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Small-fiber neuropathy/neuronopathy associated with celiac disease: skin biopsy findings
Thomas H Brannagan1, Arthur P Hays, Steven S Chin
1Department of Neurology, Weill Medical College of Cornell University, New York, NY 10022, USA. THB2006@med.cornell.edu
Background:
Celiac disease (CD) is increasingly recognized in North America and is associated with a peripheral neuropathy.
Objective:
To report the clinical characteristics and skin biopsy results in patients with CD and small-fiber neuropathy symptoms.
Design:
Case series.
Setting:
Academic peripheral neuropathy clinic.
Patients:
Eight patients with CD and neuropathy symptoms. Intervention Three-millimeter punch biopsy using the panaxonal marker protein gene product 9.5 to assess epidermal nerve fiber (ENF) density and a gluten-free diet.
Main Outcome Measure:
Clinical data and ENF density.
Results:
All patients had asymmetric numbness and paresthesias. Three had more prominent involvement of hands than feet, and 3 had facial numbness. Celiac disease was diagnosed in 5 after their neuropathy began. The following serum antibody levels were elevated: tissue transglutaminase (n = 6), IgA gliadin (n = 4), and IgG gliadin (n = 7). Results of nerve conduction studies were normal in 7 patients. One patient had mildly reduced sural amplitudes. The ENF density was reduced in 5 patients. The ENF density was at the low limit of the normal range in 3 additional patients, 2 of whom had morphologic changes in axons. Three patients had decreased ENF density at the thigh or forearm, which was more severe than at the distal leg, compatible with a non-length-dependent process. Four reported improvement with a gluten-free diet. One had no improvement after 4 months. Symptoms developed in 2 while receiving a gluten-free diet.
Conclusions:
Patients with CD may have a neuropathy involving small fibers, demonstrated by results of skin biopsy. The pattern of symptoms, with frequent facial involvement and a non-length-dependent pattern on skin biopsy findings, suggests a sensory ganglionopathy or an immune-mediated neuropathy. Improvement of symptoms in some patients after initiating a gluten-free diet warrants further study.
