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Coeliac disease and gluten sensitivity
R. Troncone1 & B. Jabri2
1
Department of Pediatrics and European Laboratory for the Investigation of Food-Induced Diseases, University Federico II, Naples, Italy, and
2
Department of Medicine, Pathology and Pediatrics, University of Chicago, Chicago, IL, USA
Abstract. Troncone R, Jabri B (University Federico II,
Naples, Italy; University of Chicago, Chicago, IL,
USA). Coeliac disease and gluten sensitivity (Sympo-
sium). J Intern Med 2011; 269: 582–590.
Coeliac disease (CD) is a systemic immune-mediated
disorder elicited by gluten in genetically susceptible
individuals. The common factor for all patients with
CD is the presence of a variable combination of
gluten-dependent clinical manifestations, specific
autoantibodies (anti-tissue transglutaminase ⁄ anti-
endomysium), HLA-DQ2 and ⁄ or DQ8 haplotypes
and different degrees of enteropathy. Recently, gluten
sensitivity has received much interest, although the
limits and possible overlap between gluten sensitivity
and CD remain poorly defined. At present, a number
Introduction
In recent years, the view of coeliac disease (CD) has
undergone a profound revision. A wide spectrum of
clinical and histological presentations has been rec-
ognized, and significant progress has been made in
the understanding of the genetic and immunological
features of this condition [1]. CD is now considered,
more than a just a gluten-sensitive enteropathy, to be
a systemic immune-mediated disorder elicited by
gluten and related prolamines in genetically suscep-
tible individuals. The common denominator for all
patients with CD is the presence of a variable combi-
nation of gluten-dependent clinical manifestations,
specific autoantibodies [anti-tissue transgluta-
minase (TG)2) ⁄ anti-endomysium (EMA) antibodies],
HLA-DQ2 and ⁄ or DQ8 haplotypes and different
degrees of enteropathy, ranging from lymphocytic
infiltration of the epithelium to complete villous
atrophy [2].
However, gluten may induce other pathological con-
ditions, such as wheat allergy [3], which is an immu-
noglobulin (Ig)E-mediated disease also well charac-
terized from the immunological and clinical point of
view but completely unrelated to CD. More recently,
attention has been given to another entity, gluten
sensitivity (GS), for which the limits and possible
582 ª 2011 The Association for the Publication of the Journal of Internal Medicine
doi: 10.1111/j.1365-2796.2011.02385.x
of morphological, functional and immunological dis-
orders that are lacking one or more of the key CD cri-
teria (enteropathy, associated HLA haplotypes and
presence of anti-transglutaminase two antibodies)
but respond to gluten exclusion are included under
the umbrella of gluten sensitivity. The possible
immunological mechanisms underlying these condi-
tions are discussed. Emphasis is given to specific
autoantibodies as markers of the coeliac spectrum
and to the hypothesis that innate epithelial stress can
exist independently from adaptive intestinal immu-
nity in gluten sensitivity.
Keywords: anti-tissue transglutaminase antibodies,
coeliac disease, gluten sensitivity, potential coeliac
disease, type 1 diabetes.
overlap with CD are still poorly defined [4]. Currently,
a number of morphological, functional and immuno-
logical disorders have been considered under the
umbrella of GS that miss one or more of the key CD
criteria (enteropathy, associated HLA haplotypes
and presence of anti-TG2 antibodies), but respond to
gluten exclusion.
Here, we will first briefly review the main features that
are now considered to characterize CD. We will then
describe in more detail the characteristics of those
subjects who, although having the immunological
(autoantibodies) and genetic (HLA-DQ2 and DQ8)
signs of CD, lack the enteropathy (potential CD, der-
matitis herpetiformis and gluten ataxia). Finally, we
will discuss disorders that are included within the
term GS.
Coeliac disease
Definitions
Several classifications of CD have been used in the
past, most importantly with the distinction between
