Reptiles and Salmonella

Reptiles and Salmonella

Did you know lizards and turtles can carry a harmful germ called Salmonella? If there are infants or small children in your home, reptiles might not be safe pets for your family.

Reptiles are popular pets with many families. Small reptiles like turtles, iguanas, snakes, geckos, horned toads, and chameleons are colorful, quiet, and often kept as caged pets. Reptiles require careful handling, however, because they can carry a germ called Salmonella that can cause serious illness in people. Although many people think of salmonellosis as an illness caused by contaminated food, it can also be caught by handling a pet reptile or contact with its environment.

Salmonellosis is a serious infection of the gastrointestinal tract. Diarrhea is the most common symptom of Salmonella infection, but other symptoms such as fever, headache, nausea, and vomiting can also occur. Salmonellosis can be very serious and sometimes fatal for young children, the elderly, and persons with weak immune systems. Therefore, families with children aged 5 years or younger in the home should avoid keeping reptiles as pets.

Salmonella occurs naturally in many reptiles and does not usually make the animals sick. You cannot tell by looking at a lizard, snake, or a turtle if it is carrying Salmonella.

Bacteria, including Salmonella, are easily passed from pet reptiles to people. Research shows that a person who handles reptiles can easily pass germs to others because bacteria are able to cling to clothing and other surfaces such as our hands. To reduce the chances of family members getting sick with salmonellosis, pet owners should:

• Wash hands with soap and water immediately after handling a reptile;
• Launder any clothing the reptile might have touched;
• Not allow reptiles to roam the house freely;
• Keep reptiles out of kitchens; and
• Use soap or a disinfectant to thoroughly clean any surfaces that have been in contact with reptiles.

Since 1975 it has been illegal in the United States to sell or distribute turtles with shells that measure less than 4 inches in length. This size was chosen because small children are more likely to treat smaller turtles as toys and put them in their mouths. This ban prohibiting the sale of small turtles likely remains the most effective public health action to prevent turtle-associated salmonellosis. Despite this ban, such turtles are still found in some pet stores. In addition, children still catch wild turtles and lizards and bring them home to keep as pets. Whether store-bought or caught in a friend's backyard, a reptile can carry Salmonella and might not be the best choice of a pet for your family, especially if there are young children or immunocompromised persons in the household.

CDC

Salmonella Outbreak Update

Water Frogs

Today's Highlights

• As of 9:00pm EST on December 21, 2009, 83 individuals infected with the outbreak strain of Salmonella Typhimurium have been reported from 31 states. The latest estimated date of illness onset is December 5, 2009.
• New information in the investigation indicates the outbreak likely began in April, which is earlier than previously reported. An additional 26 ill persons infected with the outbreak strain between April and July have been identified and are now included in the overall number of reported individuals infected.

CDC is collaborating with public health officials in many states to investigate a multistate outbreak of human Salmonella serotype Typhimurium infections due to contact with water frogs including African Dwarf Frogs. Water frogs commonly live in aquariums or fish tanks. Amphibians such as frogs and reptiles such as turtles, are recognized as a source of human Salmonella infections. In the course of routine assessment, a number of cases with the same strain have been identified over many months.

New information in the investigation indicates the outbreak likely began in April, which is earlier than previously reported. An additional 26 ill persons infected with the outbreak strain between April and July have been identified and are now included in the overall number of reported individuals infected.Only four new recent illnesses have been reported since the previous web update on December 16. Investigations are still ongoing to see if the outbreak may have been occurring prior to April.

As of 9:00pm EST on December 21, 2009, 83 individuals infected with the outbreak strain of Salmonella Typhimurium have been reported from 31 states. The number of ill persons identified in each state is as follows: Alabama (1), Arizona (1), California (4), Colorado (4), Florida (1), Georgia (1), Idaho (1), Illinois (5), Indiana (1), Kentucky (1), Louisiana (1), Massachusetts (3), Maryland (2), Michigan (4), Minnesota (1), Missouri (4), Mississippi (1), Nebraska (1), New Jersey (2), New Mexico (1), New York (2), Nevada (1), Ohio (2), Pennsylvania (4), South Dakota (3), Tennessee (3), Texas (4), Utah (13), Virginia (3), Washington (7) and Wisconsin (1).

Among the persons with reported dates available, illnesses began between May 24 and November 16, 2009. Infected individuals range in age from < 1 year old to 54 years old. Eighty percent (80%) of patients are younger than 10 years old and the median age is 4 years. Forty-nine percent (49%) of patients are female. Among the 45 patients with available information, 16 (36%) were hospitalized. No deaths have been reported.

