Clinical Findings and Anti-Neuronal Antibodies in Coeliac Disease withNeurological Disorders

U Volta R De Giorgio N Petrolini V Stanghellini G Barbara A Granito F De PontiR Corinaldesi amp F B BianchiDept of Internal Medicine Cardioangiology Hepatology Dept of Internal Medicine andGastroenterology Dept of Pharmacology University of Bologna Italy

Volta U De Giorgio R Petrolini N Stanghellin i V Barbara G Granito A De Ponti F Corinaldesi RBianchi FB Clinical findings and anti-neurona l antibodies in coeliac disease with neurologica l disorders Scand J Gastroentero l 2002371276 ndash1281

Background Little is known about the clinical and immunologica l features of coeliac disease patientswith neurologica l disorders In a large series of adult coeliac disease patients we investigated theprevalence of neurologica l disorders and anti-neurona l antibodies along with the clinical courseMethods Neurologica l symptoms were investigated in 160 consecutive patients (120 F 40 M) withbiopsy-proven coeliac disease Anti-neuronal antibodies to centralenteric nervous systems wereinvestigated in all neurologica l patients 20 unaffected ones and 20 controls Results Thirteen (8)patients had neurologica l disorders including epilepsy (n = 3) attentionmemory impairment (n = 3)cerebellar ataxia (n = 2) peripheral neuropathy (n = 2) multiple sclerosis (n = 1) Moyamoya disease(n = 1) and Steinertrsquos disease (n = 1) No signi cant demographic or clinical difference s (gastrointestina lor other gluten-related signs) were found between patients with and without neurologica l involvement Inall but 2 of the 13 cases the neurologica l disorder preceded diagnosis of coeliac disease Neurologica lsymptoms improved or disappeared in 7 patients who started a gluten-free diet within 6 months afterneurologica l onset and in none of 4 patients who began later Prevalence of central nervous system anti-neuronal antibodies was signi cantly higher in neurologica l (61) than in other patients (5) (P = 00007)or controls (0) (P = 000001) Conclusions Coeliac disease can sometimes present in the guise of aneurologica l disorder which may greatly improve when a gluten-free diet is started promptly Thereforethe possible presence of coeliac disease needs to be carefully considered in patients with cerebella r ataxiaepilepsy attentionmemory impairment or peripheral neuropathy

Key words Anti-neuronal antibody central nervous system diseases coeliac disease peripheral nervoussystem diseases

Umberto Volta MD Dept of Internal Medicine Cardioangiology Hepatology St Orsola-MalpighiHospital Via Massarenti 9 IT-40138 Bologna Italy (fax Dagger39 051 340877 e-mail uvoltaorsola -malpighimeduniboit)

Coeliac disease (CD) can be associated with a widevariety of central and peripheral nervous system(CNS and PNS) disorders such as epilepsy

myoclonus cerebellar ataxia multifocal leukoencephalopa-thy dementia and peripheral axonal and demyelinatingneuropathies (1ndash4) Gastrointestinal symptoms often lead tothe recognition of CD before the onset of neurologicaldisorders (5) However when neurological symptoms appearearly in the course of CD conditions such as epilepsy (withor without occipital calci cations) or cerebellar ataxia (6 7)may provide the only clue for suspecting the presence of anoccult gluten-sensitive enteropathy In most cases the courseof the neurological dysfunction is relentless and only aminority of epileptic and ataxic CD patients have shownimprovement after the introduction of a gluten-free diet(6 8 9)

The data regarding circulating anti-neuronal antibodies in

CD patients with neurological disorders are con ictingAntibodies reacting with human brain vessel structures thatwere reported in the sera of untreated CD patients withneurological involvement signi cantly decreased followinggluten withdrawal (10) Recently however some groupsfailed to con rm the existence of antibodies to monkeycerebellum in the same subset of CD patients (11 12)

In a large series of consecutive adult CD patients weinvestigated the prevalence of neurological disorders identi- ed before or after diagnosis of CD We examined the clinicalcourse of the neurological disorder particularly in relation tomore or less prompt start of gluten-free diet and anti-neuronalantibodies We also investigated the prevalence of anti-neuronal antibodies to the CNS (ie cerebellar cortexneurons) and to the enteric nervous system in CD patientswith and without neurological disorders (and controls) beforeand after gluten withdrawal

ORIGINAL ARTICLE

Oacute 2002 Taylor amp Francis

Methods

PatientsThis study included 160 consecutive CD patients (120 F

and 40 M median age 37 years range 18ndash79 years) diagnosedin our two Departments from January 1985 to June 2001 witha median follow-up of 6 years (range 3 months to 16 years)The majority of these subjects came from the Emilia-Romagna region (which is located in the north-east of theItalian peninsula) where the estimated prevalence of CD is 1case out of 174 inhabitants (13) CD-related antibodies (anti-gliadin (AGA) anti-endomysial (EmA) and anti-humanrecombinant tissue transglutaminase (h-tTG)) were tested inall patients (14 15) Diagnosis of CD was con rmed byendoscopic duodenal biopsy Histological ndings weregraded according to Marshrsquos revised criteria (16 17) Aformal neurological assessment was routinely performed inall CD patients on presentation including analysis of the timeof onset of any neurological symptoms with respect todiagnosis of CD Periodical dietary interviews were routinelyperformed in all CD patients to assess compliance withgluten-free diet All patients gave their informed consent toparticipate in the present study

Anti-neuronal antibodiesThe presence of anti-neuronal antibodies to CNS and

enteric nervous system (ENS) was investigated in all CDpatients with neurological involvement and in a group of CDpatients without neurological dysfunction (n = 20) Sera from20 patients with intestinal and autoimmune diseases (ie 10with in ammatory bowel disease and 10 with autoimmunehepatitis) and 10 blood donors served as controls Anti-neuronal antibodies were detected by indirect immuno uor-

escence on 5-mm cryostat sections of monkey and ratcerebellum as well as of rat ileum and colon (Medic TurinItaly) Patientsrsquo sera were tested at the initial dilution of 110and when positive were titrated up to the end-point Rabbitanti-human IgG and IgA (Dako Copenhagen Denmark) wereused as secondary antibody at the appropriate workingdilution (160 and 1100 on rat and monkey tissue respec-tively)

StatisticsThe Fisher exact test two-tailed was used to compare

clinical ndings and prevalence of anti-neuronal antibodies inCD patients with and without neurological disorders

Results

A neurological syndrome was recorded in 13 of the 160 (8)CD patients (11 F and 2 M median age at diagnosis of CD 36years range 19ndash56 years) In 11 of the 13 cases theneurological dysfunction presented before diagnosis of CDTen patients had disorders of the CNS including epilepsy(n = 3) attentionmemory impairment (n = 3) cerebellarataxia (n = 2) multiple sclerosis (n = 1) and acute cerebro-vascular disease (Moyamoya disease) (n = 1) The remainingthree patients had PNS disorders namely peripheral neuro-pathy (n = 2) and myotonic dystrophy (Steinertrsquos disease)(n = 1) (Table I)

CD patients with CNS disordersIn the three patients with epilepsy (all females) CD was

diagnosed 6 9 and 264 months after discovery of theneurological dysfunction (Table I) These patients had been

Table I Clinical immunologica l and histologica l features of the 13 CD patients with associated neurologica l disorders

CasesAge

(years) SexNeurologicaldisease (ND)

Time of ND beforeor after CDdiagnosis

Gastrointestinaland other

CD-related signs

IgAAGA

gt 110

IgAEmAgt 15

IgAh-tTGAgt7AU

Duodenalhistology

1 24 F Multiple sclerosis 48 months after Absent 140 180 15 AU 3a2 21 F Epilepsy 6 months before Constipation 1160 1160 gt20 AU 3b3 28 F Epilepsy 264 months before Absent 180 1160 18 AU 3b4 47 F Epilepsy 6 months before Iron-de ciency

anaemia120 180 12 AU 3b

5 37 F Cerebellar ataxia 24 months before Iron-de ciencyanaemia

1160 1320 gt20 AU 3c

6 39 F Cerebellar ataxia 3 months before Absent 110 120 8 AU 27 36 M Attentionmemory

impairment4 months before Raised serum

transaminases120 1160 gt20 AU 3b

8 32 F Attentionmemoryimpairment

5 months before Constipation 180 1160 gt20 AU 3b

9 34 F Attentionmemoryimpairment

6 months before Absent 110 110 9 AU 1

10 19 F Moyamoya disease 120 months after Diarrhoea 180 1160 14 AU 3b11 56 M Steinertrsquos disease 36 months before Diarrhoea 110 120 9 AU 3a12 38 F Peripheral neuropathy 4 months before Absent 110 180 16 AU 3b13 46 F Peripheral neuropathy 10 months before Absent 140 180 11 AU 3b

CD = coeliac disease AGA = antigliadin EmA = antiendomysial h-tTGA = human recombinant tissue transglutaminas e antibodies AU = arbitrary units duodenal histology Marshrsquos revised classi cation 1 ( intraepithelia l lymphocyte count -IEL) 2 ( IEL and crypthyperplasia) 3a 3b 3c (mild marked total villous atrophy)

Scand J Gastroenterol 2002 (11)

Neurologica l Dysfunction in Coeliac Disease 1277

classi ed as having respectively complex partial temporallobe seizures at the age of 20 years simple partial seizures(with motor signs) at the age of 46 years and primarygeneralized seizures with pure absence (petit male) at the ageof 3 years Brain computerized tomography (CT) scan wasnormal in all of them and showed no occipital calci cationSymptoms suggesting CD (severe constipation and iron-de ciency anaemia) were present in two patients whereas thepatient with long-standing epilepsy completely lacked non-neurological symptoms A gluten-free diet stopped theseizures in the two patients with symptomatic CD whereasit did not affect the seizures of the third patient

Of the two patients (both female) with cerebellar ataxia a39-year-old woman had a neurological onset characterized bymuscle weakness and pain associated with leg and armparaesthesias After a few months the patient began tocomplain of impaired balance A muscle biopsy showed atype-2 bre hypotrophy Despite the absence of gastrointest-inal and other CD-related signs the patient underwent a widearray laboratory screening revealing IgA EmA positivity Thefollowing duodenal biopsy performed only 3 months after theneurological onset proved the presence of CD This patienthad a striking response to gluten-free diet with completeresolution of the neurological symptoms By contrast theclinical outcome of the other patient who presented withcerebellar ataxia was unfavourable She was a 37-year-oldwoman with severe gait ataxia slurred speech and dysphagiaHer symptoms progressed rapidly so that she needed bilateralsupport and later a wheelchair to ambulate CD which wassuspected due to the nding of a severe iron-de ciencyanaemia and autoimmnune thyroiditis was diagnosed only 24months after the onset of neurological impairment Gluten-free diet associated with high-dose vitamin E treatment wascompletely unhelpful as was prednisolone and azathioprinetreatment

Three patients (1 M and 2 F) presented a neurologicalsyndrome characterized by loss of concentration along withattentionmemory impairment which started 4ndash6 monthsbefore diagnosis of CD The assessment of attentionmemoryimpairment was carefully evaluated through a thoroughneuropsychologica l examination before and after a gluten-free diet (1) All three patients had a normal brain CT ormagnetic resonance imaging (MRI) scan In one of them (a36-year-old man) CD was suspected owing to raised serumtransaminase levels of unknown origin and in another one (a32-year-old woman) owing to a severe constipation The thirdpatient was affected by a potential CD characterized bypositivity for EmA and tTG at low titre and mild histologicallesions (increased number of intraepithelial lymphocytes)(16 17) The gluten-free diet brought a substantial improve-ment in neurological symptoms in all 3 patients within 1 year

