<<Disclaimer: Verify this information before applying it to your situation.>> 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.