The gluten syndrome: A neurological disease

Sieving out non-celiac gluten sensitivity amongst patients with irritable bowel syndrome

OBJECTIVES

It is challenging to make diagnosis of non-celiac gluten sensitivity/non-celiac wheat sensitivity (NCGS/NCWS) in clinical practice, since there is no biomarker and diagnosis is based on response to gluten-free-diet (GFD). We used anti-gliadin antibody (AGA) for screening patients with IBS for gluten-sensitivity.

METHODS

492 Adult-patients with IBS underwent screening for celiac disease and gluten-sensitivity using IgA anti-tissue transglutaminase antibody and IgA-AGA and IgG-AGA, respectively. Patients with positive AGA (IgA and/or IgG) were invited to follow GFD, those willing were put on GFD for 6-weeks. Responsive patients were given gluten re-challenge. Diagnosis of NCGS was confirmed if they had recurrence of symptoms.

RESULTS

Of 492 patients with IBS, AGA was positive in 61(12.4 %), hence suspected to have gluten-sensitivity. Of 31 who agreed to participate and followed GFD for 6-weeks, 17 (54.8 %) had complete (>30 % improvement) and 10(32.2 %) had partial (>20 % improvement) response. All 17 complete-responders were given gluten re-challenge for 6-weeks, symptoms recurred in all and hence were confirmed to have NCGS/NCWS. Significant decrease in AGA levels occurred almost in all GFD-responders.

CONCLUSIONS

12.4 % IBS patients have biological evidence of gluten/wheat-sensitivity. Almost 87 % patients with IBS having AGA responded to GFD. The value of AGA may further be explored as a biomarker for screening for the presence of NCGS, before recommending this test for the clinical practice.

Celiac Disease and Neurological Manifestations: From Gluten to Neuroinflammation

Celiac disease (CD) is a complex multi-organ disease with a high prevalence of extra-intestinal involvement, including neurological and psychiatric manifestations, such as cerebellar ataxia, peripheral neuropathy, epilepsy, headache, cognitive impairment, and depression. However, the mechanisms behind the neurological involvement in CD remain controversial. Recent evidence shows these can be related to gluten-mediated pathogenesis, including antibody cross-reaction, deposition of immune-complex, direct neurotoxicity, and in severe cases, vitamins or nutrients deficiency. Here, we have summarized new evidence related to gut microbiota and the so-called "gut-liver-brain axis" involved in CD-related neurological manifestations. Additionally, there has yet to be an agreement on whether serological or neurophysiological findings can effectively early diagnose and properly monitor CD-associated neurological involvement; notably, most of them can revert to normal with a rigorous gluten-free diet. Moving from a molecular level to a symptom-based approach, clinical, serological, and neurophysiology data might help to disentangle the many-faceted interactions between the gut and brain in CD. Eventually, the identification of multimodal biomarkers might help diagnose, monitor, and improve the quality of life of patients with "neuroCD".

Extra-Intestinal Manifestations of Celiac Disease: What Should We Know in 2022?

Celiac disease (CD) is a chronic, small-intestinal, immune-mediated enteropathy due to gluten exposition in genetically predisposed individuals. It occurs in about 1% of the population and often remains an underdiagnosed condition. This could be due to the fact that the adult population often lacks the classical signs and symptoms of CD, manifesting only atypical symptoms. In this review we analyzed the main extra-intestinal manifestations of CD which include cutaneous and endocrinological disorders, abnormal liver function tests, and neuropsychiatric features. When CD is not diagnosed and therefore is not treated with a gluten-free diet (GFD), it can predispose to severe complications, not only gastrointestinal. Thus, it is important for clinicians to quickly recognize the atypical manifestations of CD, considering that an early diagnosis can significantly impact on a patient's prognosis.

Effective Degradation of Gluten and Its Fragments by Gluten-Specific Peptidases: A Review on Application for the Treatment of Patients with Gluten Sensitivity

To date, there is no effective treatment for celiac disease (CD, gluten enteropathy), an autoimmune disease caused by gluten-containing food. Celiac patients are supported by a strict gluten-free diet (GFD). However, in some cases GFD does not negate gluten-induced symptoms. Many patients with CD, despite following such a diet, retain symptoms of active disease due to high sensitivity even to traces of gluten. In addition, strict adherence to GFD reduces the quality of life of patients, as often it is difficult to maintain in a professional or social environment. Various pharmacological treatments are being developed to complement GFD. One promising treatment is enzyme therapy, involving the intake of peptidases with food to digest immunogenic gluten peptides that are resistant to hydrolysis due to a high prevalence of proline and glutamine amino acids. This narrative review considers the features of the main proline/glutamine-rich proteins of cereals and the conditions that cause the symptoms of CD. In addition, we evaluate information about peptidases from various sources that can effectively break down these proteins and their immunogenic peptides, and analyze data on their activity and preliminary clinical trials. Thus far, the data suggest that enzyme therapy alone is not sufficient for the treatment of CD but can be used as a pharmacological supplement to GFD.

