The medical world is full of gluten sceptics. These doctors believe that gluten can only cause celiac disease, and nothing else. Without evidence, they declare that if there is no histological gut damage, then gluten cannot be the culprit. However, now gluten sceptics criticised.
Hadjivassiliou gluten expert
Drs M. Hadjivassiliou and R. Grnewald (from Department of Clinical Neurology, The Royal Hallamshire Hospital, Sheffield, UK) are gluten experts, and have published over 40 papers that clearly link gluten sensitivity with brain and nerve disturbance. They write in a Letter to the Editor a reply to Gluten ataxia in perspective (Brain 2003;126 (9)).
Letter to editor
We note Dr Wills and Dr Unsworth s continued scepticism at the concept of gluten ataxia in the face of overwhelming evidence in its support.
We have proposed that IgG antigliadin antibodies are currently the best marker of the whole spectrum of gluten sensitivity although they are not specific for gluten-sensitive enteropathy. We hope that a better marker of neurological manifestations of gluten sensitivity will come with the identification of the antibodies recognizing neuronal epitopes, such as those on Purkinje cells identified by antibodies in patients with gluten ataxia. This would be analogous to the antiendomysium antibody in cases with gluten-sensitive enteropathy or epidermal transglutaminase antibodies in patients with Dermatitis Harpetiformis.
We have long recognized that the final test of the hypothesis that gluten ataxia as an entity comes with the demonstration of response to treatment. The benefit of a gluten-free diet in patients with gluten ataxia has been demonstrated in our study of 43 patients (so far) (Hadjivassiliou et al., 2003 ). The response in the treatment group was independent of the presence of an enteropathy, confirming that gluten ataxia is part of a spectrum of gluten sensitivity. It is not, unfortunately, feasible to conduct a blinded study because of the nature of the intervention (gluten-free diet).
The prevalence of coeliac disease in the 1980s was thought to be 1 in 2000. More recent prevalence studies have revealed more of the iceberg by showing the prevalence to be at least 1%, i.e. 20 times higher than previously thought. Who is to say that 10% of the healthy population who are positive for antigliadin antibodies do not have gluten sensitivity, but as yet have none of its recognized manifestations After all it is amongst these 10% antigliadin antibody-positive patients that lurk those with silent gluten-sensitive enteropathy.
Wills and Unsworth may note that in this paper we have shown that the high prevalence of gluten sensitivity in sporadic idiopathic ataxia was not dependent on a high prevalence of the HLA DQ2. The prevalence of HLA DQ2 in the antigliadin-negative patients with sporadic ataxia was the same as the rest of the population. We are perplexed at Wills and Unsworth s astonishment at the 26% prevalence of enteropathy in patients with gluten ataxia. These patients have antigliadin antibodies and are thus gluten-sensitive. This finding strengthens our contention that gluten ataxia is part of a spectrum of gluten-sensitive diseases as is coeliac disease and Dermatitis Herpetiformis. The population studied was derived from two geographically different centres in the UK to reduce selection bias.
Wills and Unsworth demonstrate selective agnosia to published controlled studies by others. Luostarinen et al. (2001 ) have showed the prevalence of coeliac disease in patients with sporadic idiopathic ataxia to be 16.7% in comparison to 2% in the healthy Finnish population. Pellecchia et al. (1999 ) showed the prevalence to be 13% in sporadic ataxia and 0% in familial ataxias compared to 1% in the healthy Italian population.
Scepticism in the face of new ideas is healthy but eventually the time must come for acceptance of scientific evidence even if it does not coincide with personal opinion.”
Hadjivassiliou M, Davies-Jones GAB, Sanders DS, Grunewald RA. Dietary treatment of gluten ataxia. J Neurol Neurosurg Neuropsychiatry 2003; in press. Luostarinen LK, Collin PO, Paraaho MJ, Maki MJ, Pirttila TA. Coeliac disease in patients with cerebellar ataxia of unknown origin. Ann Med 2001; 33: 445 9.[Web of Science][Medline] Pellecchia MT, Scala R, Filla A, De Michele G, Ciacci C, Barone P. Idiopathic cerebellar ataxia associated with celiac disease: lack of distinctive neurological features. J Neurol Neurosurg Psychiatry 1999; 66: 32 5.[Abstract/Free Full Text]