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Incidence of celiac disease
EDITORIAL CORRESPONDENCE
Ovarian microcysts with premature thelarche To the Editor: Freedman et al. 1 described a significant increase (56%) in the frequency of detectable ovarian microcysts in patients with isolated premature thelarche. We have reported similar findings2; 9 (60%) of 15 patients with premature thelarche had microcysts in the ovaries. We also studied the thickness of breast tissue by means of ultrasonography. No apparent relation was found between the thickness of breast tissue and the presence or absence of microcysts in ovaries. In one case microcysts were observed in the initial examination; the disappearance of ovarian cysts was accompanied by a decrease in breast thickness 5 weeks later. In our 47 control subjects (from birth to 6 years of age), only 4 (9%) had ovarian microcysts. Our data agree with previous studies of Orsini et al. 3 in which 8% of the girls aged 2 to 6 years had ovarian microcysts. Freedman et al.1 found as many as 21% of control subjects (6 months to 3 years of age) had microcysts. Their data differ significantly from ours (2 of 28 control subjects from 6 months to 3 years of age had microcysts) and those of Orsini et al. (0 of 11 girls from 2 to 3 years of age had microcysts). Because the results of Freedman et al. and our results were similar concerning the frequency of microcysts observed in premature thelarche, it is unclear why the results were so different in the control groups. Michiru Nakamura, MD Ichiro Okabe, MD Kouichi Itoh, MD Departments o f Clinical Pathology and Pediatrics Jichi Medical School Tochigi 329-04, Japan 9/35/54671 REFERENCES 1. Freedman SM, Kreitzer PM, Elkowitz SS, Soberrman N, Leonidas JC. Ovarian microcysts in girls with isolated premature thelarche. J PEDIATR 1993;122:246-9. 2. Nakamura M, Okabe I, Shimoizumi H, Yanagisawa M, Taniguchi N, Itoh K. Ultrasonography of ovary, uterus and breast in premature thelarche. Acta Paediatr Jpn 1991;33:645-8. 3. Orsini LF, Salardi S, Pilu G, Bovicelli L, Cacciari E. Pelvic organs in premenarcheal girls: real-time ultrasonography. Radiology 1984;153:113-6.
Incidence of celiac disease To the Editor." We read with great interest the study of the incidence of celiac disease (CD) in the United States, reported by Rossi et al. (J PEDIAT~ 1993;123:262-4). The use of data at the time of hospital admission has been a common measure of disease frequency in children. Usually the series thus obtained have been relatively small and possibly strongly influenced by the diagnostic acumen of interested clinicians. Previous reports in London indicate that the rate of diagnosis of CD was three times higher at one hospital than at
two other hospitals in the same city (reference 1 and references incorporated therein), probably because this condition is manifested differently among patients, and because there is increasing evidence of the existence of patients who are either free of symptoms or have no gastrointestinal symptoms and therefore are recognized only because of minor clinical or biochemical abnormalities. In the study by Rossi et al., only children with chronic diarrhea in association with linear or ponderal growth abnormalities were examined and included for study. It is likely other modes of clinical presentation could had been undetected. Furthermore, the authors state that "almost all" children with these symptoms were studied. The possibility that an undetermined number of additional patients were missed does exist. In our opinion, these factors could have altered the incidence figures obtained in the study. More information could have been obtained if the authors had studied the ethnic origin of the studied population. Previous reports indicate that the highest incidence occurs in white persons; CD does not occur, or is certainly uncommon, in black persons, and the condition does not appear to have been documented in Chinese or Japanese populations. 2 Perhaps the assessment of incidence in population subsets, taking into account ethnic origin, would have yielded different results. Finally, we agree with the authors on the importance of determining the presence of endomysial antibodies as a screening tool for the detection of CD. However,. the high prevalence of IgA deficiency in these patients limits the value of this test. 3 In our opinion, measuring total levels of serum IgA and antigliadin IgG and IgA antibodies may improve the accuracy of serologic tests in the screening of CD, and we suggest that they be used for clinical and epidemiologic purposes. Cristina Camarero, MD, PhD V. Urena, MD M. J. Arconada, MD B. Roldan, MD Department o f Pediatric Immunology Hospital Ramon y Cajal Universidad de Alcala de Henares Madrid, Spain 9/35/54669 REFERENCES 1. Logan RFA. Epidemiology of coeliac disease. In: Michael N, Marsh, eds. Coeliac disease. London: Blackwell Scientific Publications, 1992:192-214. 2. Walker-Smith J. Coeliac disease. In: Walker-Smith J, ed. Diseases of the small intestine in childhood. London: Butterworths, 1988:88-143. 3. Savilathi E, Pelkonen P, Visakorpi JK. IgA deficiency in children: a clinical study with special reference to intestinal findings. Arch Dis Child 1971;46:665-70.
