Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Two Exceptional Complications Revealing Celiac Disease: Ischemic Cardiomyopathy and Pellagra

Imed Ben Ghorbel, Raouf Hajji*, Nabil Bel Feki, Thouraya Ben Salem, Mounir Lamloum, Mohammed Habib Houman

Internal Medicine Department, Sidi Bouzid Regional Hospital, Sidi Bouzid, Tunisia

Abstract: Pellagra is an exceptional skin involvement in celiac disease. Ischemic cardiomyopathy is another rare event in celiac disease. Its pathogenesis remains not yet elucidated. We report a case of a 34- year old patient of presenting with pellagra and cardiomyopathy revealing a celiac disease.

Keywords: pellagra, ischemic heart disease, celiac disease

Received January 11, 2015; Revised January 15, 2015; Accepted January 17, 2015

Citation: Imed Ben Ghorbel, Raouf Hajji, Nabil Bel Feki, Thouraya Ben Salem, Mounir Lamloum, Mohammed Habib Houman, Two Exceptional Complications Revealing Celiac Disease: Ischemic Cardiomyopathy and Pellagra. International Journal of Celiac Disease, 3 (1). 31-32. January 2015. doi:10.12691/ijcd-3-1-5

1. Introduction

Pellagra (or “rough skin,” from the Italian pelle agra) is an exceptional skin involvement in celiac disease due to tryptophan and B3 vitamin (niacin) deficiency [1]. Ischemic cardiomyopathy is another rare event in celiac disease [2]. Its pathogenesis remains not yet elucidated. We report a case of a patient presenting with pellagra and cardiomyopathy revealing a celiac disease.

2. Case Report

A 34-year-old male patient was admitted in intensive care unit of cardiology in 2009 for acute chest pain. He was not smoker neither alcohol consumer. He had no family nor personal history of coronary artery disease. The myocardial infarction was diagnosed and coronary angiography concluded to severe stenosis of the anterior interventricular artery. It was rapidly complicated by severe heart failure. The heart ultrasound imaging has showed dilated cardiomyopathy with systolic ejection fraction at 25 %. The patient was treated by aspirin, ramipril, simvastatin, and nebivolol.

Three years later, he developed diffuse red skin lesions on the face and hands (Figure 1), beefy red glossitis and high skin sensitivity to sunlight. He reported also chronic diarrhea with 4 or more watery stools/ day for several months. He presented impaired general condition with moderate asthenia and weight loss. Physical examination showed mitral holosystolic murmur and lower limbs edema. Dermatologic examination revealed desquamation, erythema, and keratosis of sun-exposed areas especially on the face, hands and feet.

Figure 1. Lesions of pellagra: diffuse red skin lesions on the face and hands

The complete blood count, ferritin, calcemia, the serum protein electrophorosis and lipid profile were normal. The homocysteine rate was 23 μmol/l (Normal: 15 μmol/l).

Antiendomysial (EMA) antibodies were positive. Anti-tissue transglutaminase antibodies (TTGA) (Normal: 4 to 10 U/L) were positive with a rate at 17 U/L. Anti-nuclear antibodies and antiphospholipid antibodies were negative. Oesogastroduodenal fibroscopy showed flattened duodenal folds. The histology of duodenal biopsies had revealed a subtotal mucous atrophy type 3 b in Marsh modified (Oberhuber) histological classification of celiac disease: Increased intraepithelial lymphocytes, crypt hyperplasia and subtotal villous atrophy.

Although B3 vitamin and tryptophan dosage were not performed, the diagnosis of pellagra complicating celiac disease was retained. A gluten-free diet was introduced. The patient died of fatal cardiac failure one month after time of diagnosis: he had not followed this diet.

3. Discussion

Although pellagra used to be a disease of epidemic proportions in the developed world, it is now a rare condition confined to certain at-risk groups. Little progress has been made in our knowledge of pellagra since it was first described by Gaspar Casal in 1735 [3,4] and since Goldberger discovered that nicotinamide was a preventive factor in 1926 [5,6].

Proof of this is that there have been no changes in treatment or diagnostic criteria in the last 90 years.