In the remaining two patients with CNS disordersdiagnosis of CD preceded the onset of neurological symp-toms A 24-year-old woman was identi ed as having CDduring a screening programme of rst-degree relatives She

had no gastrointestinal sign and her biochemical parameterswere all within the normal range Her compliance with thegluten-free diet was poor due to the asymptomatic state Fouryears later she developed diplopia upper motor neuron dys-function (right hand weakness and spasticity) and posteriorcolumn lesion (tingling or tightness of the extremities andband-like sensation along the trunk) MRI showed demyeli-nating multifocal white matter lesions in the brainstem andspinal cord The patient became compliant with the gluten-free diet without any improvement in her neurologicaldisease which later partially responded to high-dose steroidsand b-interferon treatment The other patient was found tohave CD at the age of 19 years due to a malabsorptionsyndrome Ten years later she developed a cerebral infarctionwith a transient left hemiplegia Brain CT and MRI scansshowed a large right fronto-rolandic ischaemic area and smallischaemic lesions in the left hemisphere Brain angiographyled to a diagnosis of Moyamoya disease based on the typicallsquopuff of smokersquo image indicating collateral ow circulationaround the middle cerebral occlusive lesion During thefollowing 12 years she strictly adhered to a gluten-free diet inassociation with salicylic acid and had no recurrence of acutecerebrovascular disease

CD patients with PNS disordersTwo of the three patients with PNS impairment were

women They were aged 38 and 46 years at the onset ofneurological dysfunction which preceded diagnosis of CD by4 and 10 months respectively (Table I) Neither of themcomplained of gastrointestinal nor other CD-related signsThe younger woman complained of muscle pain and legparaesthesias Although electroneuromyography was normalneurological assessment led to a diagnosis of small breneuropathy and neurological symptoms signi cantly im-proved 1 year after gluten withdrawal In the older woman adistal axonopathy was diagnosed based on clinical symptoms(ie intense leg paraesthesias numbness and hypore exia)and electroneuromyography results A gluten-free diet did notaffect the neurological symptoms In the remaining patient (amale) Steinertrsquos myotonic dystrophy was diagnosed at theage of 53 years The clinical picture was characterized byweakness of eyelid facial and neck exor muscles and ofdistal extremity muscles Myotonia was demonstrable in handgrip CD was diagnosed later because of a malabsorptionsyndrome A gluten-free diet did not improve the neurologicalpicture

Anti-neuronal antibodiesAnti-neuronal antibodies to CNS were detected in 8 of the

13 (61) CD patients with neurological involvement (1 withmultiple sclerosis 2 with epilepsy 2 with attentionmemoryimpairment 2 with cerebellar ataxia and 1 with myotonicdystrophy) as compared with only 1 of 20 (5) patientswithout neurological symptoms No positive staining wasfound in control subjects The prevalence of anti-neuronal

Scand J Gastroenterol 2002 (11)

1278 U Volta et al

antibodies to CNS was signi cantly higher in patients withneurological symptoms than in those without neurologicalsymptoms (P = 00007) or controls (P = 000001) (Table II)All the positive cases belonged to the IgG class (associatedwith IgA in 2 patients) with antibody titres ranging from 150to 1200 The anti-neuronal antibody pattern was character-ized by nuclear and cytoplasmic positivity of Purkinje cells(Fig 1A and B) and nuclear staining of granular layer neurons(Fig 1A) of both monkey and rat cerebellar cortex Noimmunolabelling was visualized around blood vessels In 6 ofthe 8 positive neurological patients anti-neuronal antibodies

to CNS disappeared after 1 year of a strict gluten-free diet in5 out of 6 cases this was accompanied by improvementdisappearance of neurological symptoms (Fig 2)

No signi cant difference was found in the prevalence ofanti-neuronal antibodies to the ENS in patients and controls(Table II) These antibodies were found in two CD patientswith neurological symptoms (one with epilepsy and one withattentionmemory impairment) in one patient without neuro-logical dysfunction and in one patient with Crohn diseaseThe three positive CD patients all complained of severeconstipation The antibody pattern was characterized by a

Table II Prevalence of anti-neurona l antibodies (NA) in CD with and without neurologica l disorders and in controls

CasesNA to central nervous

system (CNS) ()NA to enteric nervous

system (ENS) ()

A ndash Coeliac disease with neurologica l dysfunction 13 61 15B ndash Coeliac disease without neurologica l dysfunction 20 5 5C ndash Autoimmune hepatitis 10 0 0D ndash In ammatory bowel disease 10 0 10E ndash Blood donors 10 0 0

NA to CNS in A versus B P = 0000686 A versus C Dagger D Dagger E P = 0000009NA to ENS in A versus B and in A versus C Dagger D Dagger E P = ns (Fisher exact test)

Fig 1 Representativ e photomicrograph s showing anti-neurona l antibody immunoreactivit y in the rat cerebellum (A B) and enteric nervoussystem (C) of patients with CD and neurologica l involvement Picture A shows intense immunostaining in the nucleus and cytoplasm ofPurkinje cells (arrow) along with positivity of granular layer neurons (arrowhead) in a CD patient with cerebella r ataxia (patient no 5 listedin Table I) Picture B displays immunolabelling of Purkinje cell cytoplasm in a CD patient with multiple sclerosis (patient no 1) Picture Cillustrates a bright staining in the myenteric plexus (mp) of the rat ileum observed in a CD patient with attentionmemory impairment andsevere constipation (patient no 8) Picture D indicates negative anti-neurona l antibody pattern in a control (blood donor) subject arrowpoints to an unlabelled Purkinje cell Magni cation pound40 in A and D pound80 in B and C

Scand J Gastroenterol 2002 (11)

Neurologica l Dysfunction in Coeliac Disease 1279

bright cytoplasmic uorescence detectable in ganglion cellbodies of the myenteric (Auerbachrsquos) (Fig 1C) and sub-mucous (Meissnerrsquos) plexus

Discussion

Growing evidence indicates that CNS and PNS diseases canbe strictly associated with CD (1ndash9) and that neurologicalsymptoms are sometimes the only clinical clue of an occultCD (18 19) Our study sheds light on the clinical andimmunological features of CD with neurological involve-ment We found that among 160 CD patients 13 (8) hadneurological disorders The neurological dysfunction com-prised a wide variety of conditions including epilepsy loss ofconcentration and attentionmemory impairment cerebellarataxia peripheral neuropathy multiple sclerosis Steinertrsquosmyotonic dystrophy and acute cerebrovascular (ie Moya-moya) disease Previous studies already established closeassociations of CD with epilepsy (most frequently withcomplex partial seizures) (5 6) cerebellar ataxia (7 9 1219) memory impairment (1) and peripheral neuropathy (18)An association with multiple sclerosis has been documentedonly in sporadic case reports (20ndash22) In the present paper wealso describe associations with Steinertrsquos myotonic dystrophyand Moyamoya disease Although clinically relevant theoccurrence of these two rare disorders in our CD patients mayhave been casual Therefore the signi cance of theseassociations with CD requires further investigation

Clinically no signi cant difference was found between CDpatients with and without neurological involvement Bothgroups showed a similar median age at diagnosis of CD and ahigher prevalence of female gender Gastrointestinal andother CD-related signs such as iron-de ciency anaemia wereabsent in about half of both the neurological and non-

neurological CD patients In all but two cases who developedmultiple sclerosis and Moyamoya disease during gluten-freediet the diagnosis of neurological impairment preceded theidenti cation of CD

Our data con rm the importance of early recognition ofCD since a gluten-free diet started promptly on appearanceof the neurological dysfunction can produce a signi cantimprovement or even complete resolution of neurologicalsymptoms (8 9) This was observed in 7 patients (2 withepilepsy 3 with memory impairment 1 with cerebellar ataxiaand 1 with peripheral neuropathy) who started glutenrestriction within 6 months of the neurological onset Incontrast four patients with long-standing neurological dis-orders (one with epilepsy one with cerebellar ataxia one withSteinertrsquos disease and one with peripheral neuropathy)showed no response to gluten withdrawal

The pathophysiology of neurological dysfunction in CD isstill unclear One hypothesis regards an overt or evensubclinical malabsorption causing de ciencies of nutrients(folic acid and vitamin B12) known to exert neurotrophic andneuroprotective effects (23) However only a minority of ourneurological patients (2 out of 13) had an overt malabsorptionsyndrome Selective vitamin E de ciency has also beensuggested as a potential cause of neurological complicationsof CD (24) although administration of large doses of thisvitamin in CD ataxic patients did not improve the clinicalpicture (25) Neurological involvement in CD might arise as aconsequence of an autoimmune mechanism mediated byAGA (7 26) In this respect CD can be considered anautoimmune disease where unusually several pathogeneticfactors are well known ie the extrinsic trigger (gliadin) aclose genetic background (HLA-DQ2 or -DQ8) and a highlyspeci c immune response directed to a well-characterizedautoantigen (tissue transglutaminase) Our data on thepresence of anti-neuronal CNS antibodies provide furthersupport for the autoimmune hypothesis of neurologicaldysfunction in CD patients In our CD patients the presenceof these antibodies was strongly associated with CNSinvolvement Furthermore the antibodies most often (in 6out of 8 cases) disappeared within a year of starting a gluten-free diet and their disappearance was frequently (in 5 out of 6cases) accompanied by improvement or disappearance of theneurological picture Anti-neuronal antibodies are not speci cfor neurological disorders associated with CD since theyhave been described in a wide array of CNS and autonomicnervous system disorders such as cerebellar ataxia subacuteperipheral sensory-motor neuropathy and others (27) Theactual pathogenetic signi cance of these anti-neuronal anti-bodies is currently unknown Speci cally designed in vitrostudies aimed at testing the effects evoked by anti-neuronalantibodies on brain cell tissue culture should clarify whetherthese antibodies may play a direct role in producingneurological damage Neuropathological ndings in CDpatients including cerebellar lymphocytic in ltration Pur-kinje cell loss and posterior columns damage provide further

Fig 2 Titre of anti-neurona l CNS antibodies before and aftergluten-free diet in CD patient responders (improvement ofneurologica l symptoms) or non-responder s to gluten withdrawal(persistence of neurologica l symptoms) Positive cases were de nedat dilution titre gt110 (broken line) CNS = central nervous systemGFD = gluten free diet

Scand J Gastroenterol 2002 (11)

1280 U Volta et al

evidence of an immune-mediated mechanism underlyingneural dysfunction in CD (2 9 23)

In conclusion the present study strongly reinforces theconcept that CD can sometimes present in the guise of aneurological disorder Our ndings suggest that in such casesthe neurological picture can greatly improve when a gluten-free diet is started promptly Closer interaction betweenneurologists and gastroenterologists should facilitate earlieridenti cation of an underlying CD Therefore the possiblepresence of CD needs to be carefully considered in patientswith cerebellar ataxia epilepsy attentionmemory impair-ment or peripheral neuropathy

Acknowledgements

Drs Umberto Volta and Roberto De Giorgio equallycontributed to this paper We are grateful to Robin M TCooke for editing

References

1 Luorostainen L Pirttila T Collin P Coeliac disease presentingwith neurologica l disorders Eur Neurol 199942132 ndash5

2 Wills AJ The neurology and neuropatholog y of coeliac diseaseNeuropat Appl Neurobiol 200026493 ndash6

3 Maki M Collin P Coeliac disease Lancet 19973491755 ndash94 Ciclitira PJ AGA technical review on celiac sprue Gastroenter -

ology 20011201526 ndash405 Holmes GKT Neurologica l and psychiatri c complications in

coeliac disease In Gobbi G Andermann F Naccarato SBanchini G editors Epilepsy and other neurologica l disorders incoeliac disease London John Libbey 1997 p 251ndash64

6 Gobbi G Bouquet F Greco L Lambertini A Tassinari CAVentura A Zaniboni MG and the Italian Working Group onCoeliac Disease and Epilepsy Coeliac disease epilepsy andcerebral calci cations Lancet 1992340439ndash43

7 Hadjivassiliou M Gibson A Davies-Jones GAB Lobo AJStephenson TJ Milford-Ward A Does cryptic gluten sensitivityplay a part in neurologica l illness Lancet 1996347369 ndash71

8 Wills A Hovell CJ Neurological complication s of entericdisease Gut 199639501ndash4

9 Hadjivassiliou M Grunewald RA Chattopadhyay AK Davies-Jones GAB Gibson A Jarratt JA et al Clinical radiological neurophysiological and neuropathologica l characteristic s ofgluten ataxia Lancet 19983521582 ndash5

10 Pratesi R Gandol L Friedman H Farage L De Castro CAMCatassi C Serum IgA antibodies from patients with coeliac

disease strongly react with human brain blood-vesse l structures Scand J Gastroenterol 199833817 ndash22

11 Pellecchia MT Scala R Filla A De Michele G Ciacci C BaroneP Idiopathic cerebellar ataxia associated with celiac diseaselack of distinctive neurologica l features J Neurol NeurosurgPsychiatry 19996632ndash5