Sustainability Opportunities for Mediterranean Food Products through New Formulations Based on Carob Flour (Ceratonia siliqua L.)

Carob flour is increasingly popular in innovative functional foods. Its main producers are Mediterranean countries, facing health and nutrition challenges, and difficulties in tackling climate change. This study aims at formulating innovative sustainable bakery products of high nutritional value while pleasing the consumer and addressing regional challenges. Hence, carob flour was obtained by grinding sun-dried carob pods, thus reducing the environmental impact, and preserving carob’s high nutraceutical value. Different bread formulations resulted from the blend of wheat flour with carob pulp (5, 10, 20, and 30%) and/or seed powder (5 and 10%), with no added fats, additives, or processing aids. New products were evaluated for their textural, chromatic, nutritional, aromatic, and hedonic properties. Carob is rich in aroma, antioxidants, and prebiotic fibers, and does not contain gluten, so when combined with wheat, the proportion of gluten in bread is reduced. Carob is also rich in minerals (4.16% and 2.00% ash, respectively in seed and pulp), and breadmaking seems to generate lesser furane derivatives than in white bread. In short, carob is typically Mediterranean and is a valuable local resource in the formulation of sustainable foods with high nutritional value, low carbon footprint, safe, healthy, tasty, and affordable, all at once.

Whole and refined grains change behavior and reduce brain derived neurotrophic factor and neurotrophin-3 in rats

In most of the world, wheat is one of the main staple foods, and is also widely used in livestock feed. In the current study, we investigated the effects of wheat grain consumption on the rat behavior and neurogenesis markers. Thirty male rats were divided into three equal groups (n = 10). Group 1 was the control group fed with chow diet (Carbohydrates 63%, fat 13% and protein 24%), the Group 2 rats were fed with whole grains and the Group 3 rats were fed with refined grains. After 12 weeks, we measured the hippocampal and prefrontal cortical brain derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3), 5-hydroxytryptamine, dopamine, norepinephrine, malondialdehyde (MDA) and reduced glutathione (GSH) levels. Also, we evaluated the rat behavior by forced swimming test (FST) and elevated plus maze (EPM) test. Additionally, we measured serum level of glucose, lipid profile, insulin and cortisol. Weight gain at the end of the study was measured in each group. The rats on a diet of whole and refined grains had low BDNF, NT-3, norepinephrine, dopamine and serotonin significantly (p < .01) in both the hippocampus and prefrontal cortex as compared to control rats. Moreover, the MDA increased significantly with significant reduction in GSH versus the control rats. Moreover, in response to grain consumption, the performance in FST showed a significant (p < .01) shortage in the latency of the attempts to escape as well as a significant prolongation (p < .01) in behavioral immobility as compared to control rats with significant (p < .05) prolongation in time spent in closed arm in EPM. An exclusive diet of either whole or refined grain in a rat model induced anxiety and depressive behaviors and negatively affected the BDNF and NT-3 and modulated the level of the neurotransmitters with significant shift in their behavior. PRACTICAL APPLICATIONS: Grains are considered the major caloric source all over the world that may predispose to the development of chronic diseases. In this research, we evaluated the role of grains in modulating the rate of production of neurogenic factors in rats.

An updated overview of spectrum of gluten-related disorders: clinical and diagnostic aspects

The incidence of gluten-related disorders (GRDs) continues to increase and its global prevalence is estimated at approximately 5% of the population. Celiac disease (CD), dermatitis herpetiformis (DH), gluten ataxia (GA), wheat allergy (WA), and non-celiac gluten sensitivity (NCGS) are the five major GRDs that present with a wide range of clinical manifestations. The diagnosis of GRDs can be challenging because the typical and atypical clinical manifestations of the GRDs overlap. In this review, the current definitions of gluten-related disorders, focusing on their clinical features, diagnostic and therapeutic approaches are presented. We concluded that GRDs are usually diagnosed using a combination of clinical features, serological tests, and histopathological findings. Treatment usually involves dietary modification.

