Abstract
Dear Editor,
We congratulate Dr. Kondala and colleagues for their excellent study investigating the natural history of potential celiac disease (PCD) in India. 1 This is a very timely and important issue as the number of these cases is constantly increasing due to active case-finding and screening. The authors note that there are major variations between studies in the natural history of PCD, these likely being at least partly explained by different study designs and selection on patients.2,3 Based on the low rate of histological progression they conclude that starting a gluten-free diet is not justified in all cases with PCD, but it is not specified in whom it might be considered. Intriguingly, despite the morphologically normal intestinal mucosa, approximately half of the PCD patients presented either with clinical symptoms or iron-deficiency anemia. Accordingly, we have recently shown that children with PCD often suffer from anemia or iron deficiency even before the development of the mucosal lesion. 4 Moreover, there is mounting evidence that such patients may benefit clinically, histologically and serologically to gluten withdrawal.5,6 It is also well known that tissue transglutaminase antibodies, particularly if measured with a reliable assay or combined with positive endomysial antibodies, elicit excellent specificity for celiac disease. Therefore, why should we delay the dietary treatment until mucosal atrophy (the end stage of the disease) develops in subjects with clear clinical symptoms or anemia? Evidently more prospective studies are needed, but at this point we would recommend that a trial with a gluten-free diet should be considered with a low threshold in PCD patients with no other obvious reason for the symptoms or anemia.