12 Salur L Uibo O Talvik I Justus I Metskula K Talvik T et alThe high frequency of coeliac disease among children withneurologica l disorders Eur J Neurol 20007707ndash11

13 Volta U Bellentani S Bianchi FB Brandi G De Franceschi LMiglioli L et al High prevalence of celiac disease in the Italiangeneral population Dig Dis Sci 2001461500 ndash5

14 Volta U Molinaro N De Franceschi L Fratangelo D BianchiFB IgA anti-endomysia l antibodies on human umbilical cordtissue for celiac disease screening save both money andmonkeys Dig Dis Sci 1995401902 ndash5

15 Sblattero D Berti I Trevisiol C Marzari M Tommasini ABradbury A et al Human recombinant tissue transglutaminas eELISA an innovative diagnostic assay for celiac disease Am JGastroentero l 2000951253ndash7

16 Marsh MN Gluten major histocompatibilit y complex and thesmall intestine Gastroenterolog y 1992102330ndash54

17 Oberhuber G Granditsch G Vogelsang H The histopathology ofcoeliac disease time for a standardize d report scheme forpathologists Eur J Gastroenterol Hepatol 1999111185 ndash94

18 Hadjivassiliou M Chattopadhyay AK Davies-Jones GABGibson A Grunewald RA Lobo A Neuromuscula r disorder asa presenting feature of coeliac disease J Neurol NeurosurgPsychiatry 199763770ndash5

19 Burk K Bosch S Muller A Melms A Zuhlke C Stern M et alSporadic cerebella r ataxia associated with gluten sensitivity Brain 20011241013 ndash9

20 Lange LS Shiner M Jejunal morphology in multiple sclerosisLancet 1979i1300 ndash1

21 Cook AW Gupta JK Pertschuk LP Nidzgorski F Multiplesclerosis and malabsorption Lancet 1978i1366

22 Fantelli FJ Mitsumoto H Sebek BA Multiple sclerosis andmalabsorption Lancet 1978i1039 ndash40

23 Cooke WT Smith WT Neurological disorders associated withcoeliac disease Brain 196689683ndash722

24 Mauro A Orsi L Mortara P Costa P Schiffer D Cerebellarsyndrome in adult coeliac disease with vitamin E de ciencyActa Neurol Scand 199184167ndash70

25 Ackerman Z Eliashiv S Reches A Zimmerman J Neurologica lmanifestation in celiac disease and vitamin E de ciency J ClinGastroentero l 198911603 ndash5

26 Collin P Pirttila T Nurmikko T Somer H Erila T KeyrilainenO Celiac disease brain atrophy and dementia Neurology199141372ndash5

27 King PH Redden D Palmgren JS Nabors LB Lennon VA Huantigens speci cities of ANNA-1 autoantibodie s in paraneoplas -tic neurologica l diseases J Autoimmun 199913435ndash43

Received 7 March 2002Accepted 8 August 2002

Scand J Gastroenterol 2002 (11)

Neurologica l Dysfunction in Coeliac Disease 1281

Methods

PatientsThis study included 160 consecutive CD patients (120 F

and 40 M median age 37 years range 18ndash79 years) diagnosedin our two Departments from January 1985 to June 2001 witha median follow-up of 6 years (range 3 months to 16 years)The majority of these subjects came from the Emilia-Romagna region (which is located in the north-east of theItalian peninsula) where the estimated prevalence of CD is 1case out of 174 inhabitants (13) CD-related antibodies (anti-gliadin (AGA) anti-endomysial (EmA) and anti-humanrecombinant tissue transglutaminase (h-tTG)) were tested inall patients (14 15) Diagnosis of CD was con rmed byendoscopic duodenal biopsy Histological ndings weregraded according to Marshrsquos revised criteria (16 17) Aformal neurological assessment was routinely performed inall CD patients on presentation including analysis of the timeof onset of any neurological symptoms with respect todiagnosis of CD Periodical dietary interviews were routinelyperformed in all CD patients to assess compliance withgluten-free diet All patients gave their informed consent toparticipate in the present study

Anti-neuronal antibodiesThe presence of anti-neuronal antibodies to CNS and

enteric nervous system (ENS) was investigated in all CDpatients with neurological involvement and in a group of CDpatients without neurological dysfunction (n = 20) Sera from20 patients with intestinal and autoimmune diseases (ie 10with in ammatory bowel disease and 10 with autoimmunehepatitis) and 10 blood donors served as controls Anti-neuronal antibodies were detected by indirect immuno uor-

escence on 5-mm cryostat sections of monkey and ratcerebellum as well as of rat ileum and colon (Medic TurinItaly) Patientsrsquo sera were tested at the initial dilution of 110and when positive were titrated up to the end-point Rabbitanti-human IgG and IgA (Dako Copenhagen Denmark) wereused as secondary antibody at the appropriate workingdilution (160 and 1100 on rat and monkey tissue respec-tively)

StatisticsThe Fisher exact test two-tailed was used to compare

clinical ndings and prevalence of anti-neuronal antibodies inCD patients with and without neurological disorders

Results

A neurological syndrome was recorded in 13 of the 160 (8)CD patients (11 F and 2 M median age at diagnosis of CD 36years range 19ndash56 years) In 11 of the 13 cases theneurological dysfunction presented before diagnosis of CDTen patients had disorders of the CNS including epilepsy(n = 3) attentionmemory impairment (n = 3) cerebellarataxia (n = 2) multiple sclerosis (n = 1) and acute cerebro-vascular disease (Moyamoya disease) (n = 1) The remainingthree patients had PNS disorders namely peripheral neuro-pathy (n = 2) and myotonic dystrophy (Steinertrsquos disease)(n = 1) (Table I)

CD patients with CNS disordersIn the three patients with epilepsy (all females) CD was

diagnosed 6 9 and 264 months after discovery of theneurological dysfunction (Table I) These patients had been

Table I Clinical immunologica l and histologica l features of the 13 CD patients with associated neurologica l disorders

CasesAge

(years) SexNeurologicaldisease (ND)

Time of ND beforeor after CDdiagnosis

Gastrointestinaland other

CD-related signs

IgAAGA

gt 110

IgAEmAgt 15

IgAh-tTGAgt7AU

Duodenalhistology

1 24 F Multiple sclerosis 48 months after Absent 140 180 15 AU 3a2 21 F Epilepsy 6 months before Constipation 1160 1160 gt20 AU 3b3 28 F Epilepsy 264 months before Absent 180 1160 18 AU 3b4 47 F Epilepsy 6 months before Iron-de ciency

anaemia120 180 12 AU 3b

5 37 F Cerebellar ataxia 24 months before Iron-de ciencyanaemia

1160 1320 gt20 AU 3c

6 39 F Cerebellar ataxia 3 months before Absent 110 120 8 AU 27 36 M Attentionmemory

impairment4 months before Raised serum

transaminases120 1160 gt20 AU 3b

8 32 F Attentionmemoryimpairment

5 months before Constipation 180 1160 gt20 AU 3b

9 34 F Attentionmemoryimpairment

6 months before Absent 110 110 9 AU 1

10 19 F Moyamoya disease 120 months after Diarrhoea 180 1160 14 AU 3b11 56 M Steinertrsquos disease 36 months before Diarrhoea 110 120 9 AU 3a12 38 F Peripheral neuropathy 4 months before Absent 110 180 16 AU 3b13 46 F Peripheral neuropathy 10 months before Absent 140 180 11 AU 3b

CD = coeliac disease AGA = antigliadin EmA = antiendomysial h-tTGA = human recombinant tissue transglutaminas e antibodies AU = arbitrary units duodenal histology Marshrsquos revised classi cation 1 ( intraepithelia l lymphocyte count -IEL) 2 ( IEL and crypthyperplasia) 3a 3b 3c (mild marked total villous atrophy)

Scand J Gastroenterol 2002 (11)

Neurologica l Dysfunction in Coeliac Disease 1277

classi ed as having respectively complex partial temporallobe seizures at the age of 20 years simple partial seizures(with motor signs) at the age of 46 years and primarygeneralized seizures with pure absence (petit male) at the ageof 3 years Brain computerized tomography (CT) scan wasnormal in all of them and showed no occipital calci cationSymptoms suggesting CD (severe constipation and iron-de ciency anaemia) were present in two patients whereas thepatient with long-standing epilepsy completely lacked non-neurological symptoms A gluten-free diet stopped theseizures in the two patients with symptomatic CD whereasit did not affect the seizures of the third patient

Of the two patients (both female) with cerebellar ataxia a39-year-old woman had a neurological onset characterized bymuscle weakness and pain associated with leg and armparaesthesias After a few months the patient began tocomplain of impaired balance A muscle biopsy showed atype-2 bre hypotrophy Despite the absence of gastrointest-inal and other CD-related signs the patient underwent a widearray laboratory screening revealing IgA EmA positivity Thefollowing duodenal biopsy performed only 3 months after theneurological onset proved the presence of CD This patienthad a striking response to gluten-free diet with completeresolution of the neurological symptoms By contrast theclinical outcome of the other patient who presented withcerebellar ataxia was unfavourable She was a 37-year-oldwoman with severe gait ataxia slurred speech and dysphagiaHer symptoms progressed rapidly so that she needed bilateralsupport and later a wheelchair to ambulate CD which wassuspected due to the nding of a severe iron-de ciencyanaemia and autoimmnune thyroiditis was diagnosed only 24months after the onset of neurological impairment Gluten-free diet associated with high-dose vitamin E treatment wascompletely unhelpful as was prednisolone and azathioprinetreatment

Three patients (1 M and 2 F) presented a neurologicalsyndrome characterized by loss of concentration along withattentionmemory impairment which started 4ndash6 monthsbefore diagnosis of CD The assessment of attentionmemoryimpairment was carefully evaluated through a thoroughneuropsychologica l examination before and after a gluten-free diet (1) All three patients had a normal brain CT ormagnetic resonance imaging (MRI) scan In one of them (a36-year-old man) CD was suspected owing to raised serumtransaminase levels of unknown origin and in another one (a32-year-old woman) owing to a severe constipation The thirdpatient was affected by a potential CD characterized bypositivity for EmA and tTG at low titre and mild histologicallesions (increased number of intraepithelial lymphocytes)(16 17) The gluten-free diet brought a substantial improve-ment in neurological symptoms in all 3 patients within 1 year

In the remaining two patients with CNS disordersdiagnosis of CD preceded the onset of neurological symp-toms A 24-year-old woman was identi ed as having CDduring a screening programme of rst-degree relatives She

had no gastrointestinal sign and her biochemical parameterswere all within the normal range Her compliance with thegluten-free diet was poor due to the asymptomatic state Fouryears later she developed diplopia upper motor neuron dys-function (right hand weakness and spasticity) and posteriorcolumn lesion (tingling or tightness of the extremities andband-like sensation along the trunk) MRI showed demyeli-nating multifocal white matter lesions in the brainstem andspinal cord The patient became compliant with the gluten-free diet without any improvement in her neurologicaldisease which later partially responded to high-dose steroidsand b-interferon treatment The other patient was found tohave CD at the age of 19 years due to a malabsorptionsyndrome Ten years later she developed a cerebral infarctionwith a transient left hemiplegia Brain CT and MRI scansshowed a large right fronto-rolandic ischaemic area and smallischaemic lesions in the left hemisphere Brain angiographyled to a diagnosis of Moyamoya disease based on the typicallsquopuff of smokersquo image indicating collateral ow circulationaround the middle cerebral occlusive lesion During thefollowing 12 years she strictly adhered to a gluten-free diet inassociation with salicylic acid and had no recurrence of acutecerebrovascular disease

CD patients with PNS disordersTwo of the three patients with PNS impairment were

women They were aged 38 and 46 years at the onset ofneurological dysfunction which preceded diagnosis of CD by4 and 10 months respectively (Table I) Neither of themcomplained of gastrointestinal nor other CD-related signsThe younger woman complained of muscle pain and legparaesthesias Although electroneuromyography was normalneurological assessment led to a diagnosis of small breneuropathy and neurological symptoms signi cantly im-proved 1 year after gluten withdrawal In the older woman adistal axonopathy was diagnosed based on clinical symptoms(ie intense leg paraesthesias numbness and hypore exia)and electroneuromyography results A gluten-free diet did notaffect the neurological symptoms In the remaining patient (amale) Steinertrsquos myotonic dystrophy was diagnosed at theage of 53 years The clinical picture was characterized byweakness of eyelid facial and neck exor muscles and ofdistal extremity muscles Myotonia was demonstrable in handgrip CD was diagnosed later because of a malabsorptionsyndrome A gluten-free diet did not improve the neurologicalpicture

