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Dry Eyes, Chronic

Microscopic View of a Liver Granuloma. Courtesy pathology.med.umich.edu/greensonlab.
Microscopic View of a Liver Granuloma. Courtesy pathology.med.umich.edu/greensonlab.

What Is Hepatic Granulomatous Disease?

H epatic granulomatous disease is an infiltrative chronic liver disorder characterized by growth of small granulomas.

Rather than being a final diagnosis, the presence of hepatic granulomas entails the need for further investigations towards identifying the underlying etiology, with a pathologist being at the center of the diagnostic process.1

Q: What are hepatic granulomas?

A: Hepatic granulomas are unique inflammatory formations that require liver biopsy for diagnosis.2

Hepatic granulomas develop through the interactions of T lymphocytes and macrophages, with the integral involvement of T-helper (T(H)) 1 or T(H)2 pathways or both, depending on the specific granulomatous disease.

Hepatic granulomas may be detected clinically by elevated levels of serum alkaline phosphatase and g-glutamyltransferase enzymes, damage to specific structures (e.g., intrahepatic bile ducts in primary biliary cirrhosis), or infrequently, progressive liver disease with portal hypertension and cirrhosis (e.g., sarcoidosis).

Systemic immunologic disorders, infectious diseases, drug hepatotoxicity, and reaction to neoplastic disease are the major causative factors responsible for granulomas in the liver.3

What Is Hepatic Granulomatous Disease In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Turhan N, Kurt M, Ozderin YO, Kurt OK. Hepatic granulomas: a clinicopathologic analysis of 86 cases. Pathol Res Pract. 2011 Jun 15;207(6):359-65. doi: 10.1016/j.prp.2011.03.003. Epub 2011 Apr 30. [↩]
  2. Bhardwaj SS, Saxena R, Kwo PY. Granulomatous liver disease. Curr Gastroenterol Rep. 2009 Feb;11(1):42-9. [↩]
  3. Lagana SM1, Moreira RK, Lefkowitch JH. Hepatic granulomas: pathogenesis and differential diagnosis. Clin Liver Dis. 2010 Nov;14(4):605-17. doi: 10.1016/j.cld.2010.07.005. [↩]

Uveitis, Non-Infectious  

Courtesy Wikipedia.com
Parathyroid Glands in the Neck. Courtesy Wikipedia.com

What Is Secondary Hyperparathyroidism?

S econdary hyperparathyroidism is a parathyroid disorder resulting from hypocalcemia (low blood calcium level) that is characterized by excessive production of parathyroid hormone in the attempt to normalize the low blood calcium by releasing calcium from bone.

Parathyroid hormone is produced by the four pea sized parathyroid glands that are located on the thyroid gland in the front of the neck. In part, because the thyroid and parathyroid glands share the same anatomic place in the body and because they have similar names, they are often confused although they have completely different actions.

Parathyroid hormone regulates calcium and the opposing mineral phosphorus in the blood. In secondary hyperparathyroidism, calcium blood levels are low to normal while phosphorus levels are increased which stimulates the outpouring of parathyroid hormone.

Q: How does secondary hyperparathyroidism differ from primary hyperparathyroidism?

A: In primary hyperparathyroidism blood calcium is high and phosphorus is low, which is the opposite of secondary hyperparathyroidism.

The most common cause of secondary hyperparathyroidism is kidney disease causing failure to reabsorb calcium followed by vitamin D deficiency and malabsorption.

What Is Secondary Hyperparathyroidism In Celiac Disease and/or Gluten Sensitivity?

Seborrhea Dermatitis

Swollen Tongue Causing Tooth Indentations. GFW
Swollen Tongue Causing Tooth Indentations. Notice the Accompanying Denuded Area Due to Riboflavin Deficiency and Mild Candida Overgrowth. GFW

What Is A Pale, Smooth, Burning Tongue?

A pale, smooth, burning tongue is an alteration in tongue tissue characteristic of iron deficiency. The tongue is also swollen.1

Additionally, the sore tongue surface may be invaded by candida yeast which takes advantage of the sore tissue.

Iron deficiency itself increases susceptibility to infection.

Q: What is iron deficiency?

A: Iron deficiency results when the level within cells is too low to meet metabolic needs of the body for this mineral.

Deficiency is characterized by impaired red blood cell formation, free-radical disposal, oxygenation of cells, immune response to infection, enzyme activity, cognitive performance, digestion, nail structure, and fetal health.2

Iron is an essential mineral that is required for normal body function. Almost two-thirds of iron in the body is found in hemoglobin, the protein in red blood cells that carries oxygen to tissues. Smaller amounts of iron are found in myoglobin, a protein that helps supply oxygen to muscle, and in enzymes that assist biochemical reactions.

