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Recently there was a post asking about transient gluten intolerance.
I asked Karoly Horvath, MD PhD of the celiac center at University
of Maryland to prepare a post about this topic, it is attached below.
(Special thanks to Dr Horvath for his continued assistance!)
My editorial comment: The erroneous view from 10+ years ago was that some
(many?) children "grow out" of Celiac Disease. What was being observed was
a temporary reduction of external symptoms during adolesence, not a
resolution of villi damage. Given that prior view, and the many parents
given dangerous advise that their celiac children could now safely consume
gluten, one must be careful not to overemphasize the importance of "real"
transient gluten intolerance ... it is apparently very very rare, much less
common that Celiac Diease.
Bill Elkus
Los Angeles
---- forward from Karoly Horvath ---
I had 5 cases of biopsy proved temporarily gluten intolerance (not published,
summarized in my Ph.D. thesis) between 1977 and 1987. All of them were
children. The oldest was an 8 years old boy with positive biopsy and
immunity for gluten at the time of diagnosis. He did not have any reaction
to gluten after a year of gluten free diet, and the immunological test became
negative. Repeat biopsy > 2 years on normal diet was negative and now he is
a medical student without any evidence of disease or serological positivity.
However, if the gluten sensitivity is proved with a RECHALLENGE (serology or
biopsy are positive) than the gluten sensitive considered as PERMANENT.
The transient intolerance exists in childhood based on my own experience
and the literature.
I attach a few references discussing this isssue.
Anonymous (1976). "Editorial: Temporary gluten intolerance." Lancet
2(1985): 555.
Berg, N. O. and T. Lindberg (1979). "Incidence of coeliac disease
and transient gluten intolerance in children in a Swedish urban
community." Acta Paediatrica Scandinavica 68(3): 397-400.
The incidence of coeliac disease in children in the city of Malmo,
South Sweden, was 1 : 982 during 1966 to 1975. The diagnostic
criteria were: flat intestinal mucosa on gluten- containing diet,
free of symptoms, and improvement in mucosal morphology on
gluten-free diet, and morphological and/or evident clinical relapse
(three times) on gluten challenge. 6 (12%) of 49 children with
initially a flat mucosa still had a normal mucosa on a
gluten-containing diet for two years or longer, having so-called
TRANSIENT GLUTEN INTOLERANCE.
Danielsson, L., L. Stenhammar, et al. (1990). "Is gluten challenge
necessary for the diagnosis of coeliac disease in young children?"
Scandinavian Journal of Gastroenterology 25(9): 957-60.
Sixty-seven children under 2 years of age presenting with a classic
clinical picture of coeliac disease with a severe small-intestinal
mucosal lesion were investigated. All improved clinically and
histologically on a gluten-free diet. During gluten challenge the
mucosal damage recurred in 64 (95.5%) children, thus fulfilling the
criteria for coeliac disease formulated by the European Society for
Paediatric Gastroenterology and Nutrition. THREE (4.5%) CHILDREN
HAD NO MUCOSAL RELAPSE 2 YEARS OR MORE AFTER RETURN TO A
GLUTEN-CONTAINING DIET. These children were classified as having
transient gluten intolerance. The low frequency of non-relapsers in
the present study calls into question the practice of performing
gluten challenge.
Dodge, J. A. (1980). "Diagnostic criteria for coeliac disease and
transient gluten intolerance [letter]." Lancet 1(8178): 1130-1.
Dyduch, A., K. Karczewska, et al. (1993). "Transmission electron
microscopy of microvilli of intestinal epithelial cells in celiac
disease in remission and transient gluten enteropathy in children
after a gluten-free diet." Journal of Pediatric Gastroenterology &
Nutrition 16(3): 269- 72.
The structure of microvilli of intestinal epithelial cells was
investigated in 70 children: 34 with celiac disease in remission,
28 WITH TRANSIENT GLUTEN ENTEROPATHY after a gluten-free diet, and
eight controls. Transmission electron microscopy was used to
determine the mean thickness of the glycocalyx layer covering the
microvilli, the mean length and width of microvilli, and the number
of microvilli per 1 micron length of enterocyte surface. The
structure of the glycocalyx was found to be intact, but in some
children with treated celiac disease the layer of glycocalyx was
either thin or absent on the surface of individual cell microvilli.