Investigation of the Outbreak

In an epidemiologic study, ill persons answered questions about contact with animals and foods consumed during the days before becoming ill and investigators compared their responses to those of persons of similar age and gender previously reported to State Health Departments with other illnesses. Preliminary analysis of this study suggests contact with frogs, including water frogs such as African Dwarf Frogs, is a likely source of the infections. In addition, environmental samples taken from aquariums containing aquatic frogs in three homes of ill persons have yielded isolates of Salmonella Typhimurium matching the outbreak strain.

Advice to Consumers

• Always wash hands thoroughly with soap and water after touching any amphibian (e.g., frog) or reptile (e.g, turtle), their housing, or anything (for example, food) that comes in contact with them or their housing.   Adults should assist young children with hand washing.
• Watch for symptoms of Salmonella infection, such as diarrhea, fever, and abdominal cramps.  Call your health care provider if you or a family member have any of these symptoms.

Persons who should avoid contact with amphibians and reptiles and their habitats (e.g., aquarium, fish tank, or terrarium)

• Persons at increased risk for serious infection from salmonellosis are children < 5 years old, elderly persons, and persons with weakened immune systems.
• These persons should avoid contact with amphibians (e.g., frogs) and reptiles (e.g., turtles) and anything that comes in contact with them (e.g., aquarium, habitat, and water).
• Keep amphibians and reptiles out of homes with children < 5 years old or people with weakened immune systems.

Placement and maintenance of habitats

• Amphibians (e.g., frogs) and reptiles (e.g., turtles) should not be kept in child-care centers.
• Habitats containing amphibians or reptiles should not be kept in a child’s bedroom, especially children aged < 5 years.
• Do not allow amphibians or reptiles to roam freely through the house, especially in food preparation areas.
• Keep amphibians and reptiles out of kitchens and other areas where food and drink is prepared or served to prevent contamination.
• Habitats and their contents should be carefully cleaned outside of the home. Use disposable gloves when cleaning and do not dispose of water in sinks used for food preparation or for obtaining drinking water.
• Do not bathe animals or their habitats in your kitchen sink. If bathtubs are used for these purposes, they should be thoroughly cleaned afterward. Use bleach to disinfect a tub or other place where reptile or amphibian habitats are cleaned.
• Children aged <5 years should not clean habitats.
• Always wash hands thoroughly with soap and water after cleaning habitats.

Advice to Pet Store Owners and Others Who Sell or Display Amphibians and Reptiles

• Pet store owners and others who sell or display amphibians (e.g., frogs) and reptiles (e.g., turtles) should provide information to owners and potential purchasers of amphibians and reptiles about the risks of acquiring salmonellosis from these animals.

Advice to Health Care Providers

• Health care providers should question patients on pet and animal ownership and should provide education about the risks of acquiring salmonellosis from amphibians (e.g., frogs) and reptiles (e.g., turtles).
• Health care providers should advise patients on proper hand washing practices.

Advice to Veterinarians

• Veterinarians should provide education to amphibian and reptile owners about the risks of acquiring salmonellosis from these animals.
• Veterinarians should provide education to amphibian and reptile owners on how to properly clean the animal habitat.

Clinical Features/Signs and Symptoms

• Most persons infected with Salmonella develop diarrhea, fever, and abdominal cramps 12–72 hours after infection. Infection is usually diagnosed by culture of a stool sample. The illness usually lasts from 4 to 7 days. Although most people recover without treatment, severe infections may occur. Infants, elderly persons, and those with weakened immune systems are more likely than others to develop severe illness. When severe infection occurs, Salmonella may spread from the intestines to the bloodstream and then to other body sites and can cause death unless the person is treated promptly with antibiotics.

CDC

Extrahepatic Bile Duct Cancer

Extrahepatic bile duct cancer is a rare disease in which malignant (cancer) cells form in the part of bile duct that is outside the liver.

A network of bile ducts (tubes) connects the liver and the gallbladder to the small intestine. This network begins in the liver where many small ducts collect bile, a fluid made by the liver to break down fats during digestion. The small ducts come together to form the right and left hepatic bile ducts, which lead out of the liver. The two ducts join outside the liver to become the common hepatic duct. The part of the common hepatic duct that is outside the liver is called the extrahepatic bile duct. The extrahepatic bile duct is joined by a duct from the gallbladder (which stores bile) to form the common bile duct. Bile is released from the gallbladder through the common bile duct into the small intestine when food is being digested.

