Abstract

The present issue of the International Journal of Celiac Disease contains multiple aspects of celiac disease, spanning rare and new clinical presentations, associated conditions, reminds us on the lectin hypothesis of celiac disease, new epidemiological data on Africa, explore compliance with gluten elimination and describes the waste bin diagnosis of Sprue-like intestinal disease. Following is an overview of the issue content with a drop of a personal dip. Congratulations to the Editor and the Editorial Board of the International Journal of Celiac Disease (CD) for publishing volume 7, No 3 issue of the Journal.

It fulfills the journal's vision of deepening various aspects of the disease, imparting knowledge, and encouraging readers and scientists to "crack" the nut of the disease. In this regard, the current issue spans rare clinical presentations, renewed pathophysiological pathways, new epidemiological data and the college hard times in compliance with a gluten-free diet (GFD). Following is an overview of the issue content with a drop of a personal dip:

The review article brings up the lectin theory in CD induction ¹. After summarizing the luminal lectins' transit, their nutrients' and drugs' effects, and sugar specificity, the CD lectin hypothesis is reviewed. The lectin hypothesis of CD started in 1972 by Ament, Douglas, Weiser, et al. ^{2, 3, 4}. It is quite controversial between the pros ^{5, 6, 7, 8}, and cons ^{9, 10}. The annual number of publications is decreasing in the last decade. However, most recently, the lectin theory was revived and even raised the question about dietary lectin exclusion as the next big food trend ¹¹. It seems that the jury is still out.

The first manuscript reported on the prevalence of CD autoimmunity in Ethiopian pregnant women to be quite low (0.05%). The authors describe the limitations of the study. However, several aspects should be zoomed out considering CD in Africa ¹² even though a lot of local and international effort is allocated to fight infections and improve public health and quality of life. Allergies, cancer, and autoimmune diseases are increasing in Africa, as is in Western societies. In the Maghreb countries, CD incidence, phenotype, and epidemiology resemble the developed world. However, lack of awareness, resources, and qualified health care professionals, change of dietary habits, poverty, illiteracy, malnutrition, and infectious load are at the heart of the problematic situation. Gudeta AN et al. ¹³ are discussing reasons for the low incidence of autoimmune CD in Ethiopian pregnant women. Most probably, the trend of Westernization of the African continent and the adoption of gluten-containing processed foods will increase the CD burden in Ethiopia and other African countries.

The next manuscript switches to CD therapy with GFD. It explored the various individual and social influences on compliance with gluten withdrawal in college students ¹⁴. GFD is a tough alley, and the adolescent and college periods are hard times ^{15, 16}. In this sense, it should be remembered that gluten has several side effects, but on the other hand, the only approved therapy for CD, the GFD, is also not performed without risks. The clinical and dieticians communities should be aware of those drawbacks in the face of the gluten withdrawal boom "fashionista" ¹⁷.

The first case report expands on a new wheat-dependent entity entitled "wheat-dependent exercise-induced anaphylaxis” ¹⁸. Until now, CD, non-CD/wheat sensitivity, wheat/gluten allergy, dermatitis herpetiformis, and gluten ataxia filled the list of wheat/gluten depended on conditions. The new entity is a particular allergy that occurs after wheat ingestion, followed by physical exercise. Dyspnea, wheezing, and respiratory allergy dominated the clinical picture. In this regard, we can show that there is an association between CD and lung disease ¹⁹. In addition, asthma seems to be a high-risk factor for CD development ²⁰. The wheat-related conditions have a broad spectrum of 'evolving diseases' ²¹. However, the associative relations should be strengthened by a more causative relationship.

The presentation of CD in the elderly and its multisystem involvement is not new ²². The authors describe the association between immune thrombocytopenic purpura (ITP), collagenous microscopic colitis, and mesangial-proliferative glomerulonephritis in elderly CD patients. The peculiar features of CD in the elderly were recently summarized ²³. Multiple environmental factors, luminal eco-events, gut-peripheral organ pathways, and axes exist, thus, connecting CD to extra-intestinal end organs ^{24, 25, 26, 27, 28, 29, 30, 31, 32, 33}.

Volume 7 issue 3 of the Journal continues with a description of the celiac crisis, manifested by hypokalemic quadriparesis ³⁴. The acute presenting symptoms of CD were summarized recently ³⁵, and the electrolyte deficiency mediated peripheral neuro-muscular abnormality should be added to the list ³⁶.

The last paper is an exception in the present issue since it does not deal with CD, but instead with the association of Sprue-like intestinal disease with Crohn's disease ³⁷. Crohn's disease is associated with CD ^{38, 39, 40, 41}, and adding Sprue-like disease, all three cohabit in the human intestine. In the case presented, Sprue-like symptoms were not affected by GFD, and CD serology was negative, despite biopsy changes mimicking those of CD. Although a "waste bin diagnosis," Sprue-like diseases are a heterogeneous group that might present as a crisis ⁴², thus, mimicking the celiac crisis ⁴³.

In summary, volume 7, issue 3 embraces several aspects of CD, including rare clinical presentations, renewed pathophysiological pathways, new epidemiological data and the college hard times in compliance with a gluten-free diet.

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