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Carcinoid Tumor Complicating Crohn Disease in a Female Adolescent.

T o the Editor: I read with great interest and appreciate the report by Khatib et al (1). They reported that the average age at diagnosis of celiac disease (CD) was much higher than previously reported (10.7 years), and that a nonclassical presentation predominated in this group of patients. These findings, however, are not limited to the region where this study was performed. We also have reported an older age of presentation (9.3 years after 2008) at diagnosis, and most had an atypical or silent presentation (2). Other investigators have also shown increased prevalence of nonclassical manifestations and older age at diagnosis (3,4). Khatib et al also reported that 22% of the patients had type I diabetes compared with 3.2% to 11.0% in previous reports of children with CD. Such a high prevalence is a new observation that needs to be corroborated. This finding is probably attributable to greater recognition of atypical presentations and screening of asymptomatic groups who are at increased risk, and to improved diagnostic specificity and sensitivity of serological tests. This finding, however, may also be ascribed to an overall increase in the prevalence. Refractory iron deficiency anemia is an important atypical feature of CD and has been reported as the sole manifestation in 7.9% to 19% of children (2,4–6). It primarily results from impaired iron absorption (7,8). Occult gastrointestinal blood loss has also been noted in 26.7% of children with CD, and the children appeared to respond to gluten-free diet (9). Although Khatib et al did not document refractory anemia, testing for anemia may have a role in screening for CD and deserves further attention.