Having colitis or certain liver diseases can increase the risk of developing extrahepatic bile duct cancer.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Risk factors include having any of the following disorders:

• Primary sclerosing cholangitis.

• Chronic ulcerative colitis.

• Choledochal cysts.
• Infection with a Chinese liver fluke parasite.

Possible signs of extrahepatic bile duct cancer include jaundice and pain.

These and other symptoms may be caused by extrahepatic bile duct cancer or by other conditions. A doctor should be consulted if any of the following problems occur:

• Jaundice (yellowing of the skin or whites of the eyes).
• Pain in the abdomen.

• Fever.

• Itchy skin.

Tests that examine the bile duct and liver are used to detect (find) and diagnose extrahepatic bile duct cancer.

The following tests and procedures may be used:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. A spiral or helical CT scan makes detailed pictures of areas inside the body using an x-ray machine that scans the body in a spiral path.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• ERCP (endoscopic retrograde cholangiopancreatography): A procedure used to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine. Sometimes bile duct cancer causes these ducts to narrow and block or slow the flow of bile, causing jaundice. An endoscope is passed through the mouth, esophagus, and stomach into the first part of the small intestine. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. A catheter (a smaller tube) is then inserted through the endoscope into the pancreatic ducts. A dye is injected through the catheter into the ducts and an x-ray is taken. If the ducts are blocked by a tumor, a fine tube may be inserted into the duct to unblock it. This tube (or stent) may be left in place to keep the duct open. Tissue samples may also be taken and checked under a microscope for signs of cancer.
• PTC (percutaneous transhepatic cholangiography): A procedure used to x-ray the liver and bile ducts. A thin needle is inserted through the skin below the ribs and into the liver. Dye is injected into the liver or bile ducts and an x-ray is taken. If a blockage is found, a thin, flexible tube called a stent is sometimes left in the liver to drain bile into the small intestine or a collection bag outside the body.
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. The sample may be taken using a thin needle inserted into the duct during an x-ray or ultrasound. This is called a fine-needle aspiration (FNA) biopsy. The biopsy is usually done during PTC or ERCP. Tissue may also be removed during surgery.
• Liver function tests: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by the liver. A higher than normal amount of a substance can be a sign of liver disease that may be caused by extrahepatic bile duct cancer.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

• The stage of the cancer (whether it affects only the bile duct or has spread to other places in the body).
• Whether the tumor can be completely removed by surgery.
• Whether the tumor is in the upper or lower part of the duct.
• Whether the cancer has just been diagnosed or has recurred (come back).

Treatment options may also depend on the symptoms caused by the tumor. Extrahepatic bile duct cancer is usually found after it has spread and can rarely be removed completely by surgery. Palliative therapy may relieve symptoms and improve the patient's quality of life.

National Cancer Institute

Esophageal Cancer

Esophageal cancer is a disease in which malignant (cancer) cells form in the tissues of the esophagus.

The esophagus is the hollow, muscular tube that moves food and liquid from the throat to the stomach. The wall of the esophagus is made up of several layers of tissue, including mucous membrane, muscle, and connective tissue. Esophageal cancer starts at the inside lining of the esophagus and spreads outward through the other layers as it grows.

The two most common forms of esophageal cancer are named for the type of cells that become malignant (cancerous):

• Squamous cell carcinoma: Cancer that forms in squamous cells, the thin, flat cells lining the esophagus. This cancer is most often found in the upper and middle part of the esophagus, but can occur anywhere along the esophagus. This is also called epidermoid carcinoma.
• Adenocarcinoma: Cancer that begins in glandular (secretory) cells. Glandular cells in the lining of the esophagus produce and release fluids such as mucus. Adenocarcinomas usually form in the lower part of the esophagus, near the stomach.

Smoking, heavy alcohol use, and Barrett esophagus can increase the risk of developing esophageal cancer.

Risk factors include the following:

• Tobacco use.
• Heavy alcohol use.
• Barrett esophagus: A condition in which the cells lining the lower part of the esophagus have changed or been replaced with abnormal cells that could lead to cancer of the esophagus. Gastric reflux (the backing up of stomach contents into the lower section of the esophagus) may irritate the esophagus and, over time, cause Barrett esophagus.
• Older age.
• Being male.
• Being African-American.

The most common signs of esophageal cancer are painful or difficult swallowing and weight loss.

These and other symptoms may be caused by esophageal cancer or by other conditions. A doctor should be consulted if any of the following problems occur:

• Painful or difficult swallowing.
• Weight loss.
• Pain behind the breastbone.
• Hoarseness and cough.
• Indigestion and heartburn.

