the patient celiac

A Case of Temporary Gluten Intolerance Following an Infection

11 comments February 04, 2015

I never in a million years would ever have guessed that I’d be writing about gastroenteritis (known to many as the “stomach flu”) for fun back when I was a medical student. But, I never would have guessed that I would eventually be diagnosed with celiac disease back when I was student either. Needless to say, I came across a really interesting case report on pubmed.gov called “Post gastroenteritis gluten intolerance” that was published last month.

Celiac researchers have hypothesized that viral infections may trigger celiac disease in some cases. This case report details a 32 year old, previously healthy woman who developed chronic diarrhea after an episode of gastroenteritis. Her tests for celiac disease (TTG antibodies and endoscopy with small bowel biopsies) were negative. After other causes of chronic diarrhea were ruled out, she was given a working diagnosis of post infectious irritable bowel syndrome (IBS).  She was treated with a gluten free diet and her IBS symptoms markedly improved. She was able to reintroduce gluten a few months later, without a return of diarrhea, leading her to be ultimately diagnosed with post infectious gluten intolerance.

Although it is well documented that many patients develop a temporary lactose intolerance after episodes of gastroenteritis, this is the first case report I have come across of a patient developing a transient gluten intolerance after having a gastrointestinal infection. The authors do an excellent job of explaining why gluten intolerance may develop after gut infections. Gut inflammation following an infection may lead to reduced activity of the enzymes (peptidases) that break down gluten. These partially intact gluten proteins may then damage the intestinal walls, leading to gluten intolerance. The authors speculate that in some cases this gluten intolerance is temporary, while in other cases it is permanent. According to the authors’ conclusion, “Transient or permanent post gastroenteritis gluten intolerance might be a common unrecognized clinical condition. Like secondary lactose intolerance, post gastroenteritis gluten intolerance could explain the prolonged symptoms that develop in a group of patients who have suffered from infectious gastroenteritis.” It is possible that many patients with post-infectious "IBS" may actually be suffering from an undiagnosed gluten intolerance.

I hope that the authors will continue to study post gastroenteritis gluten intolerance in more detail. I am interested in learn more about this condition, including how common it actually is, the average length of time that the gluten intolerance lasts, the percentage of patients with this problem who eventually develop celiac disease, etc. I also suspect that this entity may have played a role in my youngest daughter’s transient gluten sensitivity/intolerance last year--she tested negative for celiac disease on a properly obtained duodenal biopsy at age 2 and is now able to eat gluten without any problems.

Reference:

Rostami, K., Rostami-Nejad, M., Al Dulaimi, D. Post gastroenteritis gluten intolerance. Gastroenterol Hepatol Bed Bench 2015; 8(1): 66-70.

Comments
Gluten Maestro
I commented on here in March suggesting that avoiding gluten for a short time after an infection might prevent celiac disease. I found an article online that, although a few years old, might shed some light on how celiac disease develops.

Here is the reference: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2944025/

One particular section, titled “CD development: a series of unfortunate events”, hypothesizes how the loss of tolerance to gluten may be initiated.
7/21/2016 3:29:44 PM
Jess
In reply to Gluten Maestro.
Hi Gluten Maestro,
It is really nice to “meet” you and I get the impression that you have a given a lot of thought to these questions. I wish that I could answer your questions but I cannot.
It would be wonderful if we could prevent the development of celiac via removing gluten from our diets after episodes of gastroenteritis, but I don’t think that we have enough research into this yet–this is actually the first case report that I am aware of that even alludes to this possibility.

As far as know and understand, the celiac experts have stated that HLA DQ2 and/or 8 are necessary for the development of celiac disease, but there are some case reports out there of celiac developing in DQ7 and DQ9 individuals. Also, at the current time, the evidence has supported that once a person develops celiac disease that they will have it forever–the autoimmune cascade cannot be stopped once it has started. Hence, the need for a strict, lifelong GF diet for all of us.

Thanks for writing and asking your questions. If you do come across any interesting information and/or answers in regards to your questions, please feel free to share.

Jess
7/21/2016 3:28:41 PM
Gluten Maestro
In reply to Jess.
Just a few questions on this… I’d be interested in your thoughts…

Do you believe it is possible that avoiding gluten for a short time after an episode of gastroenteritis could potentially prevent celiac disease from being “initiated”, and thus keep the patient in a state of “gluten tolerance”, so that they can re-introduce gluten once they have healed from the infection? I’m thinking this could be an approach to prevention, since I suspect it is easier to lose tolerance to food antigens when the body is in a state of inflammation.

Also, would you happen to know if the HLA-DQ2/DQ8 gene is actually necessary once celiac disease is present or does it simply play a role in initiating the loss of tolerance? I suspect the former is true, but I’d be interested if you have any input.

Finally, when you talk about temporary gluten intolerance, might it be possible that some of the individuals who develop celiac disease after an infection may regain their tolerance to gluten or is it a sunken ship?

If anyone else has any thoughts I’d love to hear them. :)
7/21/2016 3:28:08 PM
Jess
In reply to shannon.
Hi Shannon,
Both you and your colleague’s daughter’s stories are fascinating.
As Julie mentioned in her comment, gut bacteria balance must play a huge role in all of this.
Thanks for sharing!
7/21/2016 3:27:37 PM
Jess
In reply to Grandma Honey.
Hi Grandma Honey,
Out of curiosity, how long did it take you to get diagnosed?
7/21/2016 3:27:18 PM
Jess
In reply to Julie.
I don’t disagree with you Julie and I hope that many patients, such as this one, are followed long term to see if celiac eventually develops.
7/21/2016 3:27:00 PM
Jess
In reply to IrishHeart.
You’re welcome IH! I feel horrible that this is the first chance that I’ve had more than a few minutes to reply to comments. But I know you understand :) I also had a bizarre viral infection when I was about 15 (kind of like mono but wasn’t Epstein Barr) and my classic celiac symptoms started shortly after.
7/21/2016 3:26:41 PM
Shannon
Interesting… I had a terrible gastroenteritis when I was in my early 30’s. I ended up on cardiac meds for over a year with suspected scarring which led to a dysrhythmia which slowly improved. It was shortly after this that my migraines and GI issues changed for the worse.
Ironically, I had a discussion earlier this week with a colleague who’s daughter has recently developed an anaphylactic peanut allergy at the age of 18. She had a terrible gastroenteritis and ended up hospitalized from it and then developed the allergy.
Definitely need to research this more.
7/21/2016 3:26:01 PM
Grandma Honey
VERY interesting because I remember clearly mine began after a stomach flu when I was 7…..and I am 60 now.
7/21/2016 3:25:17 PM
Julie
Isn’t it likely that gut bacteria was off balance by the gastroenteritis? Particularly if antibiotics were given to the patient.

I’m suggesting that without proper balance of gut bacteria, gluten intolerance was able to develop. Once the lining of the intestines have permeated there needs to be intentional steps taken to reverse that damage.

I was diagnosed via endoscopy biopsy for CD. Yet, I never experienced gut symptoms. Ever. I have gluten ataxia. All of my symptoms were neurological.

When I hear people reintroducing gluten to their diet, I’m concerned with what unknown damage may actually be going on in their guts and elsewhere.
7/21/2016 3:24:44 PM
Irish Heart
That IS a fascinating article. I have long suspected that my celiac triggered after a viral infection as a teenager. Thanks for sharing, Jess. xo
7/21/2016 3:23:51 PM
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