Reply To the Editor." Our study was designed simply to estimate the occurrence of symptomatic celiac disease in our area of the United States and to 993
Ovarian microcysts with premature thelarche To the Editor: Freedman et al. 1 described a significant increase (56%) in the frequency of detectable ovarian microcysts in patients with isolated premature thelarche. We have reported similar findings2; 9 (60%) of 15 patients with premature thelarche had microcysts in the ovaries. We also studied the thickness of breast tissue by means of ultrasonography. No apparent relation was found between the thickness of breast tissue and the presence or absence of microcysts in ovaries. In one case microcysts were observed in the initial examination; the disappearance of ovarian cysts was accompanied by a decrease in breast thickness 5 weeks later. In our 47 control subjects (from birth to 6 years of age), only 4 (9%) had ovarian microcysts. Our data agree with previous studies of Orsini et al. 3 in which 8% of the girls aged 2 to 6 years had ovarian microcysts. Freedman et al.1 found as many as 21% of control subjects (6 months to 3 years of age) had microcysts. Their data differ significantly from ours (2 of 28 control subjects from 6 months to 3 years of age had microcysts) and those of Orsini et al. (0 of 11 girls from 2 to 3 years of age had microcysts). Because the results of Freedman et al. and our results were similar concerning the frequency of microcysts observed in premature thelarche, it is unclear why the results were so different in the control groups. Michiru Nakamura, MD Ichiro Okabe, MD Kouichi Itoh, MD Departments o f Clinical Pathology and Pediatrics Jichi Medical School Tochigi 329-04, Japan 9/35/54671 REFERENCES 1. Freedman SM, Kreitzer PM, Elkowitz SS, Soberrman N, Leonidas JC. Ovarian microcysts in girls with isolated premature thelarche. J PEDIATR 1993;122:246-9. 2. Nakamura M, Okabe I, Shimoizumi H, Yanagisawa M, Taniguchi N, Itoh K. Ultrasonography of ovary, uterus and breast in premature thelarche. Acta Paediatr Jpn 1991;33:645-8. 3. Orsini LF, Salardi S, Pilu G, Bovicelli L, Cacciari E. Pelvic organs in premenarcheal girls: real-time ultrasonography. Radiology 1984;153:113-6.
Incidence of celiac disease To the Editor." We read with great interest the study of the incidence of celiac disease (CD) in the United States, reported by Rossi et al. (J PEDIAT~ 1993;123:262-4). The use of data at the time of hospital admission has been a common measure of disease frequency in children. Usually the series thus obtained have been relatively small and possibly strongly influenced by the diagnostic acumen of interested clinicians. Previous reports in London indicate that the rate of diagnosis of CD was three times higher at one hospital than at
two other hospitals in the same city (reference 1 and references incorporated therein), probably because this condition is manifested differently among patients, and because there is increasing evidence of the existence of patients who are either free of symptoms or have no gastrointestinal symptoms and therefore are recognized only because of minor clinical or biochemical abnormalities. In the study by Rossi et al., only children with chronic diarrhea in association with linear or ponderal growth abnormalities were examined and included for study. It is likely other modes of clinical presentation could had been undetected. Furthermore, the authors state that "almost all" children with these symptoms were studied. The possibility that an undetermined number of additional patients were missed does exist. In our opinion, these factors could have altered the incidence figures obtained in the study. More information could have been obtained if the authors had studied the ethnic origin of the studied population. Previous reports indicate that the highest incidence occurs in white persons; CD does not occur, or is certainly uncommon, in black persons, and the condition does not appear to have been documented in Chinese or Japanese populations. 2 Perhaps the assessment of incidence in population subsets, taking into account ethnic origin, would have yielded different results. Finally, we agree with the authors on the importance of determining the presence of endomysial antibodies as a screening tool for the detection of CD. However,. the high prevalence of IgA deficiency in these patients limits the value of this test. 3 In our opinion, measuring total levels of serum IgA and antigliadin IgG and IgA antibodies may improve the accuracy of serologic tests in the screening of CD, and we suggest that they be used for clinical and epidemiologic purposes. Cristina Camarero, MD, PhD V. Urena, MD M. J. Arconada, MD B. Roldan, MD Department o f Pediatric Immunology Hospital Ramon y Cajal Universidad de Alcala de Henares Madrid, Spain 9/35/54669 REFERENCES 1. Logan RFA. Epidemiology of coeliac disease. In: Michael N, Marsh, eds. Coeliac disease. London: Blackwell Scientific Publications, 1992:192-214. 2. Walker-Smith J. Coeliac disease. In: Walker-Smith J, ed. Diseases of the small intestine in childhood. London: Butterworths, 1988:88-143. 3. Savilathi E, Pelkonen P, Visakorpi JK. IgA deficiency in children: a clinical study with special reference to intestinal findings. Arch Dis Child 1971;46:665-70.
Reply To the Editor." Our study was designed simply to estimate the occurrence of symptomatic celiac disease in our area of the United States and to 993