Associations between migraine, celiac disease, non-celiac gluten sensitivity and activity of diamine oxidase

BACKGROUND AND PILOT STUDY

Recent reports reveal a close relationship between migraine and gastrointestinal disorders (GI), such as celiac disease (CD) and non-celiac gluten sensitivity (NCGS). CD is a genetic autoimmune disorder, which affects the mucosa of the small intestine. Gluten, found in various grains, not only plays a major role in the pathophysiology of CD and NCGS, but also aggravates migraine attacks. Another common food component, which can induce migraine headaches, is histamine. Diamine oxidase (DAO) is an enzyme, which degrades histamine. Reduced activity of DAO means reduced histamine degradation, which can cause histamine build-up and lead to various symptoms, including headaches and migraine. In this paper we propose a hypothesis, that in pathogenesis of migraine, low serum DAO activity is related to CD and NCGS. We also conducted our own pilot study of 44 patients with severe migraine in efforts to evaluate the co-presence of decreased serum DAO activity and celiac disease/NCGS in patients. 44 consecutive migraine patients were divided into 2 groups: decreased DAO activity (group 1; n = 26) and normal DAO activity (group 2; n = 18). All patients were screened for celiac disease. The diagnosis of NCGS was made after exclusion of CD, food allergies and other GI disorders in the presence of gluten sensitivity symptoms. Furthermore, dietary recommendations were given to all participants and their effects were assessed 3 months after the initial evaluation via the MIDAS (Migraine Disability Assessment) questionnaire.

RESULTS AND CONCLUSIONS

Only 1 patient fit the criteria for celiac disease, rendering this result inconclusive. Pathological findings of the remainder of patients were attributed to NCGS (n = 10). 9 of 10 patients with NCGS belonged to the decreased serum DAO activity group (group 1; n = 26), suggesting a strong relationship between reduced serum DAO activity and NCGS. MIDAS questionnaire revealed, that patients with decreased serum DAO activity were more severely impacted by migraine than those with normal DAO activity, and this remained so after our interventions. Dietary adjustments significantly reduced the impact of migraine on patients' daily activities after 3 months in both groups. We argue, that migraine, celiac disease and NCGS may benefit from treatment with a multidisciplinary approach, involving neurologists, gastroenterologists and dietitians.

Celiac Disease Symptoms in Athletes: Prevalence Indicators of Perceived Quality of Life

BACKGROUND

Celiac disease (CD) is a common gastrointestinal pathology; however, prevalence and comorbidities are unknown in collegiate athletics.

HYPOTHESES

(1) Athletes will have similar odds of CD as general population estimates (approximately 1 in 141) based on self-report and signs and symptoms, (2) athletes scoring higher on the Celiac Symptom Index (CSI) will have lower self-reported quality of life (QoL), (3) athletes scoring higher on the CSI will have higher depression scores, and (4) athletes scoring higher on the CSI will have higher perceived stress scores.

STUDY DESIGN

Epidemiological cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

The CSI, WHO Quality of Life-BREF, Beck Depression Inventory, and Perceived Stress Scale were used to assess patients' signs and symptoms of CD and psychosocial measures/QoL in male and female National Collegiate Athletic Association (all divisions) athletes (N = 141). Participants also self-reported a formal diagnosis of CD. Chi-square analyses determined CD prevalence. Odds ratios determined risk for either being diagnosed with CD or reporting more symptoms than the general population. Correlational analyses determined whether symptoms correlated with QoL and psychosocial measures.

RESULTS

Athletes were 3.85 times (95% CI, 0.42-34.89) more likely to report a CD diagnosis and were 18.36 times (95% CI, 2.40-140.48) more likely to report a high degree of CD symptoms than the general population. Athletes with more symptoms had worse physical, psychological, social, and environmental QoL indicators and higher depression and perceived stress scores.

CONCLUSION

Athletes may be a higher risk population for experiencing CD and report greater signs/symptoms compared with general population estimates. Additionally, athletes with higher CD symptom scores also reported poorer QoL.

CLINICAL RELEVANCE

Allied health care professionals should be aware of the diversity of CD symptoms and be prepared to refer athletes when gastrointestinal symptoms persist to ensure proper care and unhampered performance.