In children with treated celiac disease, microvilli were
statistically significantly shorter than those in children with
transient gluten enteropathy and controls. Microvillous width in
treated celiac disease was greater as compared with that in
controls. There was no difference in the number of microvilli on
the enterocyte surface in the three groups.
Iacono, G., A. Nocerino, et al. (1991). "Transient gluten
hypersensitivity." Journal of Pediatric Gastroenterology &
Nutrition 12(3): 400-3.
We report a CASE OF TRANSIENT GLUTEN HYPERSENSITIVITY, demonstrated
by jejunal histology at diagnosis, normalization after gluten-free
diet, and acute clinical and histological relapse after a challenge
with gluten powder at the age of 1 year, resembling that observed
in cow's milk protein intolerance. Subsequent provocation tests did
not show any alteration. Cases of supposed transient gluten
hypersensitivity are rarely reported; our patient is characterized
by the acute reaction to gluten challenge associated with a damaged
histological picture and depressed levels of complement.
McNeish, A. S., C. J. Rolles, et al. (1976). "Criteria for
diagnosis of temporary gluten intolerance." Archives of Disease in
Childhood 51(4): 275-8. Strict criteria for the diagnosis of
temporary gluten intolerance are formulated in the light of the
case of an 8-week-old infant with severe diarrhoea and failure to
thrive, who recovered on an elimination diet that was gluten-free.
8 weeks later an oral challenge with 2.5 g twice daily of powdered
gluten for one day produced diarrhoea, weight loss, and impaired
xylose absorption. Gluten was successfully reintroduced into the
diet 9 months later without incident. Jejunal histology remains
normal after 26 months of a daily diet that contains 5 to 10 g
gluten.
Miller, V. (1976). "Criteria for diagnosis of temporary gluten
intolerance [letter]." Archives of Disease in Childhood 51(12):
990.
Stenhammar, L., P. Ansved, et al. (1987). "Incidences of childhood
coeliac diseases and transient gluten intolerance move discrepantly
in UK and Sweden [letter]." Archives of Disease in Childhood
62(10): 1089.
Suranyi, Y., S. Freier, et al. (1986). "Intestinal mast cells in
different stages of celiac disease [published erratum appears in
Isr J Med Sci 1986 Jul-Aug;22(7-8):preceding 505]." Israel Journal
of Medical Sciences 22(5): 370-5.
A study of mast cell content of the small intestinal mucosa in
children with celiac disease is presented. Twenty patients with
true celiac disease were studied and compared with 7 PATIENTS WITH
TRANSIENT GLUTEN INTOLERANCE and 20 normal control patients. In
healthy children we found (mean +/- SE) 142.5 +/- 16.4 mast
cells/mm2. In children with active celiac disease, only 40.1 +/-
19.5 cells were found. This difference was highly significant (P
less than 0.001). On a gluten- free diet for 1.5 years, the number
of mast cells was 82.2 +/- 27.2/mm2 and still remained
significantly depressed (P less than 0.001). Upon gluten challenge
in celiac disease, the numbers fell to 58.3 +/- 32.6/mm2, while in
transient gluten intolerance the numbers of mast cells attained
were 102.5 +/- 22.5/mm2, near normal values. These findings
indicate that during the untreated phase of celiac disease the
number of mast cells is depressed. On a gluten-free diet, the
number rises but does not reach normal control levels even after
prolonged remission. It is suggested that even during remission of
celiac disease the mast cells continue to be damaged by
unidentified toxic agents.
Walker-Smith, J. (1970). "Transient gluten intolerance." Archives
of Disease in Childhood45(242): 523-6.
Walker-Smith, J. A. (1972). "Transient gluten intolerance."
Archives of Disease in Childhood47(251): 155.
Walker-Smith, J. A. (1980). "Diagnostic criteria for coeliac
disease and transient gluten intolerance [letter]." Lancet 1(8174):
926.
Walker-Smith, J. A. (1987). "Transient gluten intolerance: does it
exist?. [Review]." Netherlands Journal of Medicine 31(5-6): 269-78.
Walker-Smith, J. A. (1992). "Transient gluten intolerance [letter;
comment]." Archives of Disease in Childhood 67(1): 152-3.
Walker-Smith, J. A. (1996). "Transient gluten intolerance
[letter]." Archives of Disease in Childhood 74(2): 183-4.
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