Tests that examine the esophagus are used to detect (find) and diagnose esophageal cancer.

The following tests and procedures may be used:

• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• Barium swallow: A series of x-rays of the esophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus and stomach, and x-rays are taken. This procedure is also called an upper GI series.
• Esophagoscopy: A procedure to look inside the esophagus to check for abnormal areas. An esophagoscope is inserted through the mouth or nose and down the throat into the esophagus. An esophagoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. The biopsy is usually done during an esophagoscopy. Sometimes a biopsy shows changes in the esophagus that are not cancer but may lead to cancer.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

• The stage of the cancer (whether it affects part of the esophagus, involves the whole esophagus, or has spread to other places in the body).
• The size of the tumor.
• The patient’s general health.

When esophageal cancer is found very early, there is a better chance of recovery. Esophageal cancer is often in an advanced stage when it is diagnosed. At later stages, esophageal cancer can be treated but rarely can be cured. Taking part in one of the clinical trials being done to improve treatment should be considered.

National Cancer Institute

Campylobacter Infection and Animals

What is Campylobacter infection (campylobacteriosis)?

Campylobacteriosis is a bacterial disease caused by Campylobacter jejuni or Campylobacter coli. Campylobacter usually causes a mild to severe infection of the gastrointestinal system, including watery or bloody diarrhea, fever, abdominal cramps, nausea, and vomiting. A rare complication of Campylobacter infection is Guillain-Barre syndrome, a nervous system disease that occurs approximately 2 weeks after the initial illness develops.

Can animals transmit Campylobacter to me?

Sometimes, yes, animals can spread Campylobacter to humans. Most people get campylobacteriosis from contaminated food. However, animals can have Campylobacter in their feces (stool). If people touch contaminated feces, they can get sick. Animals that may carry Campylobacter in their feces include farm animals, cats, and dogs. Animals do not have to be ill to pass Campylobacter to humans. People with compromised immune systems, including those undergoing treatments for cancer, organ transplant patients, and people with HIV/AIDS, have a higher risk than others of getting Campylobacter infection from food and animals.

How do I reduce my risk of getting Campylobacter infection from animals?

After contact with animals and animal feces, wash your hands thoroughly with running water and soap.

If you are immunocompromised and are getting a new pet, avoid farm animals, cats, and dogs with diarrhea.

If your dog or cat has diarrhea, talk to your veterinarian.

If you develop symptoms, including diarrhea, vomiting, abdominal cramps, and/or nausea, contact your physician. Be sure to inform him or her of your pet and if it is ill.

If you are immunocompromised, be extra cautious around farm animals and their environment.

CDC

Ascarids and Hookworms

Ascarids (Toxocara spp.) and hookworms (Ancylostoma spp. and Uncinaria stenocephala), the common intestinal roundworms of dogs and cats, can cause larva migrans syndromes in persons who accidentally ingest eggs or larvae or have direct skin contact with hookworm larvae in soil contaminated with the feces of infected animals.

Pups and kittens are often infected by transfer of larvae from their dams in utero (T. canis) or via milk (A. caninum, T. cati, and to a lesser extent, T. canis), (1,2) and the tissue-migrating and early intestinal stages of these worms may cause severe, sometimes life-threatening, disease in the first few weeks of the animal's life. Furthermore, pups and kittens may have patent intestinal infections as early as the first 2 (hookworms) to 3 (ascarids) weeks of life, and may contaminate their environment with huge numbers of infective eggs and larvae.

The prevalence of these infections varies with climatic conditions; however, they are present in all parts of the contiguous United States and must be viewed as a potential public health hazard .

CDC

Frost Bite and Hypothermia

LOW TEMPERATURE + WIND SPEED + WETNESS = INJURIES & ILLNESS

FROST BITE

What Happens to the Body:

• FREEZING IN DEEP LAYERS OF SKIN AND TISSUE
• PALE, WAXY-WHITE SKIN COLOR
• SKIN BECOMES HARD and NUMB
• USUALLY AFFECTS THE FINGERS, HANDS, TOES, FEET, EARS, and NOSE.