Anti-neuronal antibodiesAnti-neuronal antibodies to CNS were detected in 8 of the

13 (61) CD patients with neurological involvement (1 withmultiple sclerosis 2 with epilepsy 2 with attentionmemoryimpairment 2 with cerebellar ataxia and 1 with myotonicdystrophy) as compared with only 1 of 20 (5) patientswithout neurological symptoms No positive staining wasfound in control subjects The prevalence of anti-neuronal

Scand J Gastroenterol 2002 (11)

1278 U Volta et al

antibodies to CNS was signi cantly higher in patients withneurological symptoms than in those without neurologicalsymptoms (P = 00007) or controls (P = 000001) (Table II)All the positive cases belonged to the IgG class (associatedwith IgA in 2 patients) with antibody titres ranging from 150to 1200 The anti-neuronal antibody pattern was character-ized by nuclear and cytoplasmic positivity of Purkinje cells(Fig 1A and B) and nuclear staining of granular layer neurons(Fig 1A) of both monkey and rat cerebellar cortex Noimmunolabelling was visualized around blood vessels In 6 ofthe 8 positive neurological patients anti-neuronal antibodies

to CNS disappeared after 1 year of a strict gluten-free diet in5 out of 6 cases this was accompanied by improvementdisappearance of neurological symptoms (Fig 2)

No signi cant difference was found in the prevalence ofanti-neuronal antibodies to the ENS in patients and controls(Table II) These antibodies were found in two CD patientswith neurological symptoms (one with epilepsy and one withattentionmemory impairment) in one patient without neuro-logical dysfunction and in one patient with Crohn diseaseThe three positive CD patients all complained of severeconstipation The antibody pattern was characterized by a

Table II Prevalence of anti-neurona l antibodies (NA) in CD with and without neurologica l disorders and in controls

CasesNA to central nervous

system (CNS) ()NA to enteric nervous

system (ENS) ()

A ndash Coeliac disease with neurologica l dysfunction 13 61 15B ndash Coeliac disease without neurologica l dysfunction 20 5 5C ndash Autoimmune hepatitis 10 0 0D ndash In ammatory bowel disease 10 0 10E ndash Blood donors 10 0 0

NA to CNS in A versus B P = 0000686 A versus C Dagger D Dagger E P = 0000009NA to ENS in A versus B and in A versus C Dagger D Dagger E P = ns (Fisher exact test)

Fig 1 Representativ e photomicrograph s showing anti-neurona l antibody immunoreactivit y in the rat cerebellum (A B) and enteric nervoussystem (C) of patients with CD and neurologica l involvement Picture A shows intense immunostaining in the nucleus and cytoplasm ofPurkinje cells (arrow) along with positivity of granular layer neurons (arrowhead) in a CD patient with cerebella r ataxia (patient no 5 listedin Table I) Picture B displays immunolabelling of Purkinje cell cytoplasm in a CD patient with multiple sclerosis (patient no 1) Picture Cillustrates a bright staining in the myenteric plexus (mp) of the rat ileum observed in a CD patient with attentionmemory impairment andsevere constipation (patient no 8) Picture D indicates negative anti-neurona l antibody pattern in a control (blood donor) subject arrowpoints to an unlabelled Purkinje cell Magni cation pound40 in A and D pound80 in B and C

Scand J Gastroenterol 2002 (11)

Neurologica l Dysfunction in Coeliac Disease 1279

bright cytoplasmic uorescence detectable in ganglion cellbodies of the myenteric (Auerbachrsquos) (Fig 1C) and sub-mucous (Meissnerrsquos) plexus

Discussion

Growing evidence indicates that CNS and PNS diseases canbe strictly associated with CD (1ndash9) and that neurologicalsymptoms are sometimes the only clinical clue of an occultCD (18 19) Our study sheds light on the clinical andimmunological features of CD with neurological involve-ment We found that among 160 CD patients 13 (8) hadneurological disorders The neurological dysfunction com-prised a wide variety of conditions including epilepsy loss ofconcentration and attentionmemory impairment cerebellarataxia peripheral neuropathy multiple sclerosis Steinertrsquosmyotonic dystrophy and acute cerebrovascular (ie Moya-moya) disease Previous studies already established closeassociations of CD with epilepsy (most frequently withcomplex partial seizures) (5 6) cerebellar ataxia (7 9 1219) memory impairment (1) and peripheral neuropathy (18)An association with multiple sclerosis has been documentedonly in sporadic case reports (20ndash22) In the present paper wealso describe associations with Steinertrsquos myotonic dystrophyand Moyamoya disease Although clinically relevant theoccurrence of these two rare disorders in our CD patients mayhave been casual Therefore the signi cance of theseassociations with CD requires further investigation

Clinically no signi cant difference was found between CDpatients with and without neurological involvement Bothgroups showed a similar median age at diagnosis of CD and ahigher prevalence of female gender Gastrointestinal andother CD-related signs such as iron-de ciency anaemia wereabsent in about half of both the neurological and non-

neurological CD patients In all but two cases who developedmultiple sclerosis and Moyamoya disease during gluten-freediet the diagnosis of neurological impairment preceded theidenti cation of CD

Our data con rm the importance of early recognition ofCD since a gluten-free diet started promptly on appearanceof the neurological dysfunction can produce a signi cantimprovement or even complete resolution of neurologicalsymptoms (8 9) This was observed in 7 patients (2 withepilepsy 3 with memory impairment 1 with cerebellar ataxiaand 1 with peripheral neuropathy) who started glutenrestriction within 6 months of the neurological onset Incontrast four patients with long-standing neurological dis-orders (one with epilepsy one with cerebellar ataxia one withSteinertrsquos disease and one with peripheral neuropathy)showed no response to gluten withdrawal

The pathophysiology of neurological dysfunction in CD isstill unclear One hypothesis regards an overt or evensubclinical malabsorption causing de ciencies of nutrients(folic acid and vitamin B12) known to exert neurotrophic andneuroprotective effects (23) However only a minority of ourneurological patients (2 out of 13) had an overt malabsorptionsyndrome Selective vitamin E de ciency has also beensuggested as a potential cause of neurological complicationsof CD (24) although administration of large doses of thisvitamin in CD ataxic patients did not improve the clinicalpicture (25) Neurological involvement in CD might arise as aconsequence of an autoimmune mechanism mediated byAGA (7 26) In this respect CD can be considered anautoimmune disease where unusually several pathogeneticfactors are well known ie the extrinsic trigger (gliadin) aclose genetic background (HLA-DQ2 or -DQ8) and a highlyspeci c immune response directed to a well-characterizedautoantigen (tissue transglutaminase) Our data on thepresence of anti-neuronal CNS antibodies provide furthersupport for the autoimmune hypothesis of neurologicaldysfunction in CD patients In our CD patients the presenceof these antibodies was strongly associated with CNSinvolvement Furthermore the antibodies most often (in 6out of 8 cases) disappeared within a year of starting a gluten-free diet and their disappearance was frequently (in 5 out of 6cases) accompanied by improvement or disappearance of theneurological picture Anti-neuronal antibodies are not speci cfor neurological disorders associated with CD since theyhave been described in a wide array of CNS and autonomicnervous system disorders such as cerebellar ataxia subacuteperipheral sensory-motor neuropathy and others (27) Theactual pathogenetic signi cance of these anti-neuronal anti-bodies is currently unknown Speci cally designed in vitrostudies aimed at testing the effects evoked by anti-neuronalantibodies on brain cell tissue culture should clarify whetherthese antibodies may play a direct role in producingneurological damage Neuropathological ndings in CDpatients including cerebellar lymphocytic in ltration Pur-kinje cell loss and posterior columns damage provide further

Fig 2 Titre of anti-neurona l CNS antibodies before and aftergluten-free diet in CD patient responders (improvement ofneurologica l symptoms) or non-responder s to gluten withdrawal(persistence of neurologica l symptoms) Positive cases were de nedat dilution titre gt110 (broken line) CNS = central nervous systemGFD = gluten free diet

Scand J Gastroenterol 2002 (11)

1280 U Volta et al

evidence of an immune-mediated mechanism underlyingneural dysfunction in CD (2 9 23)

In conclusion the present study strongly reinforces theconcept that CD can sometimes present in the guise of aneurological disorder Our ndings suggest that in such casesthe neurological picture can greatly improve when a gluten-free diet is started promptly Closer interaction betweenneurologists and gastroenterologists should facilitate earlieridenti cation of an underlying CD Therefore the possiblepresence of CD needs to be carefully considered in patientswith cerebellar ataxia epilepsy attentionmemory impair-ment or peripheral neuropathy

Acknowledgements

Drs Umberto Volta and Roberto De Giorgio equallycontributed to this paper We are grateful to Robin M TCooke for editing

References

1 Luorostainen L Pirttila T Collin P Coeliac disease presentingwith neurologica l disorders Eur Neurol 199942132 ndash5

2 Wills AJ The neurology and neuropatholog y of coeliac diseaseNeuropat Appl Neurobiol 200026493 ndash6

3 Maki M Collin P Coeliac disease Lancet 19973491755 ndash94 Ciclitira PJ AGA technical review on celiac sprue Gastroenter -

ology 20011201526 ndash405 Holmes GKT Neurologica l and psychiatri c complications in

coeliac disease In Gobbi G Andermann F Naccarato SBanchini G editors Epilepsy and other neurologica l disorders incoeliac disease London John Libbey 1997 p 251ndash64

6 Gobbi G Bouquet F Greco L Lambertini A Tassinari CAVentura A Zaniboni MG and the Italian Working Group onCoeliac Disease and Epilepsy Coeliac disease epilepsy andcerebral calci cations Lancet 1992340439ndash43

7 Hadjivassiliou M Gibson A Davies-Jones GAB Lobo AJStephenson TJ Milford-Ward A Does cryptic gluten sensitivityplay a part in neurologica l illness Lancet 1996347369 ndash71

8 Wills A Hovell CJ Neurological complication s of entericdisease Gut 199639501ndash4

9 Hadjivassiliou M Grunewald RA Chattopadhyay AK Davies-Jones GAB Gibson A Jarratt JA et al Clinical radiological neurophysiological and neuropathologica l characteristic s ofgluten ataxia Lancet 19983521582 ndash5

10 Pratesi R Gandol L Friedman H Farage L De Castro CAMCatassi C Serum IgA antibodies from patients with coeliac

disease strongly react with human brain blood-vesse l structures Scand J Gastroenterol 199833817 ndash22

11 Pellecchia MT Scala R Filla A De Michele G Ciacci C BaroneP Idiopathic cerebellar ataxia associated with celiac diseaselack of distinctive neurologica l features J Neurol NeurosurgPsychiatry 19996632ndash5

12 Salur L Uibo O Talvik I Justus I Metskula K Talvik T et alThe high frequency of coeliac disease among children withneurologica l disorders Eur J Neurol 20007707ndash11

13 Volta U Bellentani S Bianchi FB Brandi G De Franceschi LMiglioli L et al High prevalence of celiac disease in the Italiangeneral population Dig Dis Sci 2001461500 ndash5

14 Volta U Molinaro N De Franceschi L Fratangelo D BianchiFB IgA anti-endomysia l antibodies on human umbilical cordtissue for celiac disease screening save both money andmonkeys Dig Dis Sci 1995401902 ndash5

15 Sblattero D Berti I Trevisiol C Marzari M Tommasini ABradbury A et al Human recombinant tissue transglutaminas eELISA an innovative diagnostic assay for celiac disease Am JGastroentero l 2000951253ndash7

16 Marsh MN Gluten major histocompatibilit y complex and thesmall intestine Gastroenterolog y 1992102330ndash54

17 Oberhuber G Granditsch G Vogelsang H The histopathology ofcoeliac disease time for a standardize d report scheme forpathologists Eur J Gastroenterol Hepatol 1999111185 ndash94