symptomatic, asymptomatic, latent and potential
CD. The most common gastrointestinal and extrain-
testinal presentations are discussed later. Silent CD
is defined as the presence of positive CD-specific
 R. Troncone & B. Jabri
| Symposium: Coeliac disease and gluten sensitivity
antibodies and HLA haplotype and small bowel
biopsy findings compatible with CD, but without suf-
ficient symptoms and signs to warrant clinical suspi-
cion of CD. With the recognition of forms of CD char-
acterized by a low-grade enteropathy, other terms
have been proposed. Latent CD defines a condition in
which subjects are without enteropathy but have had
a gluten-dependent enteropathy at some time during
their lives [5]. Patients may or may not have symp-
toms. Potential CD is defined by the presence of spe-
cific CD antibodies and compatible HLA haplotypes,
but with no histological abnormalities in duodenal
biopsies [5]. Patients may or may not have symptoms
and may or may not develop a gluten-dependent
enteropathy at a later time. This condition will be dis-
cussed in detail in the next section.
General features
Coeliac disease is triggered by the ingestion of wheat
gluten and related prolamines from rye and barley
[2]. Most studies have demonstrated that oats is not
harmful; however, a few patients have oats prola-
mine-reactive mucosal T cells that can cause muco-
sal inflammation [6]. CD is relatively common (1%
prevalence of biopsy-proven disease) in populations
of mainly Caucasian descent [2]. Environmental fac-
tors might affect the risk of developing CD or the tim-
ing of its presentation. Feeding patterns in the first
year of life [7] and possibly viral infections [8] may
contribute to the development of the disease.
Clinical features of CD vary considerably [2]. Intesti-
nal symptoms are common particularly in children
Fig. 1 Coeliac disease with
villous atrophy is at the end of a
spectrum, being characterized
by gluten-induced both innate
and adaptive immunity. Our
working hypothesis suggests
gluten-induced epithelial
distress playing a role in some
forms of gluten sensitivity (e.g.
IBS like). On the other hand
milder forms of coeliac disease
(e.g. potential coeliac disease)
show gluten-specific T cell
immunity, and yet lack
important aspects of innate
immunity.
ª 2011 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 269; 582–590
diagnosed within the first 2 years of life; failure to
thrive, chronic diarrhoea, vomiting, abdominal dis-
tension, muscle wasting, anorexia and irritability are
present in most cases. The most frequent extraintes-
tinal manifestation of CD is iron-deficiency anaemia
that is unresponsive to iron therapy. Osteoporosis
may be present. Other extraintestinal manifestations
include short stature, endocrinopathies, arthritis
and arthralgia, epilepsy with bilateral occipital calci-
fications, peripheral neuropathies, cardiomyopathy,
elevation of transaminase levels, dental enamel hypo-
plasia, aphthous stomatitis and alopecia. The mech-
anisms responsible for the severity and the variety of
clinical presentations remain obscure. Nutritional
deficiencies or a dysfunctional immune (possibly
autoimmune) response have been advocated. Silent
CD is being increasingly recognized, mainly in
asymptomatic first-degree relatives of patients with
CD investigated during screening studies. Some dis-
eases, many with an autoimmune pathogenesis, are
found with a higher than normal frequency in pa-
tients with CD [2]. Amongst these conditions are type
1 diabetes, autoimmune thyroid diseases, Addison’s
disease, Sjögren’s syndrome, autoimmune cholangi-
tis, autoimmune hepatitis and primary biliary cirrho-
sis. Other associated conditions include selective IgA
deficiency, Down’s syndrome, Turner syndrome and
Williams syndrome.
Immunological aspects
A genetic predisposition is suggested by familial
aggregation of CD and more than 70% concordance
in monozygotic twins. [9]. More than 90% of patients
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 R. Troncone & B. Jabri
| Symposium: Coeliac disease and gluten sensitivity

