Rapid Responses to:

EDITORIALS: Roger Jones Coeliac disease in primary care BMJ 2007; 334: 704-705 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Coeliac disease may manifest itseslf as psychosis.

Edmond V O`Flaherty   (6 April 2007)

Dermatitis herpetiformis can unmask silent coeliac disease

Sandeep Varma   (11 April 2007)

Coeliac disease and psychiatric and neurological conditions

Shaheen E Lakhan   (28 April 2007)

Coeliac disease may manifest itseslf as psychosis. 6 April 2007
Edmond V O`Flaherty, G.P. Dublin,Ireland Send response to journal: Re: Coeliac disease may manifest itseslf as psychosis.	At a course for doctors in nutritional treatment in psychiatry that I attended a year ago in Sydney one point made by the staff of Pfeiffer Center of Chicago (www.hriptc.org)was that 4% of psychotic cases are due to coeliac disease. Immediately I started doing coeliac screening of all my patients with a history of psychosis. The very first positive one,who had relatively minor bowel discomfort, was a 38 year old lady with a 20 year history of bipolar disorder and numerous admissions for chronic severe depression. A few weeks after starting a gluten-free diet her depression lifted and she has remained well since. I believe that all patients with psychotic illness should be screened.The thought that thousands of people are suffering mental torture when a simple blood test could lead the way to dramatically improving their mental health sounds almost too good to be true but true it is. Competing interests: None declared
Dermatitis herpetiformis can unmask silent coeliac disease 11 April 2007
Sandeep Varma, Consultant Dermatologist and Dermatological Surgeon Department of Dermatology, Queens Medical Centre, Nottingham, NG7 2UH Send response to journal: Re: Dermatitis herpetiformis can unmask silent coeliac disease	Jones’ informative editorial omits an important message[1]; that cutaneous signs especially dermatitis herpetiformis (DH) may be the presenting feature of coeliac disease [2]. DH affects approximately 25% of patients with coeliac disease [3] and is an intensely pruritic papulovesicular manifestation of gluten sensitivity[4]. DH classically affects the extensor aspects of the elbows and knees, buttocks and scalp. Close inspection shows most or all of the vesicles to have been ruptured and excoriated by the patient. This pattern of skin signs and symptoms should trigger diagnostic suspicion and referral to a dermatologist. Diagnosis is clinical and by skin biopsies. Sulphones such as dapsone bring dramatic and rapid relief of DH. As over 90% of DH patients have gluten sensitivity serological testing for coeliac disease is routinely performed and may uncover silent disease as only about 20% of DH patients have intestinal symptoms [4]. If coeliac disease is subsequently confirmed then strict adherence to a gluten free diet may be sufficient to control DH. 1. Jones R. Coeliac disease in primary care. BMJ 2007; 334: 704-5. 2. Poon E, Nixon R. Cutaneous spectrum of coeliac disease. Australas J Dermatol 2001; 42: 136-8. 3.Collin P, Reunala T. Recognition and management of the cutaneous manifestations of celiac disease: a guide for the dermatologists. Am J Clin Dermatol 2003; 4: 13-20. 4. Herron MD and Zone JJ. Dermatitis herpetiformis and linear IgA bullous dermatosis. In Bolognia JL, Jorrizo JL, Rapini RP et al. Dermatology. Mosby 2003. 479-490. Competing interests: None declared
Coeliac disease and psychiatric and neurological conditions 28 April 2007
Shaheen E Lakhan, Executive Director Global Neuroscience Initiative Foundation, Los Angeles, CA, USA Send response to journal: Re: Coeliac disease and psychiatric and neurological conditions	E.V. O'Flaherty raises the interesting observation that coeliac disease may present as psychosis.[1] Both O'Flaherty's commentary and Jones' editorial [2], however, omit other neuropsychiatric clinical manifestations and their possible causes. In an attempt to explain them, I will summarize two theories. The first involves a direct nutritional consequence and the latter a shared genetic susceptibility. In severe malabsorption, there are diminished amino acid precursors for neurotransmitter synthesis. Notably, altered serotonin and melatonin may result from decreased bio-available tryptophan. Also, catecholamines (e.g., dopamine, epinephrine, norepinephrine) are underexpressed in tyrosine deficiency. Pynnonen et al. followed nine adolescents with coeliac disease and noted significantly lower tryptophan levels in patients also with depression.[3] Moreover, a gluten-free diet mitigated many of the psychiatric symptoms--suggesting a direct nutritional relationship without permanent pathology. Newer theories have delved more into the convergence of genetic etiology and a pathogenesis between coeliac disease and behavioral and neurological disorders. A general population cohort study in Sweden showed an increased risk for non-affective psychosis in individuals with coeliac disease.[4] This may be explained by an interesting hypothesis that the disease process permits psychosis-inducing agents to enter the circulation, thereby inciting schizophrenia and other mental conditions. Wei and Hemmings suggest that transmembrane barrier proteins (such as DQB1 and CLDN5, associated with coeliac disease) are the causal genes for schizophrenia susceptibility in coeliac disease.[5] The authors of the altered barrier protein theory specifically address the potential for psychosis-inducing compounds. However, many "idiopathic" neuropathologies are theorized to be due to gluten sensitivity, including cerebellar ataxia and peripheral neuropathy. Recently, anti-ganglioside antibodies have been linked to neurological impairment.[6] Gluten-free diets do not eradicate the neurological involvement, suggesting a more permanent pathology. A solid pathway has yet to be identified. Perhaps the absorption of otherwise undigested "foreign" compounds illicits a humoral immune response. The antibodies may have affinity to the gangliosides and other neuronal structures, or these structures may house the absorbed foreign compound causing their destruction. In any event, we need further research on the impact of coeliac disease on the mind. References 1. O'Flaherty EV. Coeliac disease may manifest itseslf as psychosis. eBMJ 2007. 2. Jones R. Coeliac disease in primary care. BMJ 2007;334:704-5. 3. Pynnonen PA et al. Gluten-free diet may alleviate depressive and behavioural symptoms in adolescents with coeliac disease: a prospective follow-up case-series study. BMC Psychiatry 2005;17;5:14. 4. Ludvigsson JF et al. Coeliac disease and risk of schizophrenia and other psychosis: a general population cohort study. Scand J Gastroenterol 2007;42(2):179-85. 5. Wei J and Hemmings GP. Gene, gut and schizophrenia: the meeting point for the gene-environment interaction in developing schizophrenia. Med Hypotheses 2005;64(3):547-52. 6. Volta U et al. Anti-ganglioside antibodies in coeliac disease with neurological disorders. Dig Liver Dis 2006;38(3):183-7. Competing interests: None declared