18 Hadjivassiliou M Chattopadhyay AK Davies-Jones GABGibson A Grunewald RA Lobo A Neuromuscula r disorder asa presenting feature of coeliac disease J Neurol NeurosurgPsychiatry 199763770ndash5

19 Burk K Bosch S Muller A Melms A Zuhlke C Stern M et alSporadic cerebella r ataxia associated with gluten sensitivity Brain 20011241013 ndash9

20 Lange LS Shiner M Jejunal morphology in multiple sclerosisLancet 1979i1300 ndash1

21 Cook AW Gupta JK Pertschuk LP Nidzgorski F Multiplesclerosis and malabsorption Lancet 1978i1366

22 Fantelli FJ Mitsumoto H Sebek BA Multiple sclerosis andmalabsorption Lancet 1978i1039 ndash40

23 Cooke WT Smith WT Neurological disorders associated withcoeliac disease Brain 196689683ndash722

24 Mauro A Orsi L Mortara P Costa P Schiffer D Cerebellarsyndrome in adult coeliac disease with vitamin E de ciencyActa Neurol Scand 199184167ndash70

25 Ackerman Z Eliashiv S Reches A Zimmerman J Neurologica lmanifestation in celiac disease and vitamin E de ciency J ClinGastroentero l 198911603 ndash5

26 Collin P Pirttila T Nurmikko T Somer H Erila T KeyrilainenO Celiac disease brain atrophy and dementia Neurology199141372ndash5

27 King PH Redden D Palmgren JS Nabors LB Lennon VA Huantigens speci cities of ANNA-1 autoantibodie s in paraneoplas -tic neurologica l diseases J Autoimmun 199913435ndash43

Received 7 March 2002Accepted 8 August 2002

Scand J Gastroenterol 2002 (11)

Neurologica l Dysfunction in Coeliac Disease 1281

classi ed as having respectively complex partial temporallobe seizures at the age of 20 years simple partial seizures(with motor signs) at the age of 46 years and primarygeneralized seizures with pure absence (petit male) at the ageof 3 years Brain computerized tomography (CT) scan wasnormal in all of them and showed no occipital calci cationSymptoms suggesting CD (severe constipation and iron-de ciency anaemia) were present in two patients whereas thepatient with long-standing epilepsy completely lacked non-neurological symptoms A gluten-free diet stopped theseizures in the two patients with symptomatic CD whereasit did not affect the seizures of the third patient

Of the two patients (both female) with cerebellar ataxia a39-year-old woman had a neurological onset characterized bymuscle weakness and pain associated with leg and armparaesthesias After a few months the patient began tocomplain of impaired balance A muscle biopsy showed atype-2 bre hypotrophy Despite the absence of gastrointest-inal and other CD-related signs the patient underwent a widearray laboratory screening revealing IgA EmA positivity Thefollowing duodenal biopsy performed only 3 months after theneurological onset proved the presence of CD This patienthad a striking response to gluten-free diet with completeresolution of the neurological symptoms By contrast theclinical outcome of the other patient who presented withcerebellar ataxia was unfavourable She was a 37-year-oldwoman with severe gait ataxia slurred speech and dysphagiaHer symptoms progressed rapidly so that she needed bilateralsupport and later a wheelchair to ambulate CD which wassuspected due to the nding of a severe iron-de ciencyanaemia and autoimmnune thyroiditis was diagnosed only 24months after the onset of neurological impairment Gluten-free diet associated with high-dose vitamin E treatment wascompletely unhelpful as was prednisolone and azathioprinetreatment

Three patients (1 M and 2 F) presented a neurologicalsyndrome characterized by loss of concentration along withattentionmemory impairment which started 4ndash6 monthsbefore diagnosis of CD The assessment of attentionmemoryimpairment was carefully evaluated through a thoroughneuropsychologica l examination before and after a gluten-free diet (1) All three patients had a normal brain CT ormagnetic resonance imaging (MRI) scan In one of them (a36-year-old man) CD was suspected owing to raised serumtransaminase levels of unknown origin and in another one (a32-year-old woman) owing to a severe constipation The thirdpatient was affected by a potential CD characterized bypositivity for EmA and tTG at low titre and mild histologicallesions (increased number of intraepithelial lymphocytes)(16 17) The gluten-free diet brought a substantial improve-ment in neurological symptoms in all 3 patients within 1 year

In the remaining two patients with CNS disordersdiagnosis of CD preceded the onset of neurological symp-toms A 24-year-old woman was identi ed as having CDduring a screening programme of rst-degree relatives She

had no gastrointestinal sign and her biochemical parameterswere all within the normal range Her compliance with thegluten-free diet was poor due to the asymptomatic state Fouryears later she developed diplopia upper motor neuron dys-function (right hand weakness and spasticity) and posteriorcolumn lesion (tingling or tightness of the extremities andband-like sensation along the trunk) MRI showed demyeli-nating multifocal white matter lesions in the brainstem andspinal cord The patient became compliant with the gluten-free diet without any improvement in her neurologicaldisease which later partially responded to high-dose steroidsand b-interferon treatment The other patient was found tohave CD at the age of 19 years due to a malabsorptionsyndrome Ten years later she developed a cerebral infarctionwith a transient left hemiplegia Brain CT and MRI scansshowed a large right fronto-rolandic ischaemic area and smallischaemic lesions in the left hemisphere Brain angiographyled to a diagnosis of Moyamoya disease based on the typicallsquopuff of smokersquo image indicating collateral ow circulationaround the middle cerebral occlusive lesion During thefollowing 12 years she strictly adhered to a gluten-free diet inassociation with salicylic acid and had no recurrence of acutecerebrovascular disease

CD patients with PNS disordersTwo of the three patients with PNS impairment were

women They were aged 38 and 46 years at the onset ofneurological dysfunction which preceded diagnosis of CD by4 and 10 months respectively (Table I) Neither of themcomplained of gastrointestinal nor other CD-related signsThe younger woman complained of muscle pain and legparaesthesias Although electroneuromyography was normalneurological assessment led to a diagnosis of small breneuropathy and neurological symptoms signi cantly im-proved 1 year after gluten withdrawal In the older woman adistal axonopathy was diagnosed based on clinical symptoms(ie intense leg paraesthesias numbness and hypore exia)and electroneuromyography results A gluten-free diet did notaffect the neurological symptoms In the remaining patient (amale) Steinertrsquos myotonic dystrophy was diagnosed at theage of 53 years The clinical picture was characterized byweakness of eyelid facial and neck exor muscles and ofdistal extremity muscles Myotonia was demonstrable in handgrip CD was diagnosed later because of a malabsorptionsyndrome A gluten-free diet did not improve the neurologicalpicture

Anti-neuronal antibodiesAnti-neuronal antibodies to CNS were detected in 8 of the

13 (61) CD patients with neurological involvement (1 withmultiple sclerosis 2 with epilepsy 2 with attentionmemoryimpairment 2 with cerebellar ataxia and 1 with myotonicdystrophy) as compared with only 1 of 20 (5) patientswithout neurological symptoms No positive staining wasfound in control subjects The prevalence of anti-neuronal

Scand J Gastroenterol 2002 (11)

1278 U Volta et al

antibodies to CNS was signi cantly higher in patients withneurological symptoms than in those without neurologicalsymptoms (P = 00007) or controls (P = 000001) (Table II)All the positive cases belonged to the IgG class (associatedwith IgA in 2 patients) with antibody titres ranging from 150to 1200 The anti-neuronal antibody pattern was character-ized by nuclear and cytoplasmic positivity of Purkinje cells(Fig 1A and B) and nuclear staining of granular layer neurons(Fig 1A) of both monkey and rat cerebellar cortex Noimmunolabelling was visualized around blood vessels In 6 ofthe 8 positive neurological patients anti-neuronal antibodies

to CNS disappeared after 1 year of a strict gluten-free diet in5 out of 6 cases this was accompanied by improvementdisappearance of neurological symptoms (Fig 2)

No signi cant difference was found in the prevalence ofanti-neuronal antibodies to the ENS in patients and controls(Table II) These antibodies were found in two CD patientswith neurological symptoms (one with epilepsy and one withattentionmemory impairment) in one patient without neuro-logical dysfunction and in one patient with Crohn diseaseThe three positive CD patients all complained of severeconstipation The antibody pattern was characterized by a

Table II Prevalence of anti-neurona l antibodies (NA) in CD with and without neurologica l disorders and in controls

CasesNA to central nervous

system (CNS) ()NA to enteric nervous

system (ENS) ()

A ndash Coeliac disease with neurologica l dysfunction 13 61 15B ndash Coeliac disease without neurologica l dysfunction 20 5 5C ndash Autoimmune hepatitis 10 0 0D ndash In ammatory bowel disease 10 0 10E ndash Blood donors 10 0 0

NA to CNS in A versus B P = 0000686 A versus C Dagger D Dagger E P = 0000009NA to ENS in A versus B and in A versus C Dagger D Dagger E P = ns (Fisher exact test)

Fig 1 Representativ e photomicrograph s showing anti-neurona l antibody immunoreactivit y in the rat cerebellum (A B) and enteric nervoussystem (C) of patients with CD and neurologica l involvement Picture A shows intense immunostaining in the nucleus and cytoplasm ofPurkinje cells (arrow) along with positivity of granular layer neurons (arrowhead) in a CD patient with cerebella r ataxia (patient no 5 listedin Table I) Picture B displays immunolabelling of Purkinje cell cytoplasm in a CD patient with multiple sclerosis (patient no 1) Picture Cillustrates a bright staining in the myenteric plexus (mp) of the rat ileum observed in a CD patient with attentionmemory impairment andsevere constipation (patient no 8) Picture D indicates negative anti-neurona l antibody pattern in a control (blood donor) subject arrowpoints to an unlabelled Purkinje cell Magni cation pound40 in A and D pound80 in B and C

Scand J Gastroenterol 2002 (11)

Neurologica l Dysfunction in Coeliac Disease 1279

bright cytoplasmic uorescence detectable in ganglion cellbodies of the myenteric (Auerbachrsquos) (Fig 1C) and sub-mucous (Meissnerrsquos) plexus

Discussion

Growing evidence indicates that CNS and PNS diseases canbe strictly associated with CD (1ndash9) and that neurologicalsymptoms are sometimes the only clinical clue of an occultCD (18 19) Our study sheds light on the clinical andimmunological features of CD with neurological involve-ment We found that among 160 CD patients 13 (8) hadneurological disorders The neurological dysfunction com-prised a wide variety of conditions including epilepsy loss ofconcentration and attentionmemory impairment cerebellarataxia peripheral neuropathy multiple sclerosis Steinertrsquosmyotonic dystrophy and acute cerebrovascular (ie Moya-moya) disease Previous studies already established closeassociations of CD with epilepsy (most frequently withcomplex partial seizures) (5 6) cerebellar ataxia (7 9 1219) memory impairment (1) and peripheral neuropathy (18)An association with multiple sclerosis has been documentedonly in sporadic case reports (20ndash22) In the present paper wealso describe associations with Steinertrsquos myotonic dystrophyand Moyamoya disease Although clinically relevant theoccurrence of these two rare disorders in our CD patients mayhave been casual Therefore the signi cance of theseassociations with CD requires further investigation

Clinically no signi cant difference was found between CDpatients with and without neurological involvement Bothgroups showed a similar median age at diagnosis of CD and ahigher prevalence of female gender Gastrointestinal andother CD-related signs such as iron-de ciency anaemia wereabsent in about half of both the neurological and non-

neurological CD patients In all but two cases who developedmultiple sclerosis and Moyamoya disease during gluten-freediet the diagnosis of neurological impairment preceded theidenti cation of CD

Our data con rm the importance of early recognition ofCD since a gluten-free diet started promptly on appearanceof the neurological dysfunction can produce a signi cantimprovement or even complete resolution of neurologicalsymptoms (8 9) This was observed in 7 patients (2 withepilepsy 3 with memory impairment 1 with cerebellar ataxiaand 1 with peripheral neuropathy) who started glutenrestriction within 6 months of the neurological onset Incontrast four patients with long-standing neurological dis-orders (one with epilepsy one with cerebellar ataxia one withSteinertrsquos disease and one with peripheral neuropathy)showed no response to gluten withdrawal

