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Are My Patients with Celiac Disease at Higher Risk of COVID-19 Virus?

Lerner Aaron
International Journal of Celiac Disease. 2020, 8(1), 35-38. DOI: 10.12691/ijcd-8-1-7
Received January 11, 2020; Revised February 18, 2020; Accepted April 27, 2020

Abstract

COVID-19, caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2), is now a worldwide spreading pandemic. Most of the attention is directed to the upper and lower respiratory airways, however, it appears that the gastrointestinal tract is also inoculated and infected. In this regards, celiac disease patients are a potential high-risk group for the corona virus infection and the endoscopist communities should be aware of their professional risks.

1. Introduction

The COVID-19 pandemic is an outbreak of the novel respiratory disease COVID-19 that had first was noticed at the end of 2019 in the mega-metropolis of Wuhan in the Chinese province of Hubei. The epidemy in China started around January 2020 and finally spread worldwide and became a pandemic. The outbreak was caused by the previously unknown corona virus SARS-CoV-2 triggered. This virus is also known as a novel corona virus 1.

Multiple observations indicate that this infectious virus almost certainly originated from the zoonostic kingdom, although the précised reservoir is not yet completely delineated. Initially thought to come from bats or pangolin, passed on to humans directly or via an intermediate mammal 2. Finally, it is suspected that a double infection of the virus species SARS-associated coronavirus led to recombination and that the SARS-CoV-2 virus is a new chimera from these earlier viruses 1. The past epidemic origins: the Himalayan palm civet for SARS-CoV and the dromedary camel for MERS-CoV were identified, not yet for the corona virus SARS-CoV-2. It should be stress that the corona viruses are universally spread and span numerous mammals: bats, piglets, pigs, feline (cats), horses and swine 3, 4, 5, 6, 7.

Today, the globe is facing a very contagious Pandemic, transmit from person to person. It affects mainly the respiratory tract, but information is accumulating that the gastrointestinal tract is not resilient. In fact, the corona virus infection can involve and damage the gut and other organs like heart, vessels, liver and kidneys 8, 9. Animals, including bats harbor the virus in their intestine 10 and the covid-19 can be detected in stools of infected patients 11. More so, the gastrointestinal tract can present a shedding rout for SARS-CoV-2 environmental contamination 12. The present review aims to highlight some aspects that might affect the celiac disease (CD) patients in face of the SARS-CoV-2 Pandemic that is currently globally spreading.

2. High Risk Aspects of Corona Virus Infection in Celiac Disease Patients

The following are CD features that might relay to the current SARS-CoV-2 infections

A. Celiac disease is an immune dysregulated condition. Being an autoimmune disease where loss of tolerance to gluten and gliadins is occurring, CD can be characterized as a mucosal immune dysregulated condition 13. The innate as well as the reactive systems are engaged. Enterocyte-interepithelial lymphocytes-IL-15 cross talks, Toll-like receptors, regulatory T cells, mucosal mast cells, mucosal cytokines, Th1/Th2 balance, Reactive CD4 T and activated B cells relationship are some of those derangements 14, 15, 16, 17, 18, 19, 20. Most will attenuate and normalize on streaked gluten free diet, hence, few will persist, keeping long-term degree of mucosal inflammation. One wonder what will be the outcome if SARS-CoV-2 infects such a vulnerable mucosa.

B. IgA deficiency affects 2%–3% patients with CD, a frequency approximately 10–15 times higher than the general population 21. It is the most common human immunodeficiency and is characterized by a serum IgA concentration of <7 mg/dL. Secretory IgA antibodies have various critical functions. Immune protection against infectious agents, establishment of a healthy microbiome and regulating host-commensal homeostasis are the most important. Most affected people are asymptomatic, some will present with infectious diarrhea. But approximately one third suffer from recurrent bacterial, enteroviral or protozoal infections of the respiratory and gastrointestinal tracts 22. Related to the subject of the present review, secretory IgA is important in protecting the respiratory and the gut mucosa against viruses, be it enteroviruses or pulmonary influenza. Since SARS-CoV-2 infects both of them and since IgA deficient CD patients are also deficient in secretory IgA in the respiratory tract, they might be prone to be infected. Interestingly, after acute infection with SARS-CoV-2, the median duration of the serum IgA antibody detection was 5 days, after symptom onset, with a positive rate of 92.7% 23. Unfortunately, no studies are available on the enteric and respiratory secretory IgA status in the infected patients. Epidemiological surveys on the rate of Covid-19 infection in IgA deficient patients, compared to controls are lacking. Time will tell if the IgA deficient CD population is a risk group for corona virus infection.