Iron is also found in proteins that store iron for future needs and that transport iron in blood. Iron stores are regulated by intestinal iron absorption.3

What Is A Pale, Smooth, Burning Tongue In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Krause’s Food, Nutrition, & Diet Therapy. 10th Edition. Kathleen Mahan, Sylvia Escott-Stump. 2000. W.B. Saunders Company. [↩]
  2. Kathleen Mahan and Sylvia Escott-Stump, ed. Krause’s Food, Nutrition & Diet Therapy, 10th Edition. Philadelphia, PA. USA: W.B. Saunders Company, 2000. [↩]
  3. http://ods.od.nih.gov/factsheets/Iron-HealthProfessional accessed 12/11/12 [↩]

Vitamin B2 (Riboflavin) Deficiency

Chicken Kabobs on the Grill...umm Riboflavin.
Chicken Kabobs on the Grill…umm Riboflavin.

What Is Riboflavin?

Riboflavin, also called vitamin B2, is fundamentally required for the breakdown of carbohydrates, amino acids, and fats in metabolism, enables oxygen to be used by cells, and acts as a component of more than a dozen enzymes involved in energy production and use.

Some enzymes needing riboflavin also require magnesium to properly function.

In other activities, riboflavin is required for healthy cardiovascular and nervous systems, eye health, and supports antioxidant protection.  Functions are more fully described below.

Urinary excretion of riboflavin cannot be detected when vitamin intake is below the required levels. On the other hand, when intake exceeds saturation in the body, the vitamin and/or its metabolites are actively excreted into urine to prevent excessive toxicity of the vitamins.1

There is no specific name for riboflavin deficiency disease.

What Is Riboflavin Deficiency In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Shibata K, Hirose J, Fukuwatari T. Relationship Between Urinary Concentrations of Nine Water-soluble Vitamins and their Vitamin Intakes in Japanese Adult Males. Nutr Metab Insights. 2014 Aug 5;7:61-75. doi: 10.4137/NMI.S17245. [↩]

Blurred Vision, Unexplained

Microscopic view of pancreatic islet cells. Courtesy Dr. José Sánchez Gonzales
Microscopic view of pancreatic islet cells. Courtesy Dr. José Sánchez Gonzales

What Is Type I Diabetes Mellitus?

T ype 1 diabetes mellitus (T1DM), also termed type 1A, is an inherited autoimmune disorder in which anti-islet autoantibodies destroy the islet cells of the pancreas that secrete insulin hormone. Type 1 diabetes mellitus was formerly called juvenile diabetes because it usually afflicts persons under the age of 25 years.

Loss of insulin production results in failure to metabolize glucose. Glucose is a simple sugar that is a required source of energy for the body, especially the brain and muscles.

Type 1 diabetes mellitus is characterized by sustained fasting blood glucose levels above 126 mg/dL (hyperglycemia) with subsequent loss of glucose from the body by removal through the urine (glucosuria) as the body attempts to lower blood glucose, and cell starvation that follows.

That is, while glucose accumulates in blood, the body cannot access it. Without insulin treatment, this disorder quickly produces coma and ultimately results in death. In fact, it is 5th leading cause of death in the United States.

Q: How does insulin work?

A: Insulin moves glucose from the bloodstream into body cells where it is used or reformulated for high energy storage. For example, muscles can use glucose for immediate work or store it in the form of glygogen for later work, depending on need. Healthy insulin production keeps an 8 hour fasting blood glucose level to less than 100 mg/dL. Upon eating carbohydrate food, glucose is digested and absorbed from the small intestine into the bloodstream which then raises blood glucose levels. The elevated level is controlled by prompt action of insulin to lower it to below 140 mg/dL  within 2 hours of eating.

Insulin does not work alone. The islets of Langerhans manage glucose in the body. The islets are specialized formations located on the outer surface of the pancreas. The islets are composed of two different types of cells known as alpha and beta cells. These cells make the competing hormones that keep blood glucose within a healthy range.

Alpha cells secrete glucagon to raise blood glucose levels by triggering the body to release stored energy in the form of glycogen. In the opposite, beta cells secrete insulin to lower blood glucose by opening body cells so that glucose in blood can enter. Without insulin, glucose cannot enter cells but remains in the bloodstream where it accumulates.

Insulin is also needed to move magnesium into cells from the bloodstream. On the other side, magnesium is needed to produce insulin. Insulin has other functions such as building muscle and helping regulate cholesterol which directly impacts the sex hormones, estrogen, progesterone, and testosterone.

