

Comparison of desmoglein ELISA and indirect immunofluorescence using two substrates (monkey oesophagus and normal human skin) in the diagnosis of pemphigus

A prospective study was performed to assess the usefulness of desmoglein enzyme-linked immunosorbent assay testing compared with indirect immunofluorescence in the diagnosis of new cases of pemphigus, as well as to compare the relative sensitivities of monkey oesophagus and normal human skin as substrates for indirect immunofluorescence. These tests were performed on the sera of 29 consecutive new cases of pemphigus diagnosed over a 2-year period based on clinical, histological and direct immunofluorescence findings. Desmoglein enzyme-linked immunosorbent assay was positive in all patients whereas indirect immunofluorescence was positive in only 25 of 29 patients. All four patients with negative indirect immunofluorescence had positive antinuclear antibodies or cytoplasmic fluorescence that could have masked the anti-intercellular antibodies. Desmoglein enzyme-linked immunosorbent assay appeared to reflect the disease activity better than indirect immunofluorescence in a few patients who had active disease of recent onset. Monkey oesophagus was found to be superior or equal to human skin as a substrate for indirect immunofluorescence in both pemphigus vulgaris and foliaceus.

Number II Pemphigus vulgaris

Pemphigus is a group of potentially life-threatening autoimmune diseases characterized by cutaneous and/or mucosal blistering. Pemphigus vulgaris (PV), the most common variant, is characterized by circulating IgG antibodies directed against desmoglein 3 (Dsg3), with about half the patients also having Dsg1 autoantibodies. There is a fairly strong genetic background to pemphigus with linkage to HLA class II alleles and ethnic groups such as Ashkenazi Jews and those of Mediterranean and Indian origin, are especially liable. Oral lesions are initially vesiculobullous but readily rupture, new bullae developing as the older ones rupture and ulcerate. Biopsy of perilesional tissue, with histological and immunostaining examination are essential to the diagnosis. Serum autoantibodies to either Dsg1 or Dsg3 are best detected using both normal human skin and monkey oesophagus or by enzyme-linked immunosorbent assay. Before the introduction of corticosteroids, PV was typically fatal mainly from dehydration or secondary systemic infections. Current treatment is largely based on systemic immunosuppression using corticosteroids, with azathioprine or other adjuvants or alternatives but newer therapies with potentially fewer adverse effects, also appear promising.

The diagnostic accuracy of serologic tests for celiac disease: A systematic review

Clinicians are increasingly utilizing noninvasive serologic tests for the diagnosis and screening of celiac disease (CD). The aim of this study was to conduct a systematic review of the diagnostic performance of serologic tests for the diagnosis and screening of CD. Standard systematic review methodology was used. A literature search was conducted in MEDLINE (1966 to October 2003) and EMBASE (1974 to December 2003) databases. A weighted mean of the sensitivity and specificity along with 95% confidence intervals and summary receiver operating characteristic (ROC) curves were calculated. The pooled specificity of endomyseal antibody (EMA)-monkey esophagus (ME) or EMA-human umbilical cord (HU) was close to 100% in adults and children. The pooled specificity of transglutaminase antibody (tTG)-guinea pig (GP) and tTG-human recombinant (HR) were between 95% and 99%. IgA-EMA-ME demonstrated sensitivities of 96% and 97% in children and adults, respectively. EMA-HU demonstrated a similar sensitivity of 97% in children but 90% in adults. The pooled sensitivity of tTG-GP in adults and children was 90% and 93%, respectively. The sensitivity of tTG-HR was 98% and 96%, respectively. The performance of antigliadin antibody was inferior to that of EMA and tTG. EMA and tTG offer high sensitivity and specificity. The sensitivity of these tests appears to be lower than reported when milder histologic grades are used to define CD (below 90%). If true, the nearly perfect negative predictive value of these tests would drop. The positive predictive value of these tests is likely lower than reported when the tests are applied in low-prevalence populations.

A comparison of anti‐desmoglein antibodies and indirect immunofluorescence in the serodiagnosis of pemphigus vulgaris

Indirect immunofluorescence (IIF) is the standard method for the detection of pemphigus autoantibodies. Commercially available enzyme-linked immunosorbent assays (ELISAs) have recently become available to measure serum antibodies (Abs) against desmoglein1 (Dsg1) and desmoglein3 (Dsg3). It has been suggested that patients with mucosal-dominant pemphigus vulgaris (PV) have serum Abs against Dsg3 only, patients with mucocutaneous PV have Abs to both Dsg1 and Dsg3, and patients with pemphigus foliaceus (PF) have Abs against Dsg1 only. To compare the sensitivity and specificity of the IIF and ELISA tests in the diagnosis of pemphigus and its subsets. Thirty-three patients with PV and five patients with PF were studied, and compared with 50 healthy individuals or patients with unrelated skin diseases. Monkey esophagus was used as a substrate for the IIF test. The IIF and ELISA tests were each positive in 26 of the 32 (81%) PV patients, and in none (0%) and 3 (6%) of the 50 controls, respectively. Both the IIF and ELISA results were concordant in 69% of the PV patients, and only one of these two tests was positive in the remaining 31% of patients. Forty-six per cent of the PV patients with a positive ELISA test did not have the PV phenotype (mucosal or mucocutaneous) predicted by their autoantibody profile. The IIF and ELISA tests may be used as complementary tests for the serologic diagnosis of pemphigus.