C. Immune deficiency conditions associated with celiac disease. In addition to the IgA deficiency, other immune deficiencies are associated with CD. Common Variable Immune Deficiency, Chronic Granulomatous Disease and isolated IgM deficiency are some of them 24, 25. When associated with CD, those condition represent an additional potential risk for the current pandemic viral infection.

D. Immune suppressive therapy in refractory celiac disease. Despite being rare, refractory CD is a very challenging diagnosis and therapy. Immune suppressive drugs are the main therapy, so far. Systemic steroids, budesonide, azathioprine, adenosine nucleoside analog cladribine, infliximab, campath (anti CD52), methotrexate, cyclosporine A, recombinant IL-10, anti IL-15 or hemopoietic stem cell transplantations were suggested to treat the condition and its morbid and lethal complications 26. Once again putting CD patients in high risk for the Covid-19 infections.

E. Pulmonary disease associated with celiac disease

The list of respiratory conditions associated with CD is continuously expanding. Asthma 27, pulmonary Hemosiderosis 28, hemochromatosis 29, 30, cystic fibrosis 31 and even respiratory syncytial virus 32, are some of them. It appears that Children with CD diagnosed during infancy were found to attended hospital for a prior respiratory syncytial virus infection or any other viral bronchiolitis more than other children. Even thought not celiac children, in Crohn's children, another intestinal inflammatory condition, Bronchial reactivity and lung functions are compromised 33. It goes without saying that adults or elderly with chronic health diseases, including chronic lung debilitating conditions are at increased morbidity and mortality risk, when infected with Cobid-19 virus. So, if a CD patient has such a condition, he/she is potentially at risk of corona virus infection and complications.

3. Potential Shared Aspect between Covid-19 High Risks Populations and CD Patients

Table 1 lists the shared aspects between CD and potential risks for corona virus infection and complications.

  • Table 1. SHARED aspects between CD and potential risks for corona virus infection and complications

  • View option

4. A Final Warning Message to the Endoscopic Gastroenterologists

A final warning message to the endoscopic gastroenterologists in the current SARS-CoV-2 spreading Pandemic. Although it does not appear to be related to the topics of the current review, I feel responsible to highlight same recent observations concerning the gut effects of the corona virus. A lot of attention is given to medical communities' high risks, hence, not enough is given to the gastrointestinal endoscopist who operate in an infected compartment. SARS-CoV-2 RNA is resent in the feces of the infected patients 8, 9, 11. Colonic biopsy samples positivity has been consistently documented. As mentioned above, stool's viral shedding is more prolonged then in respiratory compartments' secretions 12 and potential fecal-oral transmission was most recently suggested 44. Above all, a plethora of other viruses are part of the enteric microbiome and affect the microbiota/dysbiota balance in health and disease 45 and the covid-19 effects on the gut homeostasis are yet unknown.

Since the covid -19 is highly infectious and can survive on surfaces for certain periods and since most of the infected people are a/hypo-symptomatic, the gastrointestinal endoscopists should be educated, warned and be aware of their high professional risk to be contaminated or infected, as is the case for the helicobacter pylori.

