by Jeffrey Dach MD
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Sensitivity, Autoimmune and |
by Jeffrey Dach MD
This article is Part Three of a Series.
For Previous Parts,
Click Here: Part One and Part Two
Two Very Mysterious and Complicated Cases caused by Gluten SensitivityWhat is wheat gluten?
Gluten is a protein in grains such as wheat, rye, barley, spelt, triticale, kamut,and possibly oats. In susceptible individuals, about one per cent of the population, Wheat Gluten stimulates an immune response which may damage the inner lining of the gastrointestinal tract, or cross-react with other tissues in the body producing auto-immune, neurological and psychiatric illness.
Upper left image: A variety of foods made from wheat, all containing gluten. Courtesy of the USDA and Wikimedia Commons.
Celiac Disease or Gluten Sensitivity ? Shag Carpet or Flat Carpet ?
The immune response to gluten may cause malabsorption, and damage to the mucosal lining of the GI tract which can be seen on endoscopic biopsy as villous atrophy (see left image).
Normally, the healthy small bowel looks like a "shag carpet" under the microscope with a brush border. However, with villous atrophy, the villi or fingers are lost or shortened, and the shag carpet turns into indoor-out door carpeting with a flat surface.
Left Image: Red Arrows point to Villous Atrophy. Biopsy of small bowel showing Coeliac disease manifested by blunting of villi, crypt hyperplasia, and lymphocyte infiltration of crypts, consistent with Marsh classification III. Courtesy of wikimedia commons.
This advanced form is called Celiac Disease which may cause malabsorption of B12, Iron, and Calcium (leading to osteoporosis and stress fractures at a young age) . In addition, there may be malabsorption of fat with labs showing a low serum triglyceride level which may be "tip-off" for the diagnosis. (12-14)
However, in many people, there may be minimal or no gastrointestinal symptoms. Rather the immune response may show up elsewhere in the body as an auto-immune disease, a neurological disease or a psychiatric manifestation. This form of the disease is called Gluten Sensitivity, a diagnosis frequently missed or ignored by mainstream medicine.
Gluten Testing - Conventional Lab PanelSince Gluten sensitivity leads to villous atrophy and malabsorption of vitamins, minerals and fats, various abnormalities may show up on the conventional lab panel:
Low serum triglyceride level (below 75) is a marker for gluten sensitivity.(12-14)
Low Serum Iron, Ferritin and Vitamin B12 are frequently seen together as a "pattern". This pattern of malabsorption is strongly suggestive for gluten sensitivity.
A clinical history of stress fracture, and osteoporosis at a young age (from calcium malabsorption) is strongly suggestive for gluten sensitivity.
Enterolabs - Definitive Testing
After finding the conventional blood antibody testing to be useless, we have switched to stool antibody testing with a home test kit from Enterolabs. This kit can be ordered by anyone, without a prescription, and the test performed at home. The stool sample is sent into the lab for analysis which includes immunological response to gluten, anti-gliadin antibody and genetic testing for gluten sensitivity. They offer additional panels which examine fat malabsorption (similar to the triglyreride test), and food sensitivity to dairy, egg, and soy.
Dietary Trial Off-Gluten
Another obvious test is a 6-week trial on a strict gluten-free diet, during which time symptoms are closely observed for improvement, indicating a gluten sensitivity. These patient should remain on a strict gluten-free diet.
A 63 year old male with Recurring Cranial Nerve Palsies, Hypertransaminasemia, and Hashimotos ThyroiditisA pleasant 63 year old gentleman came to the office for a "wellness physical and some vitamins". A few years past, he had Bell's Palsy, a form of facial nerve paralysis, which had resolved. He also noticed intermittent loss of sensation involving the soles of his feet.
On physical exam, he had a mild residual facial paralysis (Bell's Palsy), and a mild sensory polyneuropathy with loss of vibratory sense in the lower extremities. His lab studies showed mildly elevated liver enzymes which "had always been present over the years", and previous doctors have told him that it is "genetic", and not to worry about it.
The patient also had elevated thyroid antibodies, with reduced thyroid function compatible with Hashimoto's thyroiditis. The patient was treated with thyroid hormone among other things, and did well over the next few years.
However a few years later, he reported eye problems. He was unable to gaze laterally with his right eye. The opthalmologist made a diagnosis of Sixth Cranial Nerve palsy (abducens nerve to the lateral rectus eye muscle) with failure of lateral gaze. Extensive neurological workup with MRI scans was unremarkable, and his neurologist suggested a test for Lyme's Disease, which was done and found negative.
Gluten and Neurological Disease
The immunologic response to gluten may cross react with the nervous system, producing various neurological symptoms, such as cranial nerve palsy, and neuropathy. These may be present in the absence of any gastrointestinal symptoms. Neuropathies and psychiatric symptoms caused by consumption of wheat gluten have been reported in the medical literature.(5-7) Recurrent cranial nerve palsy has also been reported caused by ingestion of gluten. (1)
Gluten Sensitivity Celiac Hashimoto's Connection
Patients who have Hashimoto's thyroiditis have about 15 times greater chance of also having gluten sensitivity. One Dutch study published in 2007 showed 15% of Hashimoto's patients tested positive for gluten sensitivity or celiac disease.(2).