Onset of symptoms usually occurs over a period of days or weeks, although beta cell destruction can begin years earlier. The SEARCH for Diabetes in Youth multicenter study, funded by the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), has determined that based on data from 2002 to 2003, a total of 15,000 youth in the United States were newly diagnosed with type 1 diabetes each year. Non-Hispanic white youth had the highest rate of new cases of type 1 diabetes according to NIH.

Type 1A diabetes mellitus has become one of the most intensively studied autoimmune disorders. It is now possible to predict its development, beginning with HLA-encoded genetic susceptibility, followed by the development of a series of anti-islet autoantibodies.1

What Is Type I Diabetes Mellitus In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Liu E, Eisenbarth GS. Type 1A diabetes mellitus-associated autoimmunity. Endocrinology and Metabolism Clinics of North America. Jun 2002;31(2):391-410, vii-viii. [↩]

Cheilosis (Cracks in corners of mouth)

cheilosisWhat Is Cheilosis?

Cheilosis is a painful feature of nutritional deficiencies, especially riboflavin and/or pyridoxine deficiency, and less frequently, from vitamin B12, folic acid, and iron. It is characterized by redness of the lips with cracking and weeping in the corner of the mouth.

Q: What is the consequence of weeping at the corners of the mouth?

A: The open sores that develop at the corners of the mouth invite infection by candida albicans, a yeast organism, and less commonly by bacteria normally present on the skin such as staphylococcus aureus.

These sores make opening the mouth very painful and so restrict eating, talking, socializing, and dental care.

What Is Cheilosis In Celiac Disease and/or Gluten Sensitivity?

Oral Mucosal Lesions, Chronic (Mouth Soreness)

Canker Sore Inside Mouth. Notice The White Spot on This Person's Nail Showing Zinc Deficiency.
Inflammation/Sore Inside Mouth. Notice White Spot on Fingernail Nail Showing Zinc Deficiency.

What Are Chronic Oral Mucosal Lesions?

Chronic lesions of the oral mucosa are disorders of the mouth that are characterized by soreness and sores of the soft mucosal lining of the mouth.

What Are Chronic Oral Mucosal Lesions In Celiac Disease and/or Gluten Sensitivity?

Geographic Tongue

Geographic Tongue Due to Riboflavin Deficiency.
Geographic Tongue Due to Riboflavin Deficiency.

 What Is Geographic Tongue?

Geographic tongue is a painful alteration in tongue tissue that is characteristic of riboflavin (vitamin B2) deficiency.1

Q: How does the tongue surface appear?

A: Areas of inflamed tissue with flattened papillae develop among areas of normal tissue, giving a map-like appearance to the tongue surface. There are often swollen papillae that hurt or sting, such as is seen in the photo to the left.

A diet that does not provide adequate amounts of riboflavin and any condition that 1) interferes with riboflavin absorption from the gut, 2) depletes the vitamin from the body, 3) overuses the vitamin in the body, or 4) adversely affects its use in the body will result in riboflavin deficiency causing geographic tongue.

Riboflavin is essential for converting foodstuffs into energy, maintaining the normal lifespan of red blood cells and maintaining healthy skin, eyes, hair, and nervous system. Riboflavin is converted into its active forms, flavin adenine dinucleotide (FAD) and flavin mononucleotide (FMN). These enzymes are primarily involved as co-factors in oxidation reduction reactions that are essential for cellular energy production and respiration.

Riboflavin is required for the conversion of pyridoxine (vitamin B6) to its functional form and the production of niacin (vitamin B3) from the amino acid tryptophan. Riboflavin has a role in antioxidant status by activating glutathione reductase, which regenerates used glutathione, a powerful antioxidant.

Respiratory infection, exercise, certain diseases, drugs and hormones can adversely influence riboflavin status.2 Stress is a major depleter of riboflavin.

What Is Geographic Tongue In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Krause’s Food, Nutrition, & Diet Therapy. 10th Edition. Kathleen Mahan, Sylvia Escott-Stump. 2000. W.B. Saunders Company. [↩]
  2. Lakshmi AV. Riboflavin metabolism–relevance to human nutrition. Indian J Med Res. 1998 Nov;108:182-90. [↩]

Abdominal Pain, Chronic or Recurrent

What Is Chronic Or Recurrent Abdominal Pain? Abdominal pain is characterized by pain anywhere in the abdominal cavity between the chest and groin. This region is often referred to as the belly. Abdominal pain, or…