Reviewing the literature of the SARS-CoV1, a family member of the current SARS-CoV2, it spread through the intestinal tract, kidney and sweat glands to be excreted via feces, urine and sweat 46. In this regard, the Spanish society of digestive pathology (SEPD) and gastroenterology (AEG) should be congratulated for their most recent recommendations 47. Additionally, the current cleaning and disinfections procedures should be evaluated for SARS-CoV-2 survival on the endoscopes' surfaces and channels, during and after aspiration of oral and fecal material via endoscopes. Much more, specific focus on personal protection equipment and dress code modalities should be implemented in community and hospital endoscopy suites. Those preventive measures are starting to appear in the adult medical and scientific literature 48, 49, not yet in the pediatric endoscopy one. The high risks, warning and recommendations apply for CD since many of the patients need endoscopies for diagnosis or associated complications and diseases

No reports yet are available on corona virus transmissions during gastrointestinal procedures, however, those professional risk should be explored, preferably "an hour earlier".

5. Conclusions

The current SARS-CoV-2 Pandemic is spreading with more unresolved questions then answers. CD patients are potentially a high-risk group for many reasons as well as the gastrointestinal endoscopists. CD patients, professional treatment teams like nurses, physicians and dieticians and their societies should be aware of the potential risk of the covid-19 virus and act accordingly.

Conflict of Interest

No potential conflicts of interest in authorship or publication

Financial Declaration

The authors have no relevant financial disclosures

Abbreviations List

CD-celiac disease, SARS-CoV-2-severe acute respiratory syndrome coronavirus-2.

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Published with license by Science and Education Publishing, Copyright © 2020 Lerner Aaron

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Lerner Aaron. Are My Patients with Celiac Disease at Higher Risk of COVID-19 Virus?. International Journal of Celiac Disease. Vol. 8, No. 1, 2020, pp 35-38. http://pubs.sciepub.com/ijcd/8/1/7
MLA Style
Aaron, Lerner. "Are My Patients with Celiac Disease at Higher Risk of COVID-19 Virus?." International Journal of Celiac Disease 8.1 (2020): 35-38.
APA Style
Aaron, L. (2020). Are My Patients with Celiac Disease at Higher Risk of COVID-19 Virus?. International Journal of Celiac Disease, 8(1), 35-38.
Chicago Style
Aaron, Lerner. "Are My Patients with Celiac Disease at Higher Risk of COVID-19 Virus?." International Journal of Celiac Disease 8, no. 1 (2020): 35-38.
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[1]  Wikipediade.wikipedia.org ›wiki› COVID-19 pandemic. last edited on 28 March 2020.
In article      
 
[2]  Andersen KG, Rambaut A, Lipkin WI, Holmes EC, Garry RF. The proximal origin of SARS-CoV-2. Nat Med 2020.
In article      View Article  PubMed
 
[3]  Papatsiros VG, Stylianaki I, Papakonstantinou G, Papaioannou N, Christodoulopoulos G. Case Report of Transmissible Gastroenteritis Coronavirus Infection Associated with Small Intestine and Brain Lesions in Piglets. Viral Immunol. 2019; 32: 63-67.
In article      View Article  PubMed
 
[4]  Tasker S. Diagnosis of feline infectious peritonitis: Update on evidence supporting available tests. J Feline Med Surg. 2018; 20: 228-243.
In article      View Article  PubMed
 
[5]  Pusterla N, Vin R, Leutenegger CM, Mittel LD, Divers TJ. Enteric coronavirus infection in adult horses. Vet J. 2018; 231: 13-18.
In article      View Article  PubMed
 
[6]  Zhou P, Fan H, Lan T, Yang XL, Shi WF, Zhang W, et al. Fatal swine acute diarrhoea syndrome caused by an HKU2-related coronavirus of bat origin. Nature. 2018; 556(7700): 255-258.
In article      View Article  PubMed
 
[7]  Mandelik R, Sarvas M, Jackova A, Salamunova S, Novotny J, Vilcek S. First outbreak with chimeric swine enteric coronavirus (SeCoV) on pig farms in Slovakia - lessons to learn. Acta Vet Hung. 2018; 66: 488-492.
In article      View Article  PubMed
 
[8]  Yao XH, Li TY, He ZC, Ping YF, Liu HW, Yu SC, et al. A pathological report of three COVID-19 cases by minimally invasive autopsies. Zhonghua Bing Li Xue Za Zhi. 2020 Mar 15; 49(0): E009.
In article      
 
