Maria Bavastrelli

Ciguatera Fish Poisoning: An Emerging Syndrome in Italian Travelers

Ciguatera is an acute or chronic intoxication syndrome associated with the consumption of marine tropical reef fish. The illness has a short incubation period, and the symptoms typically affect the gastrointestinal and nervous systems. Ciguatera poisoning has been extensively reviewed. 1‐5 It is endemic in many tropical and subtropical regions, also in the United States, 5,6 and Mexico, 7 where it accounts for more than half of all outbreaks related to ingestion of fish. In the Caribbean and Indo-Pacific islands, regions where coral reefs are present, the disease is the most common seafood-borne illness.Ciguatera poisoning can occur after the consumption of a wide variety of predatory tropical fish including barracuda,surgeon fish,red-snapper,amber-jack,red-grouper, and king-mackerel. These fish contain heat resistant and acid-stable toxins, mainly ciguatoxin, a lipid-soluble toxin, and maitotoxin, a water-soluble toxin. Both poisons belong to a newly described class of toxins, chemically polycyclic ether compounds, produced by tropical marine microalgae that become attached to the epiphytes of macroalgae, which herbivorous fish consume while foraging. Many small fish succumb to ciguatoxin and are eaten by other fish. Hence ciguatera toxin becomes more bioconcentrated as it passes up through the food chain from large carnivorous fish to larger predatory reef fish and ultimately to humans. Whereas the toxins are harmless in the host fish, in humans they produce illness. The earliest and commonest symptoms to appear are watery diarrhea, nausea and vomiting, abdominal pain, typically lasting about 12 hours. Usually, 24‐48 hours after ingesting the toxic fish, neurologic symptoms follow, including numbness, lip, tongue, and limb paresthesias, severe itching, and cold-to-hot temperature reversal (considered a pathognomonic sign). The illness generally subsides within a week. Neurologic symptoms may last for months or subside and then recur. Prompted by the growing number of Italian travelers returning from the Caribbean who present to our unit after experiencing symptoms of ciguatera poisoning, we designed this clinical study to assess the clinical outcome in our patients.We also sought to know whether they had received information before departure on the potential risks of ciguatera fish poisoning. Methods

Celiac disease in a large cohort of children and adolescents with recurrent headache: A retrospective study.

BACKGROUND The clinical picture of celiac disease is changing with the emergence of subclinical forms and growing evidence reporting associated neurological disorders. AIMS To establish the prevalence of celiac disease in children suffering from recurrent headache. METHODS In our retrospective study we collected charts from 1131 children attending our tertiary care Centre for Paediatric Headache over the period 2001-2012. They were screened for celiac disease and positive patients were referred to our Operative Unit for Coeliac disease and confirmed positive children underwent upper endoscopy with multiple duodenal biopsies. Celiac children started a gluten-free diet. RESULTS 883 children (481 females; median age, 9.8 years, range 3-19) performed celiac disease screening, and among them, 11 children (7 females; median age, 8.2 years, range: 4.8-13.9) were diagnosed with celiac disease. Seven children (5 females, median age, 11.9 years, range: 10.3-13.9) had been diagnosed as celiac prior to the neurological evaluation. The prevalence of celiac disease in our sample is 2.04% vs. 1.2% of the general population (p=0.034). CONCLUSIONS Our study demonstrates, on a large series, that celiac disease prevalence is doubled in patients with chronic headache. Screening for celiac disease could be advised as part of the diagnostic work-up in these paediatric patients, particularly among pharmacological non-responders.

Coeliac disease screening among a large cohort of overweight/obese children.

ABSTRACT Coeliac disease (CD) is a chronic, gluten-dependent enteropathy with a prevalence of approximately 1% in Western countries. Up to now, CD has been described only in sporadic cases of obesity. Our study aimed to evaluate retrospectively CD prevalence in a large series of overweight/obese children and adolescents. Among the 1527 overweight/obese children and adolescents consecutively evaluated, 17 (7 boys, 1.11%) were positive for serology and showed villous atrophy. In all of the patients with CD a well-balanced gluten-free diet was started, and a loss of weight rapidly obtained. Our study demonstrates that CD prevalence in overweight/obese children is similar to the general paediatric population in Italy.

Anti-transglutaminase immunoreactivity and histological lesions of the duodenum in coeliac patients

Coeliac disease (CD) is characterized by several markers, including anti-transglutaminase auto-antibodies (tTGAb) directed against multiple epitopes of the gliadin protein. We aimed to investigate the correlation among CD duodenal lesions, tTGAb titres and the immunoreactivity against tTG constructs. A total of 345 CD patients (209 females, 136 males, overall median age: 7.3 years) were tested for full-length (fl) tTGAb with a fluid-phase radioimmunoassay. Out of the total, 231 patients were also tested for immunoreactivity against tTG fragments (F1: a.a. 227-687 and F2: a.a. 473-687). Patients were classified according to diffuse (D), patchy (P) or bulb (B) histological lesions. All sera were found fltTGAb positive. Patients with D, P and B lesions had a mean Ab index of 0.84±0.39, 0.57±0.39 and 0.45±0.24, respectively. Mean tTGAb titre varied between D and localized (P+B) patients (0.84±0.39 versus 0.52±0.34, P < 0.0001). Overall, 86.1% of patients were F1 auto-antibody (F1Ab) positive (D: 89%, P: 75%, B: 40%; D versus P+B: P = 0.004) and 49% of patients were F2 auto-antibody (F2Ab) positive (D: 53%, P: 19%, B: 10%; D versus P+B: P = 0.0006). Of the D patients 50.7% showed combined F1Ab-F2Ab (D versus P+B: P = 0.001), whereas 60% of B patients were negative for both F1Ab and F2Ab (B versus D: P < 0.0001). Coeliac-specific tTGAb immunoreactivity correlates with the grading and extension of histological duodenal lesions in CD patients at diagnosis. The immunoreactivity against single and combined tTG fragments is significantly higher in patients with D lesions. This is the first evidence of a distinct coeliac-specific immunoreactivity in patients with different duodenal involvement.

Coeliac Disease-Related Antibodies Appearance in a IgA Deficiency Celiac Girl after Starting the Gluten-Free Diet

Celiac disease (CD) is a gluten-dependent autoimmune enteropathy which occurs in genetically predisposed individuals. CD can manifest in a typical form (with gastrointestinal symptoms), with an atypical form (iron-deficiency anemia, headache, recurrent aphthous stomatitis) or be asymptomatic (silent form). Over the last decades CD prevalence increased (1.2%), mainly due to the improvement and diffusion of screening tools such as anti-gliadin, anti-endomysium and anti-tissue transglutaminase antibodies. The authors report a case of a 39 months old IgA deficiency girl with a severe abdominal distention and iron deficiency anemia, negative for CD-related antibodies, who was diagnosed celiac. Surprisingly, after six months of gluten-free diet, the patient showed the appearance of IgG class – CD specific antibodies.