Mood Disorders and Gluten: It's Not All in Your Mind! A Systematic Review with Meta-Analysis

Gluten elimination may represent an effective treatment strategy for mood disorders in individuals with gluten-related disorders. However, the directionality of the relationship remains unclear. We performed a systematic review of prospective studies for effects of gluten on mood symptoms in patients with or without gluten-related disorders. Six electronic databases (CINAHL, PsycINFO, Medline, Web of Science, Scopus and Cochrane Library) were searched, from inception to 8 August 2018, for prospective studies published in English. Meta-analyses with random-effects were performed. Three randomised-controlled trials and 10 longitudinal studies comprising 1139 participants fit the inclusion criteria. A gluten-free diet (GFD) significantly improved pooled depressive symptom scores in GFD-treated patients (Standardised Mean Difference (SMD) -0.37, 95% confidence interval (CI) -0.55 to -0.20; p < 0.0001), with no difference in mean scores between patients and healthy controls after one year (SMD 0.01, 95% CI -0.18 to 0.20, p = 0.94). There was a tendency towards worsening symptoms for non-coeliac gluten sensitive patients during a blinded gluten challenge vs. placebo (SMD 0.21, 95% CI -0.58 to 0.15; p = 0.25). Our review supports the association between mood disorders and gluten intake in susceptible individuals. The effects of a GFD on mood in subjects without gluten-related disorders should be considered in future research.

Medical Comorbidities in Pediatric Headache

Comorbid conditions frequently occur in pediatric headaches and may significantly affect their management. Comorbidities that have been associated with pediatric headaches include attention-deficit or hyperactivity disorder, autism, developmental disabilities, depression, anxiety, epilepsy, obesity, infantile colic, atopic disorders, inflammatory bowel disease, and irritable bowel syndrome. The goal of this article is to review these comorbidities associated with pediatric headache, thereby empowering child neurologists to identify common triggers and tailor management strategies that address headache and its comorbidities.

Gluten ataxia in Japan

Gluten ataxia, a type of cerebellar ataxia caused by exposure to gluten in sensitive patients, has been considered common in the USA and Europe, and rare in Asia. We measured anti-deamidated gliadin peptide (DGP) antibody levels in 49 patients with cerebellar ataxia, excluding those with multiple system atrophy, hereditary spinocerebellar ataxia, or cancer, as well as those who were receiving oral administration of phenytoin. Anti-DGP antibody was positive in eight (16.3 %) patients, five of these patients were positive only for IgA, one was positive for both IgG and IgA, and two were positive only for IgG antibody. Intravenous immunoglobulin was administered to five of the eight patients, and was markedly effective in one, moderately effective in two, and ineffective in two. Steroid therapy was administered to four patients, but none had an apparent response. Ataxia symptoms improved in one patient treated with a gluten-free diet only. Although it had been thought to be extremely rare in Asia, we speculate that more than 10 % of cerebellar ataxia patients in Japan currently have gluten ataxia; therefore, measuring anti-DGP antibody or anti-gliadin antibody in cerebellar ataxia patients in Asia is important.

No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates

BACKGROUND & AIMS

Patients with non-celiac gluten sensitivity (NCGS) do not have celiac disease but their symptoms improve when they are placed on gluten-free diets. We investigated the specific effects of gluten after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates (fermentable, oligo-, di-, monosaccharides, and polyols [FODMAPs]) in subjects believed to have NCGS.

METHODS

We performed a double-blind cross-over trial of 37 subjects (aged 24-61 y, 6 men) with NCGS and irritable bowel syndrome (based on Rome III criteria), but not celiac disease. Participants were randomly assigned to groups given a 2-week diet of reduced FODMAPs, and were then placed on high-gluten (16 g gluten/d), low-gluten (2 g gluten/d and 14 g whey protein/d), or control (16 g whey protein/d) diets for 1 week, followed by a washout period of at least 2 weeks. We assessed serum and fecal markers of intestinal inflammation/injury and immune activation, and indices of fatigue. Twenty-two participants then crossed over to groups given gluten (16 g/d), whey (16 g/d), or control (no additional protein) diets for 3 days. Symptoms were evaluated by visual analogue scales.

RESULTS

In all participants, gastrointestinal symptoms consistently and significantly improved during reduced FODMAP intake, but significantly worsened to a similar degree when their diets included gluten or whey protein. Gluten-specific effects were observed in only 8% of participants. There were no diet-specific changes in any biomarker. During the 3-day rechallenge, participants' symptoms increased by similar levels among groups. Gluten-specific gastrointestinal effects were not reproduced. An order effect was observed.

CONCLUSIONS

In a placebo-controlled, cross-over rechallenge study, we found no evidence of specific or dose-dependent effects of gluten in patients with NCGS placed diets low in FODMAPs.