Niacin (B 3 vitamin) forms into nicotinic acid and nicotinamide, which serve as precursors of two important coenzymes of cellular metabolism, namely nicotinamide adenine dinucleotide (NAD) and NAD-phosphate (NADPH). The deficiency of these two coenzymes is the basis of pellagra pathogenesis. In fact, NAD and NADPH participate in multiple mechanism in cell metabolism: the metabolism of amino acids and proteins (tryptophane and B3 vitamin (niacin) absoprtion), the generation of high-energy phosphate bonds and glycolysis [7,8].

Thus, because of their deficiency, pellagra is essentially affecting tissues with a high rate of cell turnover, such as the digestive tract and the skin, and tissues with high energy needs, such as the brain [9,10,11].

In our case, deficiency of NAD and NAD phosphate (tryptophan and B3 vitamin) was due to malabsorption in celiac disease as it was reported by Schattner in 1999 [1].

Ischemic cardiomyopathy in celiac disease could be due to hyperhomocysteinemia. Makhdoom et al recently described a patient with idiopathic dilated cardiomyopathy, celiac disease and anticardiolipin syndrome presenting a dramatic cardiac improvement [12].

In our case, antiphospholipid antibodies were negative.

In literature, there are few cases of myocarditis that can be reversible as in the case of Amira H et al or complicated by dilated cardiomyopathy without vascular involvement. The outcomes of the heart and the skin involvement of celiac disease depends much free-gluten diet adherence [13].

Our patient was marked by progressive worsening till to death because he didn’t follow the gluten-free diet.

4. Conclusion

This case illustrates two rare complications revealing celiac disease in an adult patient. Pellagra, a vitamin deficiency disease, is caused in this case by chronic malabsorption of B3 vitamin or tryptophan. Ischemic cardiomyopathy is probably due to an accelerated atherosclerosis in a persistent inflammatory disease.

References

[1]   | Schattner A. A 70-year-old man with isolated weight loss and a pellagra-like syndrome due to celiac disease. Yale J Biol Med. 1999; 72: 15-18.
[2]   | Emilsson L, Carlsson R, James S, Hambraeus K, Ludvigsson JF. Follow-up of ischaemic heart disease in patients with coeliac disease. Eur J Prev Cardiol. 2015; 22(1): 83-90.
[3]   | Major RH: Classic Descriptions of Disease. Springfield, Ill, Charles C. Thomas, 3rd Ed, 1945, pp 607-615.
[4]   | Major RH: Don Gasper Casal, Francois Thiery and pellagra. Bull Hist Med 1944; 16: 351-361.
[5]   | Goldberger J, Wheeler GA, Lillie RD, et al: A further study of butter, fresh beef, and yeast as pellagra preventives, with consideration of the relation of factor P-P of pellagra (and black tongue of dogs) to vitamin B. Public Health Rep 1926; 41:297-318
[6]   | Goldberger J: Pellagra. Essays on History of Nutrition and Dietetics. Chicago, American Dietetic Association, 1967, pp 103-106.
[7]   | Piqué-Duran E, Pérez-Cejudo JA, Cameselle D, Palacios-Llopis S, García-Vázquez O. Pellagra: a clinical, histopathological, and epidemiological study of 7 cases. Actas Dermosifiliogr. 2012; 103(1): 51-8.
[8]   | Wan P1, Moat S, Anstey A. Pellagra: a review with emphasis on photosensitivity. Br J Dermatol. 2011; 164(6): 1188-200.
[9]   | Hegyi J, Schwartz RA, Hegyi V. Pellagra: dermatitis, dementia and diarrhea. Int J Dermatol. 2004; 43:1-5.
[10]   | Pitche PT. Pellagre et érythèmes pellagroïdes. Cahiers Sánte. 2005; 15: 205-8.
[11]   | Nogueira A, Duarte AF, Magina S, Azevedo F. Pellagra associated with esophageal carcinoma and alcoholism. Dermatol Online J. 2009; 15: 8.
[12]   | Makhdoom ZA, Randall NW. Dilated cardiomyopathy due to anticardiolipin syndrome in association with celiac sprue. J Clin Gastroenterol. 2000; 31(1): 91-2.
[13]   | Amira H, Raouf H, Syrine B, Haifa N, Monia SK, Slim H, Habib HM. Atypical presentation of adult celiac disease: myocarditis and liver abnormality. Anadolu Kardiyol Derg. 2013; 13(6): 615-6.