What Should Be Done: (land temperatures)

• Move the person to a warm dry area. Don’t leave the person alone.
• Remove any wet or tight clothing that may cut off blood flow to the affected area.
• DO NOT rub the affected area, because rubbing causes damage to the skin and tissue.
• Gently place the affected area in a warm (105°F) water bath and monitor the water temperature to slowly warm the tissue. Don’t pour warm water directly on the affected area because it will warm the tissue too fast causing tissue damage. Warming takes about 25-40 minutes.
• After the affected area has been warmed, it may become puffy and blister. The affected area may have a burning feeling or numbness. When normal feeling, movement, and skin color have returned, the affected area should be dried and wrapped to keep it warm. NOTE: If there is a chance the affected area may get cold again, do not warm the skin. If the skin is warmed and then becomes cold again, it will cause severe tissue damage.
• Seek medical attention as soon as possible.

HYPOTHERMIA – (Medical Emergency)

What Happens to the Body:

• NORMAL BODY TEMPERATURE (98.6° F/37°C ) DROPS TO OR BELOW 95°F (350 C)
• FATIGUE OR DROWSINESS
• UNCONTROLLED SHIVERING
• COOL BLUISH SKIN
• SLURRED SPEECH
• CLUMSY MOVEMENTS
• IRRITABLE, IRRATIONAL OR CONFUSED BEHAVIOR.

What Should Be Done: (land temperatures)

• Call for emergency help (i.e., Ambulance or Call 911).
• Move the person to a warm, dry area. Don’t leave the person alone. Remove any wet clothing and replace with warm, dry clothing or wrap the person in blankets.
• Have the person drink warm, sweet drinks (sugar water or sports-type drinks) if they are alert. Avoid drinks with caffeine (coffee, tea, or hot chocolate) or alcohol.
• Have the person move their arms and legs to create muscle heat. If they are unable to do this, place warm bottles or hot packs in the arm pits, groin, neck, and head areas. DO NOT rub the person’s body or place them in warm water bath. This may stop their heart.

What Should Be Done: (water temperatures)

• Call for emergency help (Ambulance or Call 911). Body heat is lost up to 25 times faster in water.
• DO NOT remove any clothing. Button, buckle, zip, and tighten any collars, cuffs, shoes, and hoods because the layer of trapped water closest to the body provides a layer of insulation that slows the loss of heat. Keep the head out of the water and put on a hat or hood.
• Get out of the water as quickly as possible or climb on anything floating. DO NOT attempt to swim unless a floating object or another person can be reached because swimming or other physical activity uses the body’s heat and reduces survival time by about 50 percent.
• If getting out of the water is not possible, wait quietly and conserve body heat by folding arms across the chest, keeping thighs together, bending knees, and crossing ankles. If another person is in the water, huddle together with chests held closely.

How to Protect Workers

• Recognize the environmental and workplace conditions that lead to potential cold-induced illnesses and injuries.
• Learn the signs and symptoms of cold-induced illnesses/injuries and what to do to help the worker.
• Train the workforce about cold-induced illnesses and injuries.
• Select proper clothing for cold, wet, and windy conditions. Layer clothing to adjust to changing environmental temperatures. Wear a hat and gloves, in addition to underwear that will keep water away from the skin (polypropylene).
• Take frequent short breaks in warm dry shelters to allow the body to warm up.
• Perform work during the warmest part of the day.
• Avoid exhaustion or fatigue because energy is needed to keep muscles warm.
• Use the buddy system (work in pairs).
• Drink warm, sweet beverages (sugar water, sports-type drinks). Avoid drinks with caffeine (coffee, tea, or hot chocolate) or alcohol.
• Eat warm, high-calorie foods like hot pasta dishes.

Workers Are at Increased Risk When…

• They have predisposing health conditions such as cardiovascular disease, diabetes, and hypertension.
• They take certain medication (check with your doctor, nurse, or pharmacy and ask if any medicines you are taking affect you while working in cold environments).
• They are in poor physical condition, have a poor diet, or are older.

Osha

Esophageal Tumors

Cancer of the esophagus (the muscular tube through which food passes from the throat to the stomach) is rare in the pediatric age group. Symptoms are related to difficulty in swallowing, and associated weight loss. Treatment options for esophageal cancer include either radiation therapy or chemotherapy. Prognosis generally is poor for this cancer, which rarely can be completely removed by surgery.

National Cancer Institute

What is celiac disease?

Celiac disease is a digestive disease that damages the small intestine and interferes with absorption of nutrients from food. People who have celiac disease cannot tolerate gluten, a protein in wheat, rye, and barley. Gluten is found mainly in foods but may also be found in everyday products such as medicines, vitamins, and lip balms.