The pathophysiology of neurological dysfunction in CD isstill unclear One hypothesis regards an overt or evensubclinical malabsorption causing de ciencies of nutrients(folic acid and vitamin B12) known to exert neurotrophic andneuroprotective effects (23) However only a minority of ourneurological patients (2 out of 13) had an overt malabsorptionsyndrome Selective vitamin E de ciency has also beensuggested as a potential cause of neurological complicationsof CD (24) although administration of large doses of thisvitamin in CD ataxic patients did not improve the clinicalpicture (25) Neurological involvement in CD might arise as aconsequence of an autoimmune mechanism mediated byAGA (7 26) In this respect CD can be considered anautoimmune disease where unusually several pathogeneticfactors are well known ie the extrinsic trigger (gliadin) aclose genetic background (HLA-DQ2 or -DQ8) and a highlyspeci c immune response directed to a well-characterizedautoantigen (tissue transglutaminase) Our data on thepresence of anti-neuronal CNS antibodies provide furthersupport for the autoimmune hypothesis of neurologicaldysfunction in CD patients In our CD patients the presenceof these antibodies was strongly associated with CNSinvolvement Furthermore the antibodies most often (in 6out of 8 cases) disappeared within a year of starting a gluten-free diet and their disappearance was frequently (in 5 out of 6cases) accompanied by improvement or disappearance of theneurological picture Anti-neuronal antibodies are not speci cfor neurological disorders associated with CD since theyhave been described in a wide array of CNS and autonomicnervous system disorders such as cerebellar ataxia subacuteperipheral sensory-motor neuropathy and others (27) Theactual pathogenetic signi cance of these anti-neuronal anti-bodies is currently unknown Speci cally designed in vitrostudies aimed at testing the effects evoked by anti-neuronalantibodies on brain cell tissue culture should clarify whetherthese antibodies may play a direct role in producingneurological damage Neuropathological ndings in CDpatients including cerebellar lymphocytic in ltration Pur-kinje cell loss and posterior columns damage provide further

Fig 2 Titre of anti-neurona l CNS antibodies before and aftergluten-free diet in CD patient responders (improvement ofneurologica l symptoms) or non-responder s to gluten withdrawal(persistence of neurologica l symptoms) Positive cases were de nedat dilution titre gt110 (broken line) CNS = central nervous systemGFD = gluten free diet

Scand J Gastroenterol 2002 (11)

1280 U Volta et al

evidence of an immune-mediated mechanism underlyingneural dysfunction in CD (2 9 23)

In conclusion the present study strongly reinforces theconcept that CD can sometimes present in the guise of aneurological disorder Our ndings suggest that in such casesthe neurological picture can greatly improve when a gluten-free diet is started promptly Closer interaction betweenneurologists and gastroenterologists should facilitate earlieridenti cation of an underlying CD Therefore the possiblepresence of CD needs to be carefully considered in patientswith cerebellar ataxia epilepsy attentionmemory impair-ment or peripheral neuropathy

Acknowledgements

Drs Umberto Volta and Roberto De Giorgio equallycontributed to this paper We are grateful to Robin M TCooke for editing

References

1 Luorostainen L Pirttila T Collin P Coeliac disease presentingwith neurologica l disorders Eur Neurol 199942132 ndash5

2 Wills AJ The neurology and neuropatholog y of coeliac diseaseNeuropat Appl Neurobiol 200026493 ndash6

3 Maki M Collin P Coeliac disease Lancet 19973491755 ndash94 Ciclitira PJ AGA technical review on celiac sprue Gastroenter -

ology 20011201526 ndash405 Holmes GKT Neurologica l and psychiatri c complications in

coeliac disease In Gobbi G Andermann F Naccarato SBanchini G editors Epilepsy and other neurologica l disorders incoeliac disease London John Libbey 1997 p 251ndash64

6 Gobbi G Bouquet F Greco L Lambertini A Tassinari CAVentura A Zaniboni MG and the Italian Working Group onCoeliac Disease and Epilepsy Coeliac disease epilepsy andcerebral calci cations Lancet 1992340439ndash43

7 Hadjivassiliou M Gibson A Davies-Jones GAB Lobo AJStephenson TJ Milford-Ward A Does cryptic gluten sensitivityplay a part in neurologica l illness Lancet 1996347369 ndash71

8 Wills A Hovell CJ Neurological complication s of entericdisease Gut 199639501ndash4

9 Hadjivassiliou M Grunewald RA Chattopadhyay AK Davies-Jones GAB Gibson A Jarratt JA et al Clinical radiological neurophysiological and neuropathologica l characteristic s ofgluten ataxia Lancet 19983521582 ndash5

10 Pratesi R Gandol L Friedman H Farage L De Castro CAMCatassi C Serum IgA antibodies from patients with coeliac

disease strongly react with human brain blood-vesse l structures Scand J Gastroenterol 199833817 ndash22

11 Pellecchia MT Scala R Filla A De Michele G Ciacci C BaroneP Idiopathic cerebellar ataxia associated with celiac diseaselack of distinctive neurologica l features J Neurol NeurosurgPsychiatry 19996632ndash5

12 Salur L Uibo O Talvik I Justus I Metskula K Talvik T et alThe high frequency of coeliac disease among children withneurologica l disorders Eur J Neurol 20007707ndash11

13 Volta U Bellentani S Bianchi FB Brandi G De Franceschi LMiglioli L et al High prevalence of celiac disease in the Italiangeneral population Dig Dis Sci 2001461500 ndash5

14 Volta U Molinaro N De Franceschi L Fratangelo D BianchiFB IgA anti-endomysia l antibodies on human umbilical cordtissue for celiac disease screening save both money andmonkeys Dig Dis Sci 1995401902 ndash5

15 Sblattero D Berti I Trevisiol C Marzari M Tommasini ABradbury A et al Human recombinant tissue transglutaminas eELISA an innovative diagnostic assay for celiac disease Am JGastroentero l 2000951253ndash7

16 Marsh MN Gluten major histocompatibilit y complex and thesmall intestine Gastroenterolog y 1992102330ndash54

17 Oberhuber G Granditsch G Vogelsang H The histopathology ofcoeliac disease time for a standardize d report scheme forpathologists Eur J Gastroenterol Hepatol 1999111185 ndash94

18 Hadjivassiliou M Chattopadhyay AK Davies-Jones GABGibson A Grunewald RA Lobo A Neuromuscula r disorder asa presenting feature of coeliac disease J Neurol NeurosurgPsychiatry 199763770ndash5

19 Burk K Bosch S Muller A Melms A Zuhlke C Stern M et alSporadic cerebella r ataxia associated with gluten sensitivity Brain 20011241013 ndash9

20 Lange LS Shiner M Jejunal morphology in multiple sclerosisLancet 1979i1300 ndash1

21 Cook AW Gupta JK Pertschuk LP Nidzgorski F Multiplesclerosis and malabsorption Lancet 1978i1366

22 Fantelli FJ Mitsumoto H Sebek BA Multiple sclerosis andmalabsorption Lancet 1978i1039 ndash40

23 Cooke WT Smith WT Neurological disorders associated withcoeliac disease Brain 196689683ndash722

24 Mauro A Orsi L Mortara P Costa P Schiffer D Cerebellarsyndrome in adult coeliac disease with vitamin E de ciencyActa Neurol Scand 199184167ndash70

25 Ackerman Z Eliashiv S Reches A Zimmerman J Neurologica lmanifestation in celiac disease and vitamin E de ciency J ClinGastroentero l 198911603 ndash5

26 Collin P Pirttila T Nurmikko T Somer H Erila T KeyrilainenO Celiac disease brain atrophy and dementia Neurology199141372ndash5

27 King PH Redden D Palmgren JS Nabors LB Lennon VA Huantigens speci cities of ANNA-1 autoantibodie s in paraneoplas -tic neurologica l diseases J Autoimmun 199913435ndash43

Received 7 March 2002Accepted 8 August 2002

Scand J Gastroenterol 2002 (11)

Neurologica l Dysfunction in Coeliac Disease 1281

antibodies to CNS was signi cantly higher in patients withneurological symptoms than in those without neurologicalsymptoms (P = 00007) or controls (P = 000001) (Table II)All the positive cases belonged to the IgG class (associatedwith IgA in 2 patients) with antibody titres ranging from 150to 1200 The anti-neuronal antibody pattern was character-ized by nuclear and cytoplasmic positivity of Purkinje cells(Fig 1A and B) and nuclear staining of granular layer neurons(Fig 1A) of both monkey and rat cerebellar cortex Noimmunolabelling was visualized around blood vessels In 6 ofthe 8 positive neurological patients anti-neuronal antibodies

to CNS disappeared after 1 year of a strict gluten-free diet in5 out of 6 cases this was accompanied by improvementdisappearance of neurological symptoms (Fig 2)

No signi cant difference was found in the prevalence ofanti-neuronal antibodies to the ENS in patients and controls(Table II) These antibodies were found in two CD patientswith neurological symptoms (one with epilepsy and one withattentionmemory impairment) in one patient without neuro-logical dysfunction and in one patient with Crohn diseaseThe three positive CD patients all complained of severeconstipation The antibody pattern was characterized by a

Table II Prevalence of anti-neurona l antibodies (NA) in CD with and without neurologica l disorders and in controls

CasesNA to central nervous

system (CNS) ()NA to enteric nervous

system (ENS) ()

A ndash Coeliac disease with neurologica l dysfunction 13 61 15B ndash Coeliac disease without neurologica l dysfunction 20 5 5C ndash Autoimmune hepatitis 10 0 0D ndash In ammatory bowel disease 10 0 10E ndash Blood donors 10 0 0

NA to CNS in A versus B P = 0000686 A versus C Dagger D Dagger E P = 0000009NA to ENS in A versus B and in A versus C Dagger D Dagger E P = ns (Fisher exact test)

Fig 1 Representativ e photomicrograph s showing anti-neurona l antibody immunoreactivit y in the rat cerebellum (A B) and enteric nervoussystem (C) of patients with CD and neurologica l involvement Picture A shows intense immunostaining in the nucleus and cytoplasm ofPurkinje cells (arrow) along with positivity of granular layer neurons (arrowhead) in a CD patient with cerebella r ataxia (patient no 5 listedin Table I) Picture B displays immunolabelling of Purkinje cell cytoplasm in a CD patient with multiple sclerosis (patient no 1) Picture Cillustrates a bright staining in the myenteric plexus (mp) of the rat ileum observed in a CD patient with attentionmemory impairment andsevere constipation (patient no 8) Picture D indicates negative anti-neurona l antibody pattern in a control (blood donor) subject arrowpoints to an unlabelled Purkinje cell Magni cation pound40 in A and D pound80 in B and C

Scand J Gastroenterol 2002 (11)

Neurologica l Dysfunction in Coeliac Disease 1279

bright cytoplasmic uorescence detectable in ganglion cellbodies of the myenteric (Auerbachrsquos) (Fig 1C) and sub-mucous (Meissnerrsquos) plexus

Discussion

Growing evidence indicates that CNS and PNS diseases canbe strictly associated with CD (1ndash9) and that neurologicalsymptoms are sometimes the only clinical clue of an occultCD (18 19) Our study sheds light on the clinical andimmunological features of CD with neurological involve-ment We found that among 160 CD patients 13 (8) hadneurological disorders The neurological dysfunction com-prised a wide variety of conditions including epilepsy loss ofconcentration and attentionmemory impairment cerebellarataxia peripheral neuropathy multiple sclerosis Steinertrsquosmyotonic dystrophy and acute cerebrovascular (ie Moya-moya) disease Previous studies already established closeassociations of CD with epilepsy (most frequently withcomplex partial seizures) (5 6) cerebellar ataxia (7 9 1219) memory impairment (1) and peripheral neuropathy (18)An association with multiple sclerosis has been documentedonly in sporadic case reports (20ndash22) In the present paper wealso describe associations with Steinertrsquos myotonic dystrophyand Moyamoya disease Although clinically relevant theoccurrence of these two rare disorders in our CD patients mayhave been casual Therefore the signi cance of theseassociations with CD requires further investigation

Clinically no signi cant difference was found between CDpatients with and without neurological involvement Bothgroups showed a similar median age at diagnosis of CD and ahigher prevalence of female gender Gastrointestinal andother CD-related signs such as iron-de ciency anaemia wereabsent in about half of both the neurological and non-

neurological CD patients In all but two cases who developedmultiple sclerosis and Moyamoya disease during gluten-freediet the diagnosis of neurological impairment preceded theidenti cation of CD

