title: Celiac disease in India: are they true cases of celiac disease?
abstract: BACKGROUND
  In a developing country, many conditions other then celiac disease (CD) can give rise to villous atrophy. We therefore assessed the role of immunoglobulin A (IgA)-antigliadin antibody (AGA) in addition to the ESPGHAN criteria in the diagnosis of CD in 104 Indian children.
  
  
  METHODS
  Consecutive children with suspected CD were evaluated over 3 years with an intention to diagnose CD. Complete hemogram, d-xylose absorption test, endoscopic duodenal biopsy, and IgA-AGA titers were performed in all. CD was diagnosed on the basis of modified ESPGHAN criteria irrespective of IgA-AGA positivity (>5 U/mL), and those diagnosed were put on gluten-free diet and were monitored regularly. Children with suspected CD who had a normal duodenal biopsy result were taken as controls.
  
  
  RESULTS
  The mean age of 50 children with CD was 6.3 +/- 2.6 years, with a male to female ratio of 3:2. The mean duration of symptoms was 3.4 +/- 2.2 years. Predominant symptoms were pallor in 96%, failure to thrive in 92%, and diarrhea in 80%. On follow-up (19.6 +/- 8 months), symptoms subsided within 16 +/- 9.8 days, and patients showed significant weight gain (mean weight at diagnoses and at last follow-up visit were 66% and 86% of expected, respectively; P < 0.001) and height gain (mean height at diagnoses and at last follow-up visit were 88% and 94% of expected, respectively; P = nonsignificant). The control group comprised 47 children with a mean age of 6.9 +/- 3 years. On comparing CD with controls, diarrhea, anemia, low weight, and stunting were significantly (P < 0.001) more frequent in patients with CD. Sensitivity and specificity of AGA at a cutoff value of 5 U/mL were 94% and 91.5% and at 10 U/mL 88% and 100%, respectively. Follow-up AGA test was performed in 42 of 47 positive cases. All showed significant decrease in AGA titer, and 29 (70%) had a negative test result.
  
  
  CONCLUSIONS
  Indian children with CD are true cases of CD. They present late, diarrhea is absent in 20% of cases, and AGA test results show 88% of children without false-positive results at a cutoff value of 10 U/mL. However, AGA test with 94% sensitivity at a cutoff value of 5 U/mL can be used as screening test to select suspected cases for further workup.
authors.affiliation: Division of Pediatric Gastroenterology, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. ujjalpoddar@hotmail.com
authors.forename: Ujjal
authors.initials: U
authors.lastname: Poddar
authors.forename: Babu Ram
authors.initials: BR
authors.lastname: Thapa
authors.forename: Chander Kanwal
authors.initials: CK
authors.lastname: Nain
authors.forename: Arun
authors.initials: A
authors.lastname: Prasad
authors.forename: Kartar
authors.initials: K
authors.lastname: Singh
mesh_terms: D001323:Autoantibodies / Q000097:blood*; D015415:Biomarkers / Q000097:blood; D016022:Case-Control Studies; D002446:Celiac Disease / Q000175:diagnosis* / Q000453:epidemiology / Q000276:immunology / Q000473:pathology; D002648:Child; D002675:Child, Preschool; D003937:Diagnosis, Differential; D005183:Failure to Thrive; D005189:False Positive Reactions; D005260:Female; D005903:Gliadin / Q000276:immunology*; D005983:Glutens / Q000008:administration & dosage; D006801:Humans; D007070:Immunoglobulin A / Q000097:blood*; D007194:India / Q000453:epidemiology; D008137:Longitudinal Studies; D008297:Male; D011446:Prospective Studies; D012016:Reference Values; D012680:Sensitivity and Specificity
chemical_list: D001323:Autoantibodies; D015415:Biomarkers; D007070:Immunoglobulin A; D005983:Glutens; D005903:Gliadin