title: Small-fiber neuropathy/neuronopathy associated with celiac disease: skin biopsy findings.
abstract: 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.
  
  
  METHODS
  Case series.
  
  
  METHODS
  Academic peripheral neuropathy clinic.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors.affiliation: Department of Neurology, Weill Medical College of Cornell University, New York, NY 10022, USA. THB2006@med.cornell.edu
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Brannagan
authors.forename: Arthur P
authors.initials: AP
authors.lastname: Hays
authors.forename: Steven S
authors.initials: SS
authors.lastname: Chin
authors.forename: Howard W
authors.initials: HW
authors.lastname: Sander
authors.forename: Russell L
authors.initials: RL
authors.lastname: Chin
authors.forename: Paul
authors.initials: P
authors.lastname: Magda
authors.forename: Peter H R
authors.initials: PH
authors.lastname: Green
authors.forename: Norman
authors.initials: N
authors.lastname: Latov
mesh_terms: D002446:Celiac Disease / Q000150:complications* / Q000473:pathology; D004817:Epidermis / Q000294:innervation*; D005260:Female; D005903:Gliadin / Q000097:blood; D006801:Humans; D008297:Male; D009431:Neural Conduction; D009474:Neurons / Q000473:pathology; D010523:Peripheral Nervous System Diseases / Q000209:etiology* / Q000473:pathology; D011503:Transglutaminases / Q000097:blood
chemical_list: D005903:Gliadin; D011503:Transglutaminases