Our data con rm the importance of early recognition ofCD since a gluten-free diet started promptly on appearanceof the neurological dysfunction can produce a signi cantimprovement or even complete resolution of neurologicalsymptoms (8 9) This was observed in 7 patients (2 withepilepsy 3 with memory impairment 1 with cerebellar ataxiaand 1 with peripheral neuropathy) who started glutenrestriction within 6 months of the neurological onset Incontrast four patients with long-standing neurological dis-orders (one with epilepsy one with cerebellar ataxia one withSteinertrsquos disease and one with peripheral neuropathy)showed no response to gluten withdrawal

The pathophysiology of neurological dysfunction in CD isstill unclear One hypothesis regards an overt or evensubclinical malabsorption causing de ciencies of nutrients(folic acid and vitamin B12) known to exert neurotrophic andneuroprotective effects (23) However only a minority of ourneurological patients (2 out of 13) had an overt malabsorptionsyndrome Selective vitamin E de ciency has also beensuggested as a potential cause of neurological complicationsof CD (24) although administration of large doses of thisvitamin in CD ataxic patients did not improve the clinicalpicture (25) Neurological involvement in CD might arise as aconsequence of an autoimmune mechanism mediated byAGA (7 26) In this respect CD can be considered anautoimmune disease where unusually several pathogeneticfactors are well known ie the extrinsic trigger (gliadin) aclose genetic background (HLA-DQ2 or -DQ8) and a highlyspeci c immune response directed to a well-characterizedautoantigen (tissue transglutaminase) Our data on thepresence of anti-neuronal CNS antibodies provide furthersupport for the autoimmune hypothesis of neurologicaldysfunction in CD patients In our CD patients the presenceof these antibodies was strongly associated with CNSinvolvement Furthermore the antibodies most often (in 6out of 8 cases) disappeared within a year of starting a gluten-free diet and their disappearance was frequently (in 5 out of 6cases) accompanied by improvement or disappearance of theneurological picture Anti-neuronal antibodies are not speci cfor neurological disorders associated with CD since theyhave been described in a wide array of CNS and autonomicnervous system disorders such as cerebellar ataxia subacuteperipheral sensory-motor neuropathy and others (27) Theactual pathogenetic signi cance of these anti-neuronal anti-bodies is currently unknown Speci cally designed in vitrostudies aimed at testing the effects evoked by anti-neuronalantibodies on brain cell tissue culture should clarify whetherthese antibodies may play a direct role in producingneurological damage Neuropathological ndings in CDpatients including cerebellar lymphocytic in ltration Pur-kinje cell loss and posterior columns damage provide further

Fig 2 Titre of anti-neurona l CNS antibodies before and aftergluten-free diet in CD patient responders (improvement ofneurologica l symptoms) or non-responder s to gluten withdrawal(persistence of neurologica l symptoms) Positive cases were de nedat dilution titre gt110 (broken line) CNS = central nervous systemGFD = gluten free diet

Scand J Gastroenterol 2002 (11)

1280 U Volta et al

evidence of an immune-mediated mechanism underlyingneural dysfunction in CD (2 9 23)

In conclusion the present study strongly reinforces theconcept that CD can sometimes present in the guise of aneurological disorder Our ndings suggest that in such casesthe neurological picture can greatly improve when a gluten-free diet is started promptly Closer interaction betweenneurologists and gastroenterologists should facilitate earlieridenti cation of an underlying CD Therefore the possiblepresence of CD needs to be carefully considered in patientswith cerebellar ataxia epilepsy attentionmemory impair-ment or peripheral neuropathy

Acknowledgements

Drs Umberto Volta and Roberto De Giorgio equallycontributed to this paper We are grateful to Robin M TCooke for editing

References

1 Luorostainen L Pirttila T Collin P Coeliac disease presentingwith neurologica l disorders Eur Neurol 199942132 ndash5

2 Wills AJ The neurology and neuropatholog y of coeliac diseaseNeuropat Appl Neurobiol 200026493 ndash6

3 Maki M Collin P Coeliac disease Lancet 19973491755 ndash94 Ciclitira PJ AGA technical review on celiac sprue Gastroenter -

ology 20011201526 ndash405 Holmes GKT Neurologica l and psychiatri c complications in

coeliac disease In Gobbi G Andermann F Naccarato SBanchini G editors Epilepsy and other neurologica l disorders incoeliac disease London John Libbey 1997 p 251ndash64

6 Gobbi G Bouquet F Greco L Lambertini A Tassinari CAVentura A Zaniboni MG and the Italian Working Group onCoeliac Disease and Epilepsy Coeliac disease epilepsy andcerebral calci cations Lancet 1992340439ndash43

7 Hadjivassiliou M Gibson A Davies-Jones GAB Lobo AJStephenson TJ Milford-Ward A Does cryptic gluten sensitivityplay a part in neurologica l illness Lancet 1996347369 ndash71

8 Wills A Hovell CJ Neurological complication s of entericdisease Gut 199639501ndash4

9 Hadjivassiliou M Grunewald RA Chattopadhyay AK Davies-Jones GAB Gibson A Jarratt JA et al Clinical radiological neurophysiological and neuropathologica l characteristic s ofgluten ataxia Lancet 19983521582 ndash5

10 Pratesi R Gandol L Friedman H Farage L De Castro CAMCatassi C Serum IgA antibodies from patients with coeliac

disease strongly react with human brain blood-vesse l structures Scand J Gastroenterol 199833817 ndash22

11 Pellecchia MT Scala R Filla A De Michele G Ciacci C BaroneP Idiopathic cerebellar ataxia associated with celiac diseaselack of distinctive neurologica l features J Neurol NeurosurgPsychiatry 19996632ndash5

12 Salur L Uibo O Talvik I Justus I Metskula K Talvik T et alThe high frequency of coeliac disease among children withneurologica l disorders Eur J Neurol 20007707ndash11

13 Volta U Bellentani S Bianchi FB Brandi G De Franceschi LMiglioli L et al High prevalence of celiac disease in the Italiangeneral population Dig Dis Sci 2001461500 ndash5

14 Volta U Molinaro N De Franceschi L Fratangelo D BianchiFB IgA anti-endomysia l antibodies on human umbilical cordtissue for celiac disease screening save both money andmonkeys Dig Dis Sci 1995401902 ndash5

15 Sblattero D Berti I Trevisiol C Marzari M Tommasini ABradbury A et al Human recombinant tissue transglutaminas eELISA an innovative diagnostic assay for celiac disease Am JGastroentero l 2000951253ndash7

16 Marsh MN Gluten major histocompatibilit y complex and thesmall intestine Gastroenterolog y 1992102330ndash54

17 Oberhuber G Granditsch G Vogelsang H The histopathology ofcoeliac disease time for a standardize d report scheme forpathologists Eur J Gastroenterol Hepatol 1999111185 ndash94

18 Hadjivassiliou M Chattopadhyay AK Davies-Jones GABGibson A Grunewald RA Lobo A Neuromuscula r disorder asa presenting feature of coeliac disease J Neurol NeurosurgPsychiatry 199763770ndash5

19 Burk K Bosch S Muller A Melms A Zuhlke C Stern M et alSporadic cerebella r ataxia associated with gluten sensitivity Brain 20011241013 ndash9

20 Lange LS Shiner M Jejunal morphology in multiple sclerosisLancet 1979i1300 ndash1

21 Cook AW Gupta JK Pertschuk LP Nidzgorski F Multiplesclerosis and malabsorption Lancet 1978i1366

22 Fantelli FJ Mitsumoto H Sebek BA Multiple sclerosis andmalabsorption Lancet 1978i1039 ndash40

23 Cooke WT Smith WT Neurological disorders associated withcoeliac disease Brain 196689683ndash722

24 Mauro A Orsi L Mortara P Costa P Schiffer D Cerebellarsyndrome in adult coeliac disease with vitamin E de ciencyActa Neurol Scand 199184167ndash70

25 Ackerman Z Eliashiv S Reches A Zimmerman J Neurologica lmanifestation in celiac disease and vitamin E de ciency J ClinGastroentero l 198911603 ndash5

26 Collin P Pirttila T Nurmikko T Somer H Erila T KeyrilainenO Celiac disease brain atrophy and dementia Neurology199141372ndash5

27 King PH Redden D Palmgren JS Nabors LB Lennon VA Huantigens speci cities of ANNA-1 autoantibodie s in paraneoplas -tic neurologica l diseases J Autoimmun 199913435ndash43

Received 7 March 2002Accepted 8 August 2002

Scand J Gastroenterol 2002 (11)

Neurologica l Dysfunction in Coeliac Disease 1281

bright cytoplasmic uorescence detectable in ganglion cellbodies of the myenteric (Auerbachrsquos) (Fig 1C) and sub-mucous (Meissnerrsquos) plexus

Discussion

Growing evidence indicates that CNS and PNS diseases canbe strictly associated with CD (1ndash9) and that neurologicalsymptoms are sometimes the only clinical clue of an occultCD (18 19) Our study sheds light on the clinical andimmunological features of CD with neurological involve-ment We found that among 160 CD patients 13 (8) hadneurological disorders The neurological dysfunction com-prised a wide variety of conditions including epilepsy loss ofconcentration and attentionmemory impairment cerebellarataxia peripheral neuropathy multiple sclerosis Steinertrsquosmyotonic dystrophy and acute cerebrovascular (ie Moya-moya) disease Previous studies already established closeassociations of CD with epilepsy (most frequently withcomplex partial seizures) (5 6) cerebellar ataxia (7 9 1219) memory impairment (1) and peripheral neuropathy (18)An association with multiple sclerosis has been documentedonly in sporadic case reports (20ndash22) In the present paper wealso describe associations with Steinertrsquos myotonic dystrophyand Moyamoya disease Although clinically relevant theoccurrence of these two rare disorders in our CD patients mayhave been casual Therefore the signi cance of theseassociations with CD requires further investigation

Clinically no signi cant difference was found between CDpatients with and without neurological involvement Bothgroups showed a similar median age at diagnosis of CD and ahigher prevalence of female gender Gastrointestinal andother CD-related signs such as iron-de ciency anaemia wereabsent in about half of both the neurological and non-

neurological CD patients In all but two cases who developedmultiple sclerosis and Moyamoya disease during gluten-freediet the diagnosis of neurological impairment preceded theidenti cation of CD

Our data con rm the importance of early recognition ofCD since a gluten-free diet started promptly on appearanceof the neurological dysfunction can produce a signi cantimprovement or even complete resolution of neurologicalsymptoms (8 9) This was observed in 7 patients (2 withepilepsy 3 with memory impairment 1 with cerebellar ataxiaand 1 with peripheral neuropathy) who started glutenrestriction within 6 months of the neurological onset Incontrast four patients with long-standing neurological dis-orders (one with epilepsy one with cerebellar ataxia one withSteinertrsquos disease and one with peripheral neuropathy)showed no response to gluten withdrawal

The pathophysiology of neurological dysfunction in CD isstill unclear One hypothesis regards an overt or evensubclinical malabsorption causing de ciencies of nutrients(folic acid and vitamin B12) known to exert neurotrophic andneuroprotective effects (23) However only a minority of ourneurological patients (2 out of 13) had an overt malabsorptionsyndrome Selective vitamin E de ciency has also beensuggested as a potential cause of neurological complicationsof CD (24) although administration of large doses of thisvitamin in CD ataxic patients did not improve the clinicalpicture (25) Neurological involvement in CD might arise as aconsequence of an autoimmune mechanism mediated byAGA (7 26) In this respect CD can be considered anautoimmune disease where unusually several pathogeneticfactors are well known ie the extrinsic trigger (gliadin) aclose genetic background (HLA-DQ2 or -DQ8) and a highlyspeci c immune response directed to a well-characterizedautoantigen (tissue transglutaminase) Our data on thepresence of anti-neuronal CNS antibodies provide furthersupport for the autoimmune hypothesis of neurologicaldysfunction in CD patients In our CD patients the presenceof these antibodies was strongly associated with CNSinvolvement Furthermore the antibodies most often (in 6out of 8 cases) disappeared within a year of starting a gluten-free diet and their disappearance was frequently (in 5 out of 6cases) accompanied by improvement or disappearance of theneurological picture Anti-neuronal antibodies are not speci cfor neurological disorders associated with CD since theyhave been described in a wide array of CNS and autonomicnervous system disorders such as cerebellar ataxia subacuteperipheral sensory-motor neuropathy and others (27) Theactual pathogenetic signi cance of these anti-neuronal anti-bodies is currently unknown Speci cally designed in vitrostudies aimed at testing the effects evoked by anti-neuronalantibodies on brain cell tissue culture should clarify whetherthese antibodies may play a direct role in producingneurological damage Neuropathological ndings in CDpatients including cerebellar lymphocytic in ltration Pur-kinje cell loss and posterior columns damage provide further