Chronic Mild Elevation of Liver Enzymes
Chronic mild elevation of liver enzymes may be a tip off of underlying gluten sensitivity.(3-4) These mild liver enzyme elevations will normalize 95% of the time by adhering to a strict gluten-free diet.(3)
Treatment- Gluten Free DietThis patient ordered the Enterolabs test kit for gluten sensitivity which showed a markedly positive immunologic response to wheat gluten. After adhering to a strict gluten-free diet, the patient's symptoms of cranial nerve palsy and sensory neuropathy gradually resolved. In addition, the liver enzyme elevations normalized.
A Young Patient with Systemic Lupus - Gluten Connection
A 23 year old female college student with Lupus came to my office. She had been previously diagnosed with Systemic Lupus and started on Prednisone, a commonly used immune suppressive drug. She was recently hospitalized and treated with IV antibiotics for pneumonia.
She was very ill, lost weight, and was amenorrheic, with menses stopping about 18 months ago. Her symptoms included joint pains, and buccal ulcerations. Physical examination showed a chronically ill, weak, cachectic young woman, with typical increased pigmentation of the palms and Lupus Butterfly Rash of the face (see left image).
Above left image : Butterfly Facial Rash of Systemic Lupus Courtesy of Wikimedia Commons. This is caused by low adrenal output which stimulates increased pituitary ACTH which has Melanocyte stimulating properties. This patient needs adrenal hormones.
Acetyl Co-A Deficiency in Lupus
Lupus is an autoimmune disease, and blood testing shows circulating anti-nuclear antibodies as a main feature.
Acetyl Co-A Deficiency in LupusMy previous article discussed the underlying defect in Lupus as an Acetyl Co-A Deficiency and how this produces adrenal insufficiency, with reduced hormone production.
Adrenal insufficiency causes the pituitary to increase ACTH production which has melanocyte stimulating properties. The melanin pigment accounts for the increased skin pigmentation and facial rash of lupus (see above image). Vitamin B5, Pantothenic Acid is extremely beneficial for Lupus patients because B5 increases Acetyl-Co-A which helps the adrenals recover in their important job manufacturing adrenal hormones.
My Lupus treatment program includes high dose Pantothenic Acid (300 mg three times a day of Vitamin B5), as well as direct adrenal hormones replacement with cortisol or prednisone. Over time, patients are slowly weaned off the prednisone and switched to low dose bioidentical hydro-cortisone (cortisol).
Since other hormones levels are typically low in Lupus patients, we will commonly give a bioidentical hormone topical cream containing DHEA, Estradiol, Estriol (Bi-Est), Testosterone and Progesterone.
Low vitamin D is frequently associated with autoimmune disease, correction is important. Her low Vitamin D levels were treated with Vitamin D3, 10,000 units per day.
LDN for Autoimmune Diseases including Systemic LupusLow Dose Naltrexone is an FDA approved drug which has been used off label in a variety of auto-immune diseases such as multiple sclerosis, crohn's rheumatoid arthritis and systemic lupus, with considerable benefits for these patients. See my previous articles on LDN: LDN Part One and LDN Part Two.
Lupus patients will frequently benefit from Low Dose Naltrexone Capsules 4.5 mg each evening before sleep.
Gluten Free Diet Benefits Systemic Lupus PatientsMedical science considers Lupus to be an incurable disease, and relies on prednisone, a powerful immune suppressing drug to control symptoms. Prednisone is a synthetic form of hydro-cortisone, the main adrenal hormone.
Systemc Lupus Cured With a Gluten Free Diet
I was astounded to find a report by Jonathon Wright of 500 patients cured of Lupus with a gluten free diet.
Jonathan Wright MD writes in a newsletter about how dietary exposure to wheat gluten may trigger autoimmune disease including systemic lupus. Here is an exerpt from "A Simple Solution to an Incurable Disease". (15):
In 1989, my wife Holly and I visited the office of Dr. Christopher Reading in Dee Why, a suburb of Sydney, Australia. He showed us documentation of over 500 individuals who came to see him with a diagnosis of Systemic Lupus, a usually-thought-to-be incurable auto-immune disease.Lupus is only one of a long list of auto-immune diseases triggered by Wheat Gluten Exposure. (15) Here is the complete list of auto-immune diseases triggered by gluten sensitivity:
Type One Diabetes
Systemic Lupus Erythematosis (lupus)
Chronic auto-immune hepatitis
The patient was advised to adhere to a strict gluten-free diet, and eliminate dairy products as well. (8-16) She did well, and eventually tapered off the prednisone without recurrence of joint pain, and resumption of normal menses.
How Many Cases of Gluten Sensitivity Are Missed by the Mainstream Medical System ? All of them.
Articles with Related Interest:
Wheat Gluten and Celiac Diease, Part One
Gluten Sensitivity , Is Your Food Making You Sick? Part Two
Minefield at the Grocery Store
Fast Food in Hospitals, Selling Sickness in the Lobby