[9]  Zhou J, Li C, Zhao G, Chu H, Wang D, Yan HH, et al. Human intestinal tract serves as an alternative infection route for Middle East respiratory syndrome coronavirus. Sci Adv. 2017; 3: eaao4966.
In article      View Article  PubMed
 
[10]  Bittar C, Machado RRG, Comelis MT, Bueno LM, Beguelini MR, Morielle-Versute E, et al. Alphacoronavirus Detection in Lungs, Liver, and Intestines of Bats from Brazil. Microb Ecol. 2020; 79: 203-212.
In article      View Article  PubMed
 
[11]  Mackenzie JS, Smith DW. COVID-19: a novel zoonotic disease caused by a coronavirus from China: what we know and what we don’t. Microbiol Aust. 2020 Mar 17: MA20013.
In article      View Article  PubMed
 
[12]  Wei Zhang, Rong-Hui Du, Bei Li, Xiao-Shuang Zheng, Xing-Lou Yang, Ben Hu, et al. Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes. Emerg Microbes Infect. 2020; 9: 386-389.
In article      View Article  PubMed
 
[13]  Levy J, Bernstein L, Silber N. Celiac disease: an immune dysregulation syndrome. Curr Probl Pediatr Adolesc Health Care. 2014; 44: 324-7.
In article      View Article  PubMed
 
[14]  Malamut G, Cording S, Cerf-Bensussan N. Recent advances in celiac disease and refractory celiac disease. F1000Res. 2019 Jun 26; 8. pii: F1000 Faculty Rev-969.
In article      View Article  PubMed
 
[15]  Frossi B, De Carli M, Calabrò A.Coeliac Disease and Mast Cells. Int J Mol Sci. 2019;20. pii: E3400.
In article      View Article  PubMed
 
[16]  Ghasiyari H, Rostami-Nejad M, Amani D, Rostami K, Pourhoseingholi MA, Asadzadeh-Aghdaei H, et al. Diverse Profiles of Toll-Like Receptors 2, 4, 7, and 9 mRNA in Peripheral Blood and Biopsy Specimens of Patients with Celiac Disease. J Immunol Res. 2; 2018: 7587095.
In article      View Article  PubMed
 
[17]  Lahdenperä A, Ludvigsson J, Fälth-Magnusson K, Högberg L, Vaarala O. The effect of gluten-free diet on Th1-Th2-Th3-associated intestinal immune responses in celiac disease. Scand J Gastroenterol. 2011; 46: 538-49.
In article      View Article  PubMed
 
[18]  Goel G, Daveson AJM, Hooi CE, Tye-Din JA, Wang S, Szymczak E, et al. Serum cytokines elevated during gluten-mediated cytokine release in coeliac disease. Clin Exp Immunol. 2020; 199: 68-78.
In article      View Article  PubMed
 
[19]  Hmida NB, Ben Ahmed M, Moussa A, Rejeb MB, Said Y, Kourda N, et al. Impaired control of effector T cells by regulatory T cells: a clue to loss of oral tolerance and autoimmunity in celiac disease? Am J Gastroenterol. 2012; 107: 604-11.
In article      View Article  PubMed
 
[20]  Sharma N, Bhatia S, Chunduri V, Kaur S, Sharma S, Kapoor P, et al. Pathogenesis of Celiac Disease and Other Gluten Related Disorders in Wheat and Strategies for Mitigating Them. Front Nutr. 2020; 7: 6.
In article      View Article  PubMed
 
[21]  Chow MA, Lebwohl B, Reilly NR, Green PH. Immunoglobulin A deficiency in celiac disease. J Clin Gastroenterol. 2012; 46: 850-4.
In article      View Article  PubMed
 
[22]  Gommerman JL, Rojas OL, Fritz JH. Re-thinking the functions of IgA+ plasma cells. Gut Microbes. 2014; 5: 652-662.
In article      View Article  PubMed
 
[23]  Guo L, Ren L, Yang S, Xiao M, Chang, Yang F, et al. Profiling Early Humoral Response to Diagnose Novel Coronavirus Disease (COVID-19). Clin Infect Dis. 2020 Mar 21. pii: ciaa310.
In article      
 
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