Fig 2 Titre of anti-neurona l CNS antibodies before and aftergluten-free diet in CD patient responders (improvement ofneurologica l symptoms) or non-responder s to gluten withdrawal(persistence of neurologica l symptoms) Positive cases were de nedat dilution titre gt110 (broken line) CNS = central nervous systemGFD = gluten free diet

Scand J Gastroenterol 2002 (11)

1280 U Volta et al

evidence of an immune-mediated mechanism underlyingneural dysfunction in CD (2 9 23)

In conclusion the present study strongly reinforces theconcept that CD can sometimes present in the guise of aneurological disorder Our ndings suggest that in such casesthe neurological picture can greatly improve when a gluten-free diet is started promptly Closer interaction betweenneurologists and gastroenterologists should facilitate earlieridenti cation of an underlying CD Therefore the possiblepresence of CD needs to be carefully considered in patientswith cerebellar ataxia epilepsy attentionmemory impair-ment or peripheral neuropathy

Acknowledgements

Drs Umberto Volta and Roberto De Giorgio equallycontributed to this paper We are grateful to Robin M TCooke for editing

References

1 Luorostainen L Pirttila T Collin P Coeliac disease presentingwith neurologica l disorders Eur Neurol 199942132 ndash5

2 Wills AJ The neurology and neuropatholog y of coeliac diseaseNeuropat Appl Neurobiol 200026493 ndash6

3 Maki M Collin P Coeliac disease Lancet 19973491755 ndash94 Ciclitira PJ AGA technical review on celiac sprue Gastroenter -

ology 20011201526 ndash405 Holmes GKT Neurologica l and psychiatri c complications in

coeliac disease In Gobbi G Andermann F Naccarato SBanchini G editors Epilepsy and other neurologica l disorders incoeliac disease London John Libbey 1997 p 251ndash64

6 Gobbi G Bouquet F Greco L Lambertini A Tassinari CAVentura A Zaniboni MG and the Italian Working Group onCoeliac Disease and Epilepsy Coeliac disease epilepsy andcerebral calci cations Lancet 1992340439ndash43

7 Hadjivassiliou M Gibson A Davies-Jones GAB Lobo AJStephenson TJ Milford-Ward A Does cryptic gluten sensitivityplay a part in neurologica l illness Lancet 1996347369 ndash71

8 Wills A Hovell CJ Neurological complication s of entericdisease Gut 199639501ndash4

9 Hadjivassiliou M Grunewald RA Chattopadhyay AK Davies-Jones GAB Gibson A Jarratt JA et al Clinical radiological neurophysiological and neuropathologica l characteristic s ofgluten ataxia Lancet 19983521582 ndash5

10 Pratesi R Gandol L Friedman H Farage L De Castro CAMCatassi C Serum IgA antibodies from patients with coeliac

disease strongly react with human brain blood-vesse l structures Scand J Gastroenterol 199833817 ndash22

11 Pellecchia MT Scala R Filla A De Michele G Ciacci C BaroneP Idiopathic cerebellar ataxia associated with celiac diseaselack of distinctive neurologica l features J Neurol NeurosurgPsychiatry 19996632ndash5

12 Salur L Uibo O Talvik I Justus I Metskula K Talvik T et alThe high frequency of coeliac disease among children withneurologica l disorders Eur J Neurol 20007707ndash11

13 Volta U Bellentani S Bianchi FB Brandi G De Franceschi LMiglioli L et al High prevalence of celiac disease in the Italiangeneral population Dig Dis Sci 2001461500 ndash5

14 Volta U Molinaro N De Franceschi L Fratangelo D BianchiFB IgA anti-endomysia l antibodies on human umbilical cordtissue for celiac disease screening save both money andmonkeys Dig Dis Sci 1995401902 ndash5

15 Sblattero D Berti I Trevisiol C Marzari M Tommasini ABradbury A et al Human recombinant tissue transglutaminas eELISA an innovative diagnostic assay for celiac disease Am JGastroentero l 2000951253ndash7

16 Marsh MN Gluten major histocompatibilit y complex and thesmall intestine Gastroenterolog y 1992102330ndash54

17 Oberhuber G Granditsch G Vogelsang H The histopathology ofcoeliac disease time for a standardize d report scheme forpathologists Eur J Gastroenterol Hepatol 1999111185 ndash94

18 Hadjivassiliou M Chattopadhyay AK Davies-Jones GABGibson A Grunewald RA Lobo A Neuromuscula r disorder asa presenting feature of coeliac disease J Neurol NeurosurgPsychiatry 199763770ndash5

19 Burk K Bosch S Muller A Melms A Zuhlke C Stern M et alSporadic cerebella r ataxia associated with gluten sensitivity Brain 20011241013 ndash9

20 Lange LS Shiner M Jejunal morphology in multiple sclerosisLancet 1979i1300 ndash1

21 Cook AW Gupta JK Pertschuk LP Nidzgorski F Multiplesclerosis and malabsorption Lancet 1978i1366

22 Fantelli FJ Mitsumoto H Sebek BA Multiple sclerosis andmalabsorption Lancet 1978i1039 ndash40

23 Cooke WT Smith WT Neurological disorders associated withcoeliac disease Brain 196689683ndash722

24 Mauro A Orsi L Mortara P Costa P Schiffer D Cerebellarsyndrome in adult coeliac disease with vitamin E de ciencyActa Neurol Scand 199184167ndash70

25 Ackerman Z Eliashiv S Reches A Zimmerman J Neurologica lmanifestation in celiac disease and vitamin E de ciency J ClinGastroentero l 198911603 ndash5

26 Collin P Pirttila T Nurmikko T Somer H Erila T KeyrilainenO Celiac disease brain atrophy and dementia Neurology199141372ndash5

27 King PH Redden D Palmgren JS Nabors LB Lennon VA Huantigens speci cities of ANNA-1 autoantibodie s in paraneoplas -tic neurologica l diseases J Autoimmun 199913435ndash43

Received 7 March 2002Accepted 8 August 2002

Scand J Gastroenterol 2002 (11)

Neurologica l Dysfunction in Coeliac Disease 1281

evidence of an immune-mediated mechanism underlyingneural dysfunction in CD (2 9 23)

In conclusion the present study strongly reinforces theconcept that CD can sometimes present in the guise of aneurological disorder Our ndings suggest that in such casesthe neurological picture can greatly improve when a gluten-free diet is started promptly Closer interaction betweenneurologists and gastroenterologists should facilitate earlieridenti cation of an underlying CD Therefore the possiblepresence of CD needs to be carefully considered in patientswith cerebellar ataxia epilepsy attentionmemory impair-ment or peripheral neuropathy

Acknowledgements

Drs Umberto Volta and Roberto De Giorgio equallycontributed to this paper We are grateful to Robin M TCooke for editing

References

1 Luorostainen L Pirttila T Collin P Coeliac disease presentingwith neurologica l disorders Eur Neurol 199942132 ndash5

2 Wills AJ The neurology and neuropatholog y of coeliac diseaseNeuropat Appl Neurobiol 200026493 ndash6

3 Maki M Collin P Coeliac disease Lancet 19973491755 ndash94 Ciclitira PJ AGA technical review on celiac sprue Gastroenter -

ology 20011201526 ndash405 Holmes GKT Neurologica l and psychiatri c complications in

coeliac disease In Gobbi G Andermann F Naccarato SBanchini G editors Epilepsy and other neurologica l disorders incoeliac disease London John Libbey 1997 p 251ndash64

6 Gobbi G Bouquet F Greco L Lambertini A Tassinari CAVentura A Zaniboni MG and the Italian Working Group onCoeliac Disease and Epilepsy Coeliac disease epilepsy andcerebral calci cations Lancet 1992340439ndash43

7 Hadjivassiliou M Gibson A Davies-Jones GAB Lobo AJStephenson TJ Milford-Ward A Does cryptic gluten sensitivityplay a part in neurologica l illness Lancet 1996347369 ndash71

8 Wills A Hovell CJ Neurological complication s of entericdisease Gut 199639501ndash4

9 Hadjivassiliou M Grunewald RA Chattopadhyay AK Davies-Jones GAB Gibson A Jarratt JA et al Clinical radiological neurophysiological and neuropathologica l characteristic s ofgluten ataxia Lancet 19983521582 ndash5

10 Pratesi R Gandol L Friedman H Farage L De Castro CAMCatassi C Serum IgA antibodies from patients with coeliac

disease strongly react with human brain blood-vesse l structures Scand J Gastroenterol 199833817 ndash22

11 Pellecchia MT Scala R Filla A De Michele G Ciacci C BaroneP Idiopathic cerebellar ataxia associated with celiac diseaselack of distinctive neurologica l features J Neurol NeurosurgPsychiatry 19996632ndash5

12 Salur L Uibo O Talvik I Justus I Metskula K Talvik T et alThe high frequency of coeliac disease among children withneurologica l disorders Eur J Neurol 20007707ndash11

13 Volta U Bellentani S Bianchi FB Brandi G De Franceschi LMiglioli L et al High prevalence of celiac disease in the Italiangeneral population Dig Dis Sci 2001461500 ndash5

14 Volta U Molinaro N De Franceschi L Fratangelo D BianchiFB IgA anti-endomysia l antibodies on human umbilical cordtissue for celiac disease screening save both money andmonkeys Dig Dis Sci 1995401902 ndash5

15 Sblattero D Berti I Trevisiol C Marzari M Tommasini ABradbury A et al Human recombinant tissue transglutaminas eELISA an innovative diagnostic assay for celiac disease Am JGastroentero l 2000951253ndash7

16 Marsh MN Gluten major histocompatibilit y complex and thesmall intestine Gastroenterolog y 1992102330ndash54

17 Oberhuber G Granditsch G Vogelsang H The histopathology ofcoeliac disease time for a standardize d report scheme forpathologists Eur J Gastroenterol Hepatol 1999111185 ndash94

18 Hadjivassiliou M Chattopadhyay AK Davies-Jones GABGibson A Grunewald RA Lobo A Neuromuscula r disorder asa presenting feature of coeliac disease J Neurol NeurosurgPsychiatry 199763770ndash5

19 Burk K Bosch S Muller A Melms A Zuhlke C Stern M et alSporadic cerebella r ataxia associated with gluten sensitivity Brain 20011241013 ndash9

20 Lange LS Shiner M Jejunal morphology in multiple sclerosisLancet 1979i1300 ndash1

21 Cook AW Gupta JK Pertschuk LP Nidzgorski F Multiplesclerosis and malabsorption Lancet 1978i1366

22 Fantelli FJ Mitsumoto H Sebek BA Multiple sclerosis andmalabsorption Lancet 1978i1039 ndash40

23 Cooke WT Smith WT Neurological disorders associated withcoeliac disease Brain 196689683ndash722

24 Mauro A Orsi L Mortara P Costa P Schiffer D Cerebellarsyndrome in adult coeliac disease with vitamin E de ciencyActa Neurol Scand 199184167ndash70

25 Ackerman Z Eliashiv S Reches A Zimmerman J Neurologica lmanifestation in celiac disease and vitamin E de ciency J ClinGastroentero l 198911603 ndash5

26 Collin P Pirttila T Nurmikko T Somer H Erila T KeyrilainenO Celiac disease brain atrophy and dementia Neurology199141372ndash5

27 King PH Redden D Palmgren JS Nabors LB Lennon VA Huantigens speci cities of ANNA-1 autoantibodie s in paraneoplas -tic neurologica l diseases J Autoimmun 199913435ndash43

Received 7 March 2002Accepted 8 August 2002

Scand J Gastroenterol 2002 (11)

Neurologica l Dysfunction in Coeliac Disease 1281