with CD express the HLA-DQ2.5 heterodimer, and al-

Extraintestinal

Autoimmunity
Variable Neurological
most all others express HLA-DQ8 [10]. By contrast,
symptoms
symptoms

only 30–40% of control patients express these CD-

Variable
Allergic

associated MHC class II molecules. CD is a T-cell-

Variable Skin
mediated chronic inflammatory disorder with an

+
–

–
autoimmune component (for review see [1, 2]). Al-
tered processing by intraluminal enzymes, changes
atrophy
Villus

in intestinal permeability and activation of innate

immunity mechanisms precede the activation of the
+
–

Stress? IL-15? –
–
Stress? IL-15? –
adaptive immune response. Immunodominant epi-
topes from gliadin are highly resistant to intraluminal
alterations

and mucosal digestion; incomplete degradation

Variable

favours the immunostimulatory and toxic effects of

Anti-gluten IEC

these sequences. Some gliadin peptides (p31–43) that

+
–

are not recognized by T cells are able to activate innate

immunity in antigen-presenting cells and intestinal
epithelial cells; in particular, they induce interleukin
T cells

(IL)-15. Others activate lamina propria T cells

+?

+?

presented by HLA-DQ2 or DQ8 molecules [11, 12].

+
+
+

+
–

Signs of dysfunctional –

Gliadin-specific T-cell responses have been found to

Mast cells eosinophils

Innate IEC response?

be enhanced by the action of tissue TG [13, 14]; the

response to gluten
mucosalimmune

enzyme converts particular glutamine residues into

Anti-gluten Ab Anti-TG2 Ab manifestations
Other immune

glutamic acid, which results in higher affinity of these

Neutrophils

gliadin peptides for HLA-DQ2 or DQ8. The pattern of

cytokines produced by gluten-specific T cells follow-
Table 1 HLA, immunological, pathological and clinical features of gluten-related conditions

ing gliadin activation is clearly dominated by inter-

feron (IFN)c (Th1 skewed) [15] and IL-21 [16]. In addi-
?

?
–

tion, the innate cytokines IFNa [17], IL-15 [18] and

IL-18 [19] are also produced. A complex remodelling
of the mucosa takes place downstream of T-cell acti-
+ (TG3)
+ (TG6)

vation, involving increased levels of metalloprotein-

ases and growth factors, which leads to the classical
+
+
–

–
–

‘flat mucosa’ of CD. An increased density of CD8+

cytotoxic intraepithelial lymphocytes is a hallmark of
CD [20]. IL-15 is implicated in the expression of natu-
Variable Variable

ral killer receptors CD94 [21] and NKG2D [22, 23], as

well as in epithelial expression of stress molecules
Variable +

+
+
+
+

Extraintestinal Variable +
Variable –

[24], thus enhancing cytotoxicity, cell apoptosis and

villous atrophy. The most evident expression of
HLA CD

80% +a

autoimmunity is the presence of serum antibodies to

tissue TG [25]. However, the mechanisms leading to
+
+
+

autoimmunity are largely unknown, as are their

pathogenetic significance.
Gluten ataxia

Autoimmune
Gluten-dependent Potential CD

IBS, irritable bowel syndrome.

(T1D)

Gluten-dependent pathology characterized by the presence of anti-TG

Active

IBS
DH

antibodies with low-grade or no enteropathy

Potential CD
Gluten sensitivity

20% HLA- DQ1.

