Celiac disease associated with autoimmune myocarditis.
BACKGROUND
Both celiac disease (CD) and myocarditis can be associated with systemic autoimmune disorders; however, the coexistence of the 2 entities has never been investigated, although its identification may have a clinical impact.


RESULTS
We screened the serum of 187 consecutive patients with myocarditis (118 males and 69 females, mean age 41.7+/-14.3 years) for the presence of cardiac autoantibodies, anti-tissue transglutaminase (IgA-tTG), and anti-endomysial antibodies (AEAs). IgA-tTG-positive and AEA-positive patients underwent duodenal endoscopy and biopsy and HLA analysis. Thirteen of the 187 patients were positive for IgA-tTG, and 9 (4.4%) of them were positive for AEA. These 9 patients had iron-deficient anemia and exhibited duodenal endoscopic and histological evidence of CD. CD was observed in 1 (0.3%) of 306 normal controls (P<0.003). In CD patients, myocarditis was associated with heart failure in 5 patients and with ventricular arrhythmias (Lown class III-IVa) in 4 patients. From histological examination, a lymphocytic infiltrate was determined to be present in 8 patients, and giant cell myocarditis was found in 1 patient; circulating cardiac autoantibodies were positive and myocardial viral genomes were negative in all patients. HLA of the patients with CD and myocarditis was DQ2-DR3 in 8 patients and DQ2-DR5(11)/DR7 in 1 patient. The 5 patients with myocarditis and heart failure received immunosuppression and a gluten-free diet, which elicited recovery of cardiac volumes and function. The 4 patients with arrhythmia, after being put on a gluten-free diet alone, showed improvement in the arrhythmia (Lown class I).


CONCLUSIONS
A common autoimmune process toward antigenic components of the myocardium and small bowel can be found in >4% of the patients with myocarditis. In these patients, immunosuppression and a gluten-free diet can be effective therapeutic options.
Frustaci
Andrea
A
Department of Cardiology, Catholic University, Rome, Italy. biocard@rm.unicatt.it
Cuoco
Lucio
L
Chimenti
Cristina
C
Pieroni
Maurizio
M
Fioravanti
Giuseppina
G
Gentiloni
Nicola
N
Maseri
Attilio
A
Gasbarrini
Giovanni
G
D000293:Adolescent; D000328:Adult; D001145:Arrhythmias, Cardiac / Q000175:diagnosis / Q000453:epidemiology / Q000276:immunology / Q000628:therapy; D001323:Autoantibodies / Q000097:blood; D001327:Autoimmune Diseases / Q000175:diagnosis / Q000453:epidemiology* / Q000276:immunology / Q000628:therapy; D002446:Celiac Disease / Q000175:diagnosis / Q000453:epidemiology* / Q000276:immunology / Q000628:therapy; D015897:Comorbidity; D004035:Diet Therapy; D004384:Duodenoscopy; D004386:Duodenum / Q000276:immunology / Q000473:pathology; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D019204:GTP-Binding Proteins / Q000276:immunology; D006334:Heart Function Tests; D006650:Histocompatibility Testing; D006801:Humans; D007070:Immunoglobulin A / Q000097:blood; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007558:Italy / Q000453:epidemiology; D008297:Male; D009205:Myocarditis / Q000175:diagnosis / Q000453:epidemiology* / Q000276:immunology / Q000628:therapy; D009206:Myocardium / Q000276:immunology / Q000473:pathology; D015995:Prevalence; D000091345:Protein Glutamine gamma Glutamyltransferase 2; D016036:Seroepidemiologic Studies; D011503:Transglutaminases / Q000276:immunology; D044465:White People
D001323:Autoantibodies; D007070:Immunoglobulin A; D007166:Immunosuppressive Agents; D000091345:Protein Glutamine gamma Glutamyltransferase 2; D011503:Transglutaminases; D019204:GTP-Binding Proteins