P0391 DIET COMPLIANCE EVALUATION OF COELIAC PATIENTS IN POINT-OF-CARE FASHION

Introduction: Circulating IgA antibodies against endomysium (EMA) and transglutaminase 2 (TG2) are activity markers of coeliac disease and their regular measurement is important in the diet surveillance and consueling of treated coeliac patients. In this study we investigated whether significant dietary transgressions could be detected onsite in the outpatient department and whether the prompt availability of results would promote the improvement of the compliance. Methods: 257 patients (aged 2.2–76 years, median 13) with previously diagnosed coeliac disease and on diet for 1 month-12 years were evaluated in a point-of-care fashion in two paediatric gastroenterology departments in connection with independently scheduled check-up visits that included laboratory measurements of serum EMA and anti-TG2 antibodies. Diet compliance was estimated by a questionnaire and an interview. Nine of the patients were IgA deficient. The point-of-care testing was performed from one drop of whole blood with a recently developed rapid stick test which utilises the patients’ own red blood cell TG2 for the detection of IgA class plasma antibodies against TG2 and does not require a purified TG2 antigen. The test also has a positive control line for plasma IgA detection to sort out IgA deficient samples. The rapid test has been previously validated in untreated patients undergoing jejunal biopsy where it showed 97.5% sensivity and 96% specificity. Serum EMA was assayed on monkey oesophagus in 1:2.5 dilutions and anti-TG2 by ELISA with human recombinant TG2. Results: The rapid test was positive in 53 (20.6%), EMA in 52 (20.3%) and TG2-ELISA in 45 (17.5%) of the patients. Agreement in all three tests was seen in 90.6% of samples. The rapid test results were in agreement with EMA in 94.9 % and with TG2-ELISA results in 91.4% of the samples whereas EMA and TG2-ELISA results were congruent in 94.9% of samples. The rapid test correctly identified IgA deficient subjects. The antibody tests detected more dietary lapses than estimated by the clinical interview. Positive rapid test results were discussed with the patients. The rapid test was repeated after 2–6 months in 14 patients with positive results and it came out as negative in 12/14 after diet correction. Conclusion: The performance of the rapid test was as good as those of laboratory tests in detecting disease activity. Point-of-care coeliac antibody testing is a convenient, economical and easy tool in the care of coeliac patients which promotes diet compliance.

P0394 ROLE OF ANTI-TRANSGLUTAMINASE ANTIBODIES IN THE DIAGNOSIS OF CHILDREN COALIAC DISEASE: RESULTS OF A FIVE YEARS PROSPECTIVE STUDY

Introduction: The aim of this study is to evaluate the interest of IgA antibodies to tissue transglutaminase in the diagnosis of children celiac disease compared with anti-endomysium and anti-gliadin antibodies. Methods: Seventy one children with coeliac disease (mean age: 5 years and 8 months) and 101 disease controls (mean age: 4 years and 5 months). IgA anti-transglutaminase were tested by ELISA using a human recombinant tissue transglutaminase. IgA anti endomysium were detected by indirect immunofluorescence on monkey oesophagus. Results: The middle rate of IgA anti-transglutaminase was 101,06 AU in patients and only 0,47 AU in controls. IgA anti-transglutaminase and IgA anti-endomysium were in agreement in 98,8 % of cases; only 2 cases were discordant (+/− and −/+). Globally, the 2 markers had the same sensitivity (90,14 %), specificity (98,02 %), negative (93,39 %) and positive (96,97 %) predictive values. For anti-gliadin antibodies, the IgG were more sensitive (88,73 %) and the IgA more specific (93,39 %). Conclusion: IgA anti-tissue transglutaminase can be used instead of IgA anti-endomysium as a serological marker of screening and diagnosis of coeliac disease.

Patchy Villous Atrophy of the Duodenum in Childhood Celiac Disease

ABSTRACTObjectivesPatchy villous atrophy of the duodenal mucosa has been described in adults with untreated celiac disease (CD) but not in children. The authors evaluated the presence and the distribution of villous atrophy in children with celiac disease to see whether this histologic pattern exists in children.MethodsWe studied 95 children at diagnosis (Group 1) and seven during gluten challenge (Group 2). We measured anti‐endomysium antibodies (EMA) by immunofluorescence on monkey esophagus, antihuman‐tissue transglutaminase autoantibodies (anti‐tTG Abs) by radioimmunoprecipitation, and HLA‐DQ2/DQ8 heterodimers by polymerase chain reaction using specific primers. During upper intestinal endoscopy, at least five duodenal biopsy samples were obtained, one from the duodenal bulb and four from the distal duodenum.ResultsThirteen of 95 (13.7%) patients in Group 1 and in 3 of 7 (42.9%) in Group 2 had patchy villous atrophy of the duodenum. In all 16 patients, villous atrophy of the bulb was present. In four children from Group 1, villous atrophy was observed only in the bulb samples. EMA, anti‐tTG Abs, and HLA‐DQ2/DQ8 heterodimers were present in all patients. Fourteen of 16 had symptomatic CD, and two were silent, detected during screening in subjects at risk for CD.ConclusionsThis is the first study demonstrating that children with CD may have patchy villous atrophy of the duodenum. The bulb mucosa may be the only duodenal area involved, both at diagnosis and after gluten challenge. Therefore, multiple endoscopic biopsies should always be performed, not only in the distal duodenum, but also in the bulb.