with anti-TG2

Clinical features. The histological changes in the

Wheat allergy

small intestinal mucosa in CD cover a wide spectrum

pathology

ranging from infiltration of the epithelium by lympho-

cytes to complete villous atrophy. Potential CD is de-
CD

fined by the presence of specific CD antibodies and

a

584 ª 2011 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 269; 582–590
 R. Troncone & B. Jabri
| Symposium: Coeliac disease and gluten sensitivity
compatible HLA haplotypes, but without histological
abnormalities in duodenal biopsies. In fact, a small
percentage of subjects positive for CD antibodies
[anti-gliadin antibody (AGA), EMA and anti-tTG] have
a small intestinal mucosa without villous atrophy.
Some of these patients have a Marsh 0 lesion (i.e. no
intraepithelial infiltration). In a significant proportion
of cases, these subjects belong to at-risk groups (fam-
ily members or presence of autoimmune disorders
associated with CD). The titre of antibodies is often
lower than that found in untreated CD patients with
villous atrophy [26]. In some cases, fluctuating titres
are noted, and it is not uncommon for antibodies to
disappear from serum during follow-up [26]. The
number of such patients is increasing because of the
raised awareness of CD and the more diffuse screen-
ing of ‘at-risk’ subjects. In our institution, potential
patients with CD now account for nearly 20% of pa-
tients with positive serology who undergo a small
intestinal biopsy (R. Troncone, personal communica-
tion). It is very unlikely that these are false-positive re-
sults, as both the serology and the genetics are con-
sistent with CD. There is no agreement on how to
treat these patients. If symptomatic, they are usually
offered a trial with gluten-free diet. Otherwise, most
physicians advise a very strict follow-up. In fact, the
natural history of these patients is still unknown, as
are the risks if they remain on a gluten-containing
diet. We recently performed a prospective, 3-year co-
hort study to determine the natural history of poten-
tial CD in children [26]. The study included 106 chil-
dren with potential CD, based on serological analysis
and normal jejunal architecture. All but two carried
the HLA-DQ2 and ⁄ or DQ8 haplotype. In all children,
growth, nutritional parameters, CD serology and au-
toimmunity were evaluated every 6 months. cd intra-
epithelial-, CD3- and lamina propria CD25-positive
cells were counted in biopsy specimens, and jejunal
deposits of anti-TG2 IgA were detected. Biopsy analy-
sis was repeated after 2 years on patients with persis-
tent positive serology and ⁄ or symptoms. Potential CD
was detected primarily in first-degree relatives and
patients with autoimmune disorders (40.6%).
Eighty-nine of the 106 patients entered the follow-up
study, with normal daily consumption of gluten. Dur-
ing the follow-up, antibodies disappeared in 14.6% of
subjects and fluctuated in 32.6%. Villous atrophy
was observed in 12 ⁄ 39 (30.8%) patients who under-
went a repeat biopsy. The only useful parameter for
identifying those patients more at risk of developing
severe damage of the intestinal mucosa was the pres-
ence of intestinal deposits of anti-TG2 IgA at the time
of the first observation. Most children with potential
CD remained healthy. It is known that undiagnosed
ª 2011 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 269; 582–590
CD may predispose to nutritional deficiencies, in
most cases subtle, even in the absence of overt clini-
cal symptoms. However, there were no significant
nutritional or bone complications in these patients.
Immunological features. The presence of anti-gluten
and anti-TG antibodies indicates that these patients,
with potential CD in general, despite the absence of a
clear enteropathy, have developed an anti-gluten
adaptive immune response. Therefore, despite a nor-
mal architecture, the immunohistochemical analysis
of jejunal mucosa from patients with potential CD
shows signs of T-cell and B-cell activation. The ab-
sence of villous atrophy in patients with potential CD
is associated with increased IL-10 expression and
subsequently an increased IL-10 ⁄ IFNc ratio as com-
pared to those with active CD. Furthermore, the
expression of IL-21 appears to be downregulated in
the biopsies from patients with potential CD, com-
pared to controls (R. Troncone, personal communica-
tion). In addition, there is a preferential increase in
TCR cd IEL over TCRab IEL in patients with potential
CD. Finally, intraepithelial cytotoxic TCRab lympho-
cytes in patients with potential CD, in contrast to
those with active CD, continue to express inhibitory
NK receptors and have low levels of activating NK
receptors (B. Jabri, personal communication). Alto-
gether these observations suggest that patients with
potential CD, compared to those with active CD, de-
velop an inflammatory anti-gluten CD4 T-cell im-
mune response of lower magnitude and lack IELs
with an activated killer phenotype.
Mechanisms and unanswered questions. The mech-
anisms underlying the low-grade inflammatory pat-
tern in potential CD remain unclear. There are two
main nonmutually exclusive possible explanations
for this pattern. First, epithelial cells in patients with
potential CD are normal, i.e. they show no signs of
distress and lack high levels of IL-15 expression and
ligands for activating NK receptors (e.g. nonclassical
MHC class I molecules HLA-E and MICA ⁄ B). The
hypothesis that a lack of innate activation of epithe-
lial cells explains the absence of villous atrophy is