When people with celiac disease eat foods or use products containing gluten, their immune system responds by damaging or destroying villi—the tiny, fingerlike protrusions lining the small intestine. Villi normally allow nutrients from food to be absorbed through the walls of the small intestine into the bloodstream. Without healthy villi, a person becomes malnourished, no matter how much food one eats.

Villi on the lining of the small intestine help absorb nutrients.

Celiac disease is both a disease of malabsorption—meaning nutrients are not absorbed properly—and an abnormal immune reaction to gluten. Celiac disease is also known as celiac sprue, nontropical sprue, and gluten-sensitive enteropathy. Celiac disease is genetic, meaning it runs in families. Sometimes the disease is triggered—or becomes active for the first time—after surgery, pregnancy, childbirth, viral infection, or severe emotional stress.

What are the symptoms of celiac disease?
Symptoms of celiac disease vary from person to person. Symptoms may occur in the digestive system or in other parts of the body. Digestive symptoms are more common in infants and young children and may include:

• abdominal bloating and pain
• chronic diarrhea
• vomiting
• constipation
• pale, foul-smelling, or fatty stool
• weight loss
• Irritability is another common symptom in children. Malabsorption of nutrients during the years when nutrition is critical to a child’s normal growth and development can result in other problems such as failure to thrive in infants, delayed growth and short stature, delayed puberty, and dental enamel defects of the permanent teeth.

Adults are less likely to have digestive symptoms and may instead have one or more of the following:

• unexplained iron-deficiency anemia
• fatigue
• bone or joint pain
• arthritis
• bone loss or osteoporosis
• depression or anxiety
• tingling numbness in the hands and feet
• seizures
• missed menstrual periods
• infertility or recurrent miscarriage
• canker sores inside the mouth
• an itchy skin rash called dermatitis herpetiformis

People with celiac disease may have no symptoms but can still develop complications of the disease over time. Long-term complications include malnutrition—which can lead to anemia, osteoporosis, and miscarriage, among other problems—liver diseases, and cancers of the intestine.

Why are celiac disease symptoms so varied?
Researchers are studying the reasons celiac disease affects people differently. The length of time a person was breastfed, the age a person started eating gluten-containing foods, and the amount of gluten-containing foods one eats are three factors thought to play a role in when and how celiac disease appears. Some studies have shown, for example, that the longer a person was breastfed, the later the symptoms of celiac disease appear.

Symptoms also vary depending on a person’s age and the degree of damage to the small intestine. Many adults have the disease for a decade or more before they are diagnosed. The longer a person goes undiagnosed and untreated, the greater the chance of developing long-term complications.

What other health problems do people with celiac disease have?
People with celiac disease tend to have other diseases in which the immune system attacks the body’s healthy cells and tissues. The connection between celiac disease and these diseases may be genetic. They include:

• type 1 diabetes
• autoimmune thyroid disease
• autoimmune liver disease
• rheumatoid arthritis
• Addison’s disease, a condition in which the glands that produce critical hormones are damaged
• Sjögren’s syndrome, a condition in which the glands that produce tears and saliva are destroyed

How common is celiac disease?
Celiac disease affects people in all parts of the world. Originally thought to be a rare childhood syndrome, celiac disease is now known to be a common genetic disorder. More than 2 million people in the United States have the disease, or about 1 in 133 people.1 Among people who have a first-degree relative—a parent, sibling, or child—diagnosed with celiac disease, as many as 1 in 22 people may have the disease.2

Celiac disease is also more common among people with other genetic disorders including Down syndrome and Turner syndrome, a condition that affects girls’ development.

How is celiac disease diagnosed?
Recognizing celiac disease can be difficult because some of its symptoms are similar to those of other diseases. Celiac disease can be confused with irritable bowel syndrome, iron-deficiency anemia caused by menstrual blood loss, inflammatory bowel disease, diverticulitis, intestinal infections, and chronic fatigue syndrome. As a result, celiac disease has long been underdiagnosed or misdiagnosed. As doctors become more aware of the many varied symptoms of the disease and reliable blood tests become more available, diagnosis rates are increasing.

Blood Tests
People with celiac disease have higher than normal levels of certain autoantibodies—proteins that react against the body’s own cells or tissues—in their blood. To diagnose celiac disease, doctors will test blood for high levels of anti-tissue transglutaminase antibodies (tTGA) or anti-endomysium antibodies (EMA). If test results are negative but celiac disease is still suspected, additional blood tests may be needed.

Before being tested, one should continue to eat a diet that includes foods with gluten, such as breads and pastas. If a person stops eating foods with gluten before being tested, the results may be negative for celiac disease even if the disease is present.