The irritable bowel syndrome-celiac disease connection

Irritable bowel syndrome (IBS) is a prevalent functional gastrointestinal disorder that has a significant impact on quality of life and health care resources. Celiac disease (CD), a gluten-sensitive enteropathy, can be mistaken for IBS. This article discusses the connection between IBS and CD and the new concept of nonceliac gluten sensitivity (NCGS). NCGS may occur in the presence of a normal or near-normal small bowel biopsy. Some patients with IBS without CD may derive symptomatic benefit from a gluten-free diet. Future research could facilitate a significant impact on the quality of life in this potential subgroup of patients.

[Gluten-related disorders and demyelinating diseases]

Gluten-related disorders are a spectrum of systemic immune mediated conditions that occur at any age in genetically susceptible individuals upon ingesting gluten. Celiac disease and gluten sensitivity are the most important conditions of the spectrum. They may be associated with other autoimmune diseases, such as multiple sclerosis and neuromyelitis optica. Treatment with a gluten-free diet can provide considerable benefits to the patients having both a gluten-related disorder and one of these 2 demyelinating diseases of the central nervous system.

Gluten sensitivity: problems of an emerging condition separate from celiac disease

Gluten sensitivity appears to be emerging as a separate condition from celiac disease, yet no clear definition or diagnosis exists. As a result, patients with gluten sensitivity experience delayed diagnosis and continuing symptoms if they consume gluten. This emerging medical problem may involve human genetics, plant genetic modifications, gluten as a food additive, environmental toxins, hormonal influences, intestinal infections and autoimmune diseases. The treatment is similar to that for celiac disease - a gluten-free diet. The use of a gluten-free diet or an elimination diet is encouraged in assisting people to determine whether or not they are gluten sensitive. It is time to not only recognize, but to treat and further research gluten sensitivity, as unconfirmed environmental factors continue to spread this problem further into the general population.

Does food intolerance play a role in recurrent respiratory papillomatosis?

BACKGROUND

The purpose of this study is to evaluate the potential role of food intolerances in the management of recurrent respiratory papillomatosis (RRP).

METHODS

This is a retrospective case review of 4 pediatric patients with RRP. All of the patients, cared for by the primary author between 2005 and 2010, were managed using microdebrider resection, intralesional injection of cidofovir, and required multiple surgeries. Skin prick test (SPT) and/or radioallergosorbent test (RAST) were obtained for 2 patients. Oral food challenge was utilized in all 4 patients.

RESULTS

Standard SPT and RAST did not identify any immunoglobulin E (IgE)-based allergens. A detailed medical history followed by an oral food challenge was successful at identifying food intolerances in all 4 patients. When specific food elimination was implemented in these patients' treatments in addition to microdebrider resection and cidofovir injection, statistically significant long-term remissions were achieved.

CONCLUSION

Food intolerance and its impact on RRP and immune dysfunction deserve further investigation and may benefit some patients with RRP.

Celiac disease: from pathogenesis to novel therapies

Celiac disease has become one of the best-understood HLA-linked disorders. Although it shares many immunologic features with inflammatory bowel disease, celiac disease is uniquely characterized by (1) a defined trigger (gluten proteins from wheat and related cereals), (2) the necessary presence of HLA-DQ2 or HLA-DQ8, and (3) the generation of circulating autoantibodies to the enzyme tissue transglutaminase (TG2). TG2 deamidates certain gluten peptides, increasing their affinity to HLA-DQ2 or HLA-DQ8. This generates a more vigorous CD4(+) T-helper 1 T-cell activation, which can result in intestinal mucosal inflammation, malabsorption, and numerous secondary symptoms and autoimmune diseases. Moreover, gluten elicits innate immune responses that act in concert with the adaptive immunity. Exclusion of gluten from the diet reverses many disease manifestations but is usually not or less efficient in patients with refractory celiac disease or associated autoimmune diseases. Based on the advanced understanding of the pathogenesis of celiac disease, targeted nondietary therapies have been devised, and some of these are already in phase 1 or 2 clinical trials. Examples are modified flours that have been depleted of immunogenic gluten epitopes, degradation of immunodominant gliadin peptides that resist intestinal proteases by exogenous endopeptidases, decrease of intestinal permeability by blockage of the epithelial ZOT receptor, inhibition of intestinal TG2 activity by transglutaminase inhibitors, inhibition of gluten peptide presentation by HLA-DQ2 antagonists, modulation or inhibition of proinflammatory cytokines, and induction of oral tolerance to gluten. These and other experimental therapies will be discussed critically.