ORIGINAL ARTICLE: GASTROENTEROLOGY
Leonardo da Vinci Meets Celiac Disease
Chiara Zanchi, yGiovanna Ventura, Grazia Di Leo, zNicoletta Orzes, Luca Ronfani, yTarcisio Not, and yAlessandro Ventura
ABSTRACT Background and Aim: Leonardo da Vinci’s face symmetry derives from 3 equal craniofacial segments: trichion-nasion (tn), which represents the superior third of the face, nasion-subnasal (ns) that is the medium third of the face, and subnasal-gnathion (sg) that is the length of the lower third of the face. It has been reported that adult subjects with celiac disease (CD) can be identified on the basis of a greater extension of the forehead in comparison to the medium third of the face, with a high tn/ns ratio. The aim of the present study was to investigate the correlation between facial asymmetry and CD in childhood and adulthood. Methods: We studied 126 biopsy-proven patients with CD (76 children and 50 adults) and 102 healthy controls (43 children and 59 adults). Their faces were photographed; the pictures were edited using a software program to calculate the facial segments. Results: The tn length was significantly different between adult celiac and adult controls (7.43 1.46 cm vs 6.38 1.73 cm, P ¼ 0.001). The cutoff of 6.5 cm tn, derived from receiver operating characteristic curve analysis, identified 43 of 50 patients (sensitivity 86%), but 34 of 59 controls were positive (specificity 54.2%). The positive predictive value was 56%; however, the tn/ns ratio was not significantly different between celiacs and controls. Neither the tn length nor the tn/ns ratio in celiacs correlated to the time of gluten exposure. Conclusions: Adults, but not children, with celiac disease show a forehead extension significantly greater than controls, but this test’s specificity appears too low to be used in the screening of CD. Key Words: bone metabolism, celiac disease, facial asymmetry, forehead extension, gluten
(JPGN 2013;56: 206–210)
C
eliac disease (CD) is an autoimmune disorder triggered by gluten in genetically predisposed individuals (1). The clinical picture varies from apparently asymptomatic cases to severe malabsorption syndrome. Gluten-free diet is the only effective therapy, whereas unrecognized and untreated cases are exposed to an increased risk of malignancy, osteoporosis, other autoimmune disorders, and an increased mortality (1–3). The
Received June 5, 2012; accepted August 14, 2012. From the Institute for Maternal and Child Health—IRCCS ‘‘Burlo Garofolo,’’ yUniversity of Trieste, and zDepartment of Gastroenterology and Digestive Endoscopy, Civil Hospital, Gorizia, Italy. Address correspondence and reprint requests to Chiara Zanchi, Department of Pediatrics, Institute for Maternal and Child Health—IRCCS ‘‘Burlo Garofolo’’—University of Trieste, Via dell’Istria 65, 34100 Trieste, Italy (e-mail:
[email protected]). The authors report no conflicts of interest. Copyright # 2013 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0b013e31827114a4
detection of some apparently negligible signs (eg, systematic dental enamel defect) may help in recognizing the cases that otherwise may remain unrecognized (4,5). In his famous ‘‘Vitruvian Man,’’ a mathematic design in which the union between scientific spirit and artistic intuition is expressed, Leonardo da Vinci defines the ideal and perfect proportions of the human body, and divides the face into 3 equal parts (Fig. 1). A recent study suggests that adult celiac patients have a typical asymmetry of the face, with a forehead that is larger than the other two-thirds of the face. The authors’ suggestion is that this measurement could be useful for the diagnosis and screening of CD because it is feasible at a glance (7). This hypothesis has not yet been confirmed in the literature. In our work we verified whether the measurement of the length and the proportions of the face’s segments according to Leonardo da Vinci may be useful for the clinical diagnosis of CD, both in adulthood and in childhood.
METHODS Subjects A total of 126 celiac subjects (87 females and 39 males) and 102 healthy controls (62 females and 40 males) were enrolled and 4 subgroups were compared: 50 adults with known CD (from now on referred to as group 1), 76 children with known CD (group 2), 59 healthy adults (group 3), and 43 healthy children (group 4). Celiac adult and children patients (groups 1 and 2) were recruited among the outpatient clinic for periodic follow-up (subjects already on a gluten-free diet) and, in some cases, among the day-hospital patients coming for CD diagnosis formalization. In all of the patients, the diagnosis of CD was based on the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition criteria (positive serology and typical duodenal mucosa aspect). Healthy adult and children controls (groups 3 and 4) were recruited among inpatients accessed to the hospital for acute disease and among outpatients; none of these subjects had a gastroenterological problem. All of the controls had a negative antitransglutaminase antibodies rapid assay. Subjects with facial asymmetry, or who had had facial trauma and/or facial plastic surgery, and bold subjects in whom a precise extracranic cephalometric analysis was difficult, were excluded. Moreover, subjects with chronic diseases (rheumatologic, endocrinologic, and metabolic diseases) were excluded. The present study took place at the Pediatric Department of the IRCCS Burlo Garofolo of the University of Trieste, Italy, and at the Gastroenterology and Digestive Endoscopy Division of the Civil Hospital of Gorizia, Italy.
Methods Pictures were taken from a distance of 150 cm with a digital camera (3.2 megapixels) and with the subject’s head in a ‘‘natural
206 JPGN Volume 56, Number 2, February 2013 Copyright 2013 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Volume 56, Number 2, February 2013
Leonardo da Vinci Meets Celiac Disease
tn tg
ns sg
FIGURE 1. ‘‘Vitruvian Man’’ of Leonardo da Vinci, which defines the ideal and perfect proportions of the human body and face. (Pen and ink with wash over metalpoint, on paper, circa 1487, 34.4 25.5 cm, Gallerie dell’Accademia, Venice, Italy.)
head orientation’’; natural head orientation is the position that the physician considers the natural head position, that is, the position studied to make the cephalometric analysis using extracranic reference points instead of intracranic ones (8–11). Basically, natural head position is the natural position assumed by the head when a subject is asked to stand up and to look straight forward to a distant point at an eye level (9–12). The same person, who did not know the diagnosis, took all the pictures with a constant zoom. The pictures were thereafter digitally edited using Adobe Photoshop CS (Adobe, San Jose, CA). Each picture was rotated until the interpupil distance resulted parallel to the lower side of the picture frame; in most cases, the rotation needed was