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Celiac Disease: A Challenging Disease Uneasy to Diagnose in Sub-Saharan Africa

Diallo Ibrahima, Coton Thierry

Diallo Ibrahima, Coton Thierry, Digestive diseases unit. Army Teaching Hospital Laveran. BP 60149-13384 Marseilles cedex13, France

Correspondence to: Thierry Coton, Digestive diseases unit, Army Teaching Hospital Laveran, BP 60149- 13384 Marseilles Cedex 13, France.
thierrycoton@msn.com
Telephone:+33491617252
Fax:+33491617023
Received: May 13, 2013
Revised: May 29, 2013
Accepted: May 30, 2013
Published online: August 21, 2013

ABSTRACT

AIM: Celiac disease is rarely described in sub-Saharan Africa.

METHODS: From a series of 17 cases diagnosed between 2005 and 2007 in Djibouti, we describe our diagnosis an management difficulties.

RESULTS: African ethnics represented 64.7%. Sex ratio (F/M) is 1.4, mean age 82 months, associated diseases in 47%. Anti-gliadine, anti-endomysium and anti-transglutaminase antibodies were positive in 100%, 66.6% and 100%. Upper digestive tract endoscopy was realized 4 times. Eleven patients (64.7%) began gluten free diet, 7 recovered. Two patients died (11.7%).

CONCLUSION: CD is difficult to diagnose for technical reasons. GFD is successful thanks to parental continuous medical education.

Key words: Celiac disease; Gluten; Djibouti; Eastern Africa

© 2013 The Authors. Published by ACT Publishing Group Ltd.

Diallo I, Coton C. Celiac Disease: a Challenging Disease Uneasy to Diagnose in sub-Saharan Africa. Journal of Gastroenterology and Hepatology Research 2013; 2(8): 753-756 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/459

INTRODUCTION

Celiac disease (CD) is well known in developed countries and, although more and more often described in northern Africa[1], is rarely described in sub-Saharan areas[2,3,4,5]. From a series of 17 Djiboutian patients, we try to build a diagnosis algorithm adapted inter-tropical Africa.

METHODS

Between August 2005 and August 2007, we prospectively registered all cases of celiac disease admitted in Medicine Unit in Bouffard French Military Hospital in Djibouti (Republic of Djibouti, Horn of Africa). This hospital is located in the town of Djibouti and is opened to french military families and local population through cooperation convention (Djiboutian soldiers’ families), free medical aid (allowed by French Forces Sanitary Service) and through adapted or full charges (based on French sanitary system charges). In selected patients with digestive complaints or malnutrition assessed by WHO 95327 weight curves adapted to developing countries, inclusion criteria were seropositivity for gliadine and/or endomysium and/or transglutaminase antibodies. Basic blood analyses were carried out in Bouffard hospital laboratory. Serologic analyses were sent by plane to Val de Grace French military hospital laboratory in Paris. If possible, anti-gliadine (IgA, IgG) (Elisa Bioadvance™, threshold >100 UR/mL before 4 years old, >50 UR/mL after 4 years old), anti-endomysium (IFI Bioadvance™, threshold=1/10, The Binding Site™, threshold=10U/mL) and anti-transglutaminase antibodies (IgA, IgG) (Elisa The Binding site™, threshold=10 U/mL) were coupled. Upper digestive tract endoscopies (Olympus™ GIF XQ40 gastroscope) were realized by one operator (TC) in Bouffard hospital sometimes under general anesthesia. Duodenal biopsies, practiced with single use biopsy forceps Cook™ without methylene blue coloration, were fixed in F2A and sent by plane to the Military Teaching Hospital Laveran Pathology Unit in Marseilles (France). MGG coloration was used for pathological examination. Gluten free diet (GFD) clinical response was assessed clinically, serologically and pathologically if possible.

RESULTS

Seventeen patients were included (10 females and 7 males; mean age 82 months (9-276). Malnutrition was constant (100%) and associated with digestive complaints (abdominal pains, bloating, chronic diarrhea) in 15/17 patients (88%). Eight patients (47%) had associated diseases: pulmonary tuberculosis (2; 11.2%) or distal gastric adenocarcinoma, giardiasis, taeniasis, oral candisosis, Klebsiella pneumonia septicemia, cytomegalovirus primo-infection and urinary infection (all 1; 5.9%). Anti-gliadine, anti-endomysium and anti-transglutaminase were positive in the 16/16 patients (100%), 10/15 patients (66.6%), in 3/3 patients (100%) respectively. Upper digestive tract endoscopy was realized in 4/17 patients (23.5%) and duodenal biopsies in 3: total villous atrophy with raised intra-epithelial lymphocytosis twice (66.6%) (stage IV in Marsh classification) and once normal (33.3%).

GFD was introduced in 11/17 (64.7%) with clinical follow up in 9 (52.9%). Mean follow-up was 9 months (2-18 months). Two patients died during this period (11.7%).

Partial weight recovery under GFD was observed in 7/9 followed patients; mean weight gain was 3.1 kilograms (0.2-5.4 kg). Gluten free diet observance was poor in two patients who clinically relapsed.

DISCUSSION

CD is unknown because rarely reported in inter-tropical Africa[2,3,4,5]. So we recorded it in Eastern-Africa in Djibouti during two years. Our study population reflects Djibouti ethnics repartition and our hospital specific recruitment (pediatrics and adults from middle and high class). In this population, dietary habits differ from general population with large use of bread, biscuit, noodles and sweeties. Some particularities must be underline. Confounding associated diseases were present in 41.2%. Even realized through optimized technical conditions in Bouffard French military hospital, our study highlights the low availability of endoscopy and pathological analysis which cannot be systematically recommended in Africa. It also focuses on the high diagnosis performance of anti-gliadin (46.8€) or anti-transglutaminase (70.2€) serology (to be preferred) and the low sensitivity of anti-endomysium (81.9€) antibodies (66.6%)[6]. Eleven patients (64.7%) began GFD which is quite easy to manage in inter-tropical Africa even presumptively when diagnosis means lack: in Djibouti, we excluded bread, biscuits, semolina and noodles and use rice extensively. In Western Africa, substitution seams easier because sorghum, wood-millet or cassava are traditionally widely used[7]. GFD is effective as illustrated by our 77.8% recovery rate. The main reason of regimen’s failure is misunderstanding of this life-long regime benefits by parents who need continuing medical education with the help of health care workers. Our mortality rate (11.7%) is twice Turkish hospitalized CD[1] probably linked to late diagnosis.

CONCLUSION

Celiac disease does exist in sub-Saharan Africa especially in Djibouti, where it emerges in middle and high-class population because massive gluten introduction in food. The lack of awareness and diagnosis means, the association with confounding affections to treat before, explain its ignorance. In this specific situation, GFD can be introduced presumptively because it is simple to manage in sub Saharan Africa and is not expansive. Continuing parental education on the aim of GFD is the way of success. We, therefore, propose a celiac disease diagnosis algorithm adapted to sub-Saharan African (figure 1).

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Peer reviewers: Lorete Maria Da Silva Kotze, MD, PhD, Professor Rua Bruno Filgueira, 369 – Cj 1205, Curitiba – Paraná – Brazil, Cep 80240-220; Luis Rodrigo, Professor, Gastroenterology Department, University Hospital Central of Asturias, c/ Celestino Villamil s. nº, 33.006. Oviedo. Spain.

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