Alimentary Tract
Frontal cortical perfusion abnormalities related to gluten intake and associated autoimmune disease in adult coeliac disease: 99mTc-ECD brain SPECT study

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Abstract

Objective. Since brain perfusion abnormalities have been described by single-photon emission computed tomography in some autoimmune diseases, the aim of the present study was to evaluate the incidence of perfusion abnormalities by brain single-photon emission computed tomography in a group of coeliac disease patients, and to investigate whether gluten intake and associated autoimmune diseases may be considered risk factors in causing cerebral impairment.

Methods. Thirty-four adult coeliac patients (16 on a gluten-free diet and 18 on a gluten-containing diet, 18 (53%) with autoimmune diseases) underwent 99mTc-ethyl cysteinate dimer brain single-photon emission computed tomography and qualitative evaluation of brain perfusion was performed together with a semiquantitative estimation using the asymmetry index. Ten subjects on our database, matched for sex, age and ethnic group, who were proved normal by histology of jejunal mucosa (four males and six females; median age 39 years, range 27–55 years), were included as control group.

Results. Twenty-four out of 34 patients (71%) showed brain single-photon emission computed tomography abnormalities confirmed by abnormal regional asymmetry index (>5%; range 5.8–18.5%). Topographic comparison of the brain areas showed that the more significant abnormalities were localised in frontal regions, and were significantly different from controls only in coeliac disease patients on unrestricted diet. The prevalence of single-photon emission computed tomography abnormalities was similar in coeliac disease patients with (74%) and without (69%) associated autoimmune disease.

Conclusions. Abnormalities of brain perfusion seem common in coeliac disease. This phenomenon is similar to that previously described in other autoimmune diseases, but does not appear to be related to associated autoimmunity and, at least in the frontal region, may be improved by a gluten-free diet.

Introduction

Coeliac disease (CD) is characterised by gluten-induced intestinal mucosal injury and malabsorption. Its clinical presentation may be variable [1]: while some symptoms may be related to malabsorption, others such as involvement of the joints and of the central nervous system (CNS) appear to be the consequence of autoimmunity. In particular, some neurological illness, peripheral neuropathy [2] and sporadic idiopathic ataxia [3], seem to be the result of gluten sensitivity with or without histological evidence of small bowel involvement, but with serologic markers (serum antiglidin-antibodies) and genetic susceptibility (HLA DQ2) [4]. Furthermore, it is well known that CD may be associated with other autoimmune disorders such as diabetes mellitus [5], dermatitis herpetiformis [6], thyroid autoimmune disease [7], [8] and Sjögren’s syndrome [9], as well as with migraine and neurological disorder [10] and primary biliary cirrhosis [11]. In some autoimmune disorders such as SLE [12], Sjögren’s syndrome [13], antiphospholipid antibody syndrome [14], and in sporadic cases of autoimmune thyroiditis [15], an involvement of the cerebrovascular system has recently been shown by brain perfusion single-photon emission computed tomography (SPECT), a sensitive method for detecting brain perfusion abnormalities [16].

The aim of this study was to evaluate the cortical brain perfusion in a group of adult coeliac patients by means of ethyl cysteinate dimer (ECD) brain SPECT, and to investigate the possible role of diet and of concomitant presence of other autoimmune diseases in the manifestation of cortical impairment.

Section snippets

Study groups

The study population consisted of two groups:

  • (A)

    Thirty-four consecutive adult coeliac patients, recruited in our clinic departments of Cagliari University between 1999 and 2001, 16 (11 females and five males, aged 17–77 years, mean 37±16 years) diagnosed between 1980 and 1999 on gluten-free diet at least for 4 years (range 4–20, median 7 years) and 18 on gluten-containing diet (17 females and one male, aged 18–67 years, mean 41±15 years). The diagnosis of CD was based on clinical, serological and

Results

Neurological examination and MRI yielded normal findings. The clinical and serological data are detailed in Table 1. All patients on gluten-free diet were compliant as assessed by negative serum AGA-A and EMA. Positive anti-TPO values (>20 IU/ml) were observed in 17/34 (50%) coeliac patients, 14 women and three men. Anti-TPO prevalence was significantly higher (50%) than that found in healthy controls (9.6%) (P<0.001). Eight out of 17 anti-TPO positive patients were clinically euthyroid, seven

Discussion

The results of the present study provide clear evidence of high prevalence of cortical perfusion abnormalities in adult coeliac patients, up to 71% displaying brain perfusion defects. The prevalence of cortical abnormalities and the severity of AI values observed in our series of coeliac patients were similar to those observed by Sanna et al. [12] in systemic lupus erythematosus (SLE) with or without overt neuropsychiatric manifestation.

The origin of the described generalised cortical perfusion

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