Autoimmune gastritis presenting as iron deficiency anemia in childhood.
OBJECTIVE
To characterize clinical, laboratorial, and histological profile of pediatric autoimmune gastritis in the setting of unexplained iron deficiency anemia investigation.


METHODS
A descriptive, observational study including pediatric patients with a diagnosis of autoimmune gastritis (positive parietal cell antibody and gastric corpus atrophy) established in a 6 year period (2006-2011) in the setting of refractory iron deficiency anemia (refractoriness to oral iron therapy for at least 6 mo and requirement for intravenous iron therapy) investigation, after exclusion of other potentially contributing causes of anemia. Helicobacter pylori (H. pylori) infection and anti-secretory therapy were also excluded. Data were retrospectively collected from clinical files, including: demographic data (age, gender, and ethnic background), past medical history, gastrointestinal symptoms, familial history, laboratorial evaluation (Hb, serum ferritin, serum gastrin, pepsinogen I/ pepsinogen II, B12 vitamin, intrinsic factor autoantibodies, thyroid autoantibodies, and anti-transglutaminase antibodies), and endoscopic and histological findings (HE, Periodic Acid-Schiff/Alcian blue, gastrin, chromogranin A and immunochemistry analysis for CD3, CD20 and CD68). Descriptive statistical analysis was performed (mean, median, and standard deviation).


RESULTS
We report a case-series concerning 3 girls and 2 boys with a mean age of 13.6 ± 2.8 years (3 Caucasian and 2 African). One girl had type I diabetes. Familial history was positive in 4/5 cases, respectively for autoimmune thyroiditis (2/5), sarcoidosis (1/5) and multiple myeloma (1/5). Laboratorial evaluation on admission included: Hb: 9.5 ± 0.7 g/dL; serum ferritin: 4.0 ± 0.9 ng/mL; serum gastrin: 393 ± 286 pg/mL; low pepsinogen I/ pepsinogen II ratio in 1/5 patients; normal vitamin B12 levels (analyzed in 3 patients). Endoscopy findings included: duodenal nodularity (2/5) and gastric fold softening (2/5), and histological evaluation showed corpus atrophic gastritis with lymphocytic infiltration (5/5), patchy oxyntic gland mononuclear cell infiltration (5/5), intestinal and/or pseudo-pyloric metaplasia in corpus mucosa (4/5), and enterochromaffin cell hyperplasia (4/5). Immunochemistry for gastrin on corpus biopsies was negative in all cases. Duodenal histology was normal. All biopsies were negative for H. pylori (Giemsa staining and cultural examination).


CONCLUSIONS
We highlight autoimmune gastritis as a diagnosis to be considered when investigating refractory iron deficiency anemia in children, particularly in the setting of a personal/familial history of autoimmune disease, as well as the diagnostic contribution of a careful immunohistological evaluation.
Cristina Gonçalves, Ana Isabel Lopes, Gastroenterology Unit, Pediatric Department, University Hospital Santa Maria, Lisbon Academic Medical Centre, 1649-035 Lisboa, Portugal.
Cristina
C
Gonçalves
Cristina Gonçalves, Ana Isabel Lopes, Gastroenterology Unit, Pediatric Department, University Hospital Santa Maria, Lisbon Academic Medical Centre, 1649-035 Lisboa, Portugal.
Maria Emília
ME
Oliveira
Cristina Gonçalves, Ana Isabel Lopes, Gastroenterology Unit, Pediatric Department, University Hospital Santa Maria, Lisbon Academic Medical Centre, 1649-035 Lisboa, Portugal.
Ana M
AM
Palha
Cristina Gonçalves, Ana Isabel Lopes, Gastroenterology Unit, Pediatric Department, University Hospital Santa Maria, Lisbon Academic Medical Centre, 1649-035 Lisboa, Portugal.
Anabela
A
Ferrão
Cristina Gonçalves, Ana Isabel Lopes, Gastroenterology Unit, Pediatric Department, University Hospital Santa Maria, Lisbon Academic Medical Centre, 1649-035 Lisboa, Portugal.
Anabela
A
Morais
Cristina Gonçalves, Ana Isabel Lopes, Gastroenterology Unit, Pediatric Department, University Hospital Santa Maria, Lisbon Academic Medical Centre, 1649-035 Lisboa, Portugal.
Ana Isabel
AI
Lopes
D000293:Adolescent; D000367:Age Factors; D018798:Anemia, Iron-Deficiency / Q000097:blood / Q000175:diagnosis / Q000209:etiology*; D001327:Autoimmune Diseases / Q000097:blood / Q000150:complications* / Q000175:diagnosis / Q000276:immunology; D015415:Biomarkers / Q000097:blood; D001706:Biopsy; D002648:Child; D016099:Endoscopy, Gastrointestinal; D005260:Female; D005756:Gastritis / Q000097:blood / Q000150:complications* / Q000175:diagnosis / Q000276:immunology; D006801:Humans; D007150:Immunohistochemistry; D008297:Male; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D012698:Serologic Tests; D013270:Stomach / Q000737:chemistry / Q000276:immunology / Q000473:pathology
D015415:Biomarkers
Autoimmune gastritis; Children; Iron deficiency anemia