Intestinal Biopsy
If blood tests and symptoms suggest celiac disease, a biopsy of the small intestine is performed to confirm the diagnosis. During the biopsy, the doctor removes tiny pieces of tissue from the small intestine to check for damage to the villi. To obtain the tissue sample, the doctor eases a long, thin tube called an endoscope through the patient’s mouth and stomach into the small intestine. The doctor then takes the samples using instruments passed through the endoscope.

Dermatitis Herpetiformis
Dermatitis herpetiformis (DH) is an intensely itchy, blistering skin rash that affects 15 to 25 percent of people with celiac disease.3 The rash usually occurs on the elbows, knees, and buttocks. Most people with DH have no digestive symptoms of celiac disease.

DH is diagnosed through blood tests and a skin biopsy. If the antibody tests are positive and the skin biopsy has the typical findings of DH, patients do not need to have an intestinal biopsy. Both the skin disease and the intestinal disease respond to a gluten-free diet and recur if gluten is added back into the diet. The rash symptoms can be controlled with antibiotics such as dapsone. Because dapsone does not treat the intestinal condition, people with DH must maintain a gluten-free diet.

Screening
Screening for celiac disease means testing for the presence of autoantibodies in the blood in people without symptoms. Americans are not routinely screened for celiac disease. However, because celiac disease is hereditary, family members of a person with the disease may wish to be tested. Four to 12 percent of an affected person’s first-degree relatives will also have the disease.4

How is celiac disease treated?
The only treatment for celiac disease is a gluten-free diet. Doctors may ask a newly diagnosed person to work with a dietitian on a gluten-free diet plan. A dietitian is a health care professional who specializes in food and nutrition. Someone with celiac disease can learn from a dietitian how to read ingredient lists and identify foods that contain gluten in order to make informed decisions at the grocery store and when eating out.

For most people, following this diet will stop symptoms, heal existing intestinal damage, and prevent further damage. Improvement begins within days of starting the diet. The small intestine usually heals in 3 to 6 months in children but may take several years in adults. A healed intestine means a person now has villi that can absorb nutrients from food into the bloodstream.

To stay well, people with celiac disease must avoid gluten for the rest of their lives. Eating even a small amount of gluten can damage the small intestine. The damage will occur in anyone with the disease, including people without noticeable symptoms. Depending on a person’s age at diagnosis, some problems will not improve, such as short stature and dental enamel defects.

Some people with celiac disease show no improvement on the gluten-free diet. The most common reason for poor response to the diet is that small amounts of gluten are still being consumed. Hidden sources of gluten include additives such as modified food starch, preservatives, and stabilizers made with wheat. And because many corn and rice products are produced in factories that also manufacture wheat products, they can be contaminated with wheat gluten.

Rarely, the intestinal injury will continue despite a strictly gluten-free diet. People with this condition, known as refractory celiac disease, have severely damaged intestines that cannot heal. Because their intestines are not absorbing enough nutrients, they may need to receive nutrients directly into their bloodstream through a vein, or intravenously. Researchers are evaluating drug treatments for refractory celiac disease.

The Gluten-free Diet
A gluten-free diet means not eating foods that contain wheat, rye, and barley. The foods and products made from these grains should also be avoided. In other words, a person with celiac disease should not eat most grain, pasta, cereal, and many processed foods.

Despite these restrictions, people with celiac disease can eat a well-balanced diet with a variety of foods. They can use potato, rice, soy, amaranth, quinoa, buckwheat, or bean flour instead of wheat flour. They can buy gluten-free bread, pasta, and other products from stores that carry organic foods, or order products from special food companies. Gluten-free products are increasingly available from mainstream stores.

“Plain” meat, fish, rice, fruits, and vegetables do not contain gluten, so people with celiac disease can freely eat these foods. In the past, people with celiac disease were advised not to eat oats. New evidence suggests that most people can safely eat small amounts of oats, as long as the oats are not contaminated with wheat gluten during processing. People with celiac disease should work closely with their health care team when deciding whether to include oats in their diet. Examples of other foods that are safe to eat and those that are not are provided in the table.

The gluten-free diet requires a completely new approach to eating. Newly diagnosed people and their families may find support groups helpful as they learn to adjust to a new way of life. People with celiac disease must be cautious about what they buy for lunch at school or work, what they purchase at the grocery store, what they eat at restaurants or parties, and what they grab for a snack. Eating out can be a challenge. When in doubt about a menu item, a person with celiac disease should ask the waiter or chef about ingredients and preparation or if a gluten-free menu is available.

