Pengiran Tengah, Dayangku Siti Nur Ashikin
(2013)
The neurology of gluten sensitivity.
DM thesis, University of Nottingham.
Abstract
Classical coeliac disease (CD) is a well-defined syndrome of small bowel villous atrophy associated with abdominal pain, malabsorption, and weight loss as a result of gluten-sensitivity, reversed rapidly by gluten exclusion diet. Disease associations include dermatitis herpetiformis (DH), Addison’s disease, type 1 diabetes mellitus, autoimmune thyroid disease and a variety of neurological disorders. This thesis aims to investigate the hypothesis of the existence of a gluten sensitive neurological disease
CD with coexistent neurological dysfunction is only rarely reported in a neurological setting. 23 cases were reported from the British Neurological Surveillance Unit (BNSU) over 24 months and 13 locally over 31 months. 18 sets of notes (50%) were reviewed. These patients comprise a heterogeneous group of neurological disorders including epilepsy, myelopathy, axonal neuropathy and migraine.
Neurological disorders in patients with confirmed gluten sensitivity may occur simply by chance. In a cohort of 801 CD patients, 54 neurological disorders were identified in 177 patients including stroke (2.9%), migraine (2.7%), epilepsy (2.6%) and carpal tunnel syndrome (2.0%).
More detailed investigation of 35 patients with DH and 53 patients with CD, confirmed a low prevalence of idiopathic neurological abnormalities (DH 11%; CD 25%). Analysis of sera from these patients did not identify the presence of anti-neuronal antibodies. A novel anti-spinal antibody was identified in over 50% of the subjects with DH but this requires further characterisation.
It has been postulated that patients with idiopathic neurological disease and anti-gliadin antibody (AGA) seropositivity are gluten sensitive. However, AGA lacks disease specificity being found in 10% of healthy blood donors. Screening of 49 unselected multiple sclerosis cases found IgG AGA in 12% of patients and 13% of blood donors confirming that AGA (especially IgG isotype) can be a non-specific finding.
AGA, other food antibodies and tissue transglutaminase antibody (TTG) were measured in patients with idiopathic ataxia (20), hereditary ataxia (7) and idiopathic peripheral neuropathy (32). None of the cases was positive for IgA TTG making occult CD unlikely. Cerebellar ataxia with positive AGA (so-called ‘gluten ataxia’) was rare (4 cases in 2 years from a population of 2 million). All food antibodies tested (AGA, hen’s egg albumen, and cow’s milk lactoglobulin), particularly IgG, were a common finding in both ataxia and peripheral neuropathy groups.
This study found no evidence for gluten neurotoxicity. Serological tests, particularly AGA, need to be interpreted with caution. Further study is required regarding the nature of the association between neurological illness and gluten sensitivity.
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