Gluten is also used in some medications. People with celiac disease should ask a pharmacist if prescribed medications contain wheat. Because gluten is sometimes used as an additive in unexpected products—such as lipstick and play dough—reading product labels is important. If the ingredients are not listed on the label, the manufacturer should provide a list upon request. With practice, screening for gluten becomes second nature.

New Food Labeling
The Food Allergen Labeling and Consumer Protection Act (FALCPA), which took effect on January 1, 2006, requires food labels to clearly identify wheat and other common food allergens in the list of ingredients. FALCPA also requires the U.S. Food and Drug Administration to develop and finalize rules for the use of the term “gluten free” on product labels.

The Gluten-free Diet: Some Examples
In 2006, the American Dietetic Association updated its recommendations for a gluten-free diet. The following chart is based on the 2006 recommendations. This list is not complete, so people with celiac disease should discuss gluten-free food choices with a dietitian or physician who specializes in celiac disease. People with celiac disease should always read food ingredient lists carefully to make sure the food does not contain gluten.

Allowed Foods:

• amaranth
• arrowroot
• buckwheat
• cassava
• corn
• flax
• Indian rice grass
• Job’s tears legumes
• millet
• nuts
• potatoes
• quinoa
• rice
• sago seeds
• sorghum
• soy
• tapioca
• teff
• wild rice
• yucca

Foods To Avoid:

• wheat
• including einkorn, emmer, spelt, kamut
• wheat starch, wheat bran, wheat germ, cracked wheat, hydrolyzed wheat
• protein
• barley
• rye
• triticale (a cross between wheat and rye)

Other Wheat Products

• bromated flour
• durum flour
• enriched flour
• farina graham flour
• phosphated flour
• plain flour self-rising flour
• semolina
• white flour

Processed Foods that May Contain Wheat, Barley, or Rye*

• bouillon cubes
• brown rice syrup
• candy
• chips/potato chips
• cold cuts, hot dogs, salami, sausage
• communion wafers French fries
• gravy
• imitation fish
• matzo
• rice mixes
• sauces seasoned tortilla chips
• self-basting turkey
• soups
• soy sauce
• vegetables in sauce

* Most of these foods can be found gluten-free. When in doubt, check with the food manufacturer.

Source: Thompson T. Celiac Disease Nutrition Guide, 2nd ed. Chicago: American Dietetic Association; 2006. © American Dietetic Association. Adapted with permission.

Points to Remember
People with celiac disease cannot tolerate gluten, a protein in wheat, rye, and barley.

Untreated celiac disease damages the small intestine and interferes with nutrient absorption.

Without treatment, people with celiac disease can develop complications such as osteoporosis, anemia, and cancer.

A person with celiac disease may or may not have symptoms.

Diagnosis involves blood tests and, in most cases, a biopsy of the small intestine.

Since celiac disease is hereditary, family members of a person with celiac disease may wish to be tested.

Celiac disease is treated by eliminating all gluten from the diet. The gluten-free diet is a lifetime requirement.

A dietitian can teach a person with celiac disease about food selection, label reading, and other strategies to help manage the disease.

Hope through Research
The National Institute of Diabetes and Digestive and Kidney Diseases conducts and supports research on celiac disease. Researchers are studying new options for diagnosing celiac disease, including capsule endoscopy. In this technique, patients swallow a capsule containing a tiny video camera that records images of the small intestine.

Several drug treatments for celiac disease are under evaluation. Researchers are also studying a combination of enzymes—proteins that aid chemical reactions in the body—that detoxify gluten before it enters the small intestine.

Scientists are also developing educational materials for standardized medical training to raise awareness among health care providers. The hope is that increased understanding and awareness will lead to earlier diagnosis and treatment of celiac disease.

CDC

What is a Food Allergy

Food allergy is an abnormal response to a food triggered by your body's immune system. Allergic reactions to food can sometimes cause serious illness and death. Tree nuts and peanuts are the leading causes of deadly allergic reactions called anaphylaxis.

In adults, the foods that most often trigger allergic reactions include:

• 
  Fish and shellfish, such as shrimp, lobster and crab
• 
  Peanuts
• 
  Tree nuts, such as walnuts
• 
  Eggs

Problem foods for children are eggs, milk (especially in infants and young children) and peanuts.

Sometimes a reaction to food is not an allergy. It is often a reaction called "food intolerance". Your immune system does not cause the symptoms of food intolerance. However, these symptoms can look and feel like those of a food allergy.

National Institute of Allergy and Infectious Diseases

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