supported by studies in humanized HLA-DQ2 and
DQ8 mice showing that adaptive anti-gluten immu-
nity and the presence of anti-TG2 antibodies is insuf-
ficient to induce villous atrophy. It is also in accor-
dance with our observations that patients with
potential CD do not display signs of epithelial dis-
tress, as defined by the upregulation of IL-15 and
heat shock proteins. The second possible explanation
is that a low level of proinflammatory adaptive anti-
gluten immunity may be responsible for the lack of
585
 R. Troncone & B. Jabri
| Symposium: Coeliac disease and gluten sensitivity
villous atrophy observed in patients with potential
CD. This could be observed either because the num-
ber of inflammatory anti-gluten CD4 T cells is insuffi-
cient to induce pathology or because of the presence
of a protective regulatory IL-10 response. The former
is supported by reports suggesting that there is an
HLA gene dosage effect [27], i.e. the number of T-cell-
stimulatory HLA-DQ ⁄ gluten peptide complexes is
critical for disease development [28]. The latter is
supported by the well-known anti-inflammatory
properties of IL-10; the level of this cytokine was
found to be increased in patients with potential CD
compared to those with active CD. The role of FOXP3
T cells is difficult to assess as inducible gluten-spe-
cific FOXP3 T cells cannot be distinguished from nat-
ural regulatory T cells with specificity for self that
may infiltrate inflamed intestinal tissue in a nonspe-
cific manner. Supporting the difficulty in interpreting
these data, FOXP3-positive cells are at significantly
lower level in patients with potential CD than in those
with active CD with villous atrophy [29]. Future stud-
ies will determine whether patients with low-grade
enteropathy have a different genetic make-up (HLA
and non-HLA) from those with active CD or whether
they lack key environmental triggers in addition to
gluten.
Gluten-dependent extraintestinal pathology with anti-TG antibodies
Clinical presentations. Dermatitis herpetiformis.
Dermatitis herpetiformis (DH) is an example of a con-
dition characterized by genetic (HLA association) and
immunological (adaptive anti-gluten immunity and
anti-TG antibodies) features typical of CD, but asso-
ciated mainly with skin lesions and a variable degree
of enteropathy. This gluten-dependent blistering skin
disorder is characterized by skin IgA anti-TG deposits
associated with an adaptive anti-gluten immune re-
sponse. Epidermal TG3 and the closely related TG2
are considered to be autoantigens in DH because a
majority of patients with this condition have IgA spe-
cific for TG2 and TG3 [30]. The levels of circulating
autoantibodies against TG2 and TG3 are correlated
with each other and both appear related to the degree
of enteropathy, suggesting that the gut is the site at
which the autoimmune response occurs [31]. Depos-
its of anti-TG2 are present at the jejunal level as in
classical CD. DH is considered by many as an extrain-
testinal presentation of CD [32].
Gluten ataxia.
In a series of studies conducted in the UK over a peri-
od of 13 years, 101 of 215 subjects with idiopathic
sporadic ataxia showed serological evidence of an
abnormal immune response to gluten (for review see
586 ª 2011 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 269; 582–590
[33]). A response to treatment with a gluten-free diet
was evident in some cases, although it appeared to
depend on the duration of symptoms. Subsequently,
other neurological conditions, in particular axonal
peripheral neuropathy, were found to be related to a
gluten-induced immune response. In patients with
ataxia and other neurological conditions, the HLA
distribution was slightly different from that seen in
those with classical CD, with HLA-DQ2 (70%) and
DQ8 (10%) accounting overall for only 80% and HLA-
DQ1 in the remaining patients. The prevalence of
AGA-positive patients amongst those with idiopathic
sporadic ataxia was as high as 45%, compared with
10% in genetically confirmed ataxia. Less than 10%
of patients with gluten ataxia presented gastrointesti-
nal symptoms, and only a third showed evidence of
enteropathy. Once anti-TG assessment became
available, up to 38% of patients were found to be posi-
tive, often at lower titres than those seen in CD, with
IgG class antibodies being more common than IgA.
IgG ⁄ IgA antibodies against the TG isoenzyme TG6,
primarily expressed in the brain, were present in
more than half of patients with gluten ataxia. Overall,
85% of patients with ataxia and AGAs had antibodies
to tissue TG2 and ⁄ or TG6. It is interesting that IgA
deposition on jejunal TG2 in gut tissue from patients
with gluten ataxia was associated with widespread
deposition around vessels in their brain [34]. To what
extent this is responsible for the clinical symptoms
remains uncertain.
Mechanisms and unanswered questions.
A particular genetic background and ⁄ or environmen-
tal factors may predispose some patients with adap-
tive anti-gluten immunity and anti-TG antibodies to
develop extraintestinal pathology. DH is associated
with anti-TG3 antibodies and gluten ataxia with anti-
TG6 antibodies. In line with this, the TG6 and TG3
isoenzymes are particularly expressed in the brain
and skin, respectively. Of interest, both are able to
specifically deamidate gliadin peptides, although
their precise specificities are different [35]. By con-
trast, only 10% of patients with gluten ataxia have
antibodies against deamidated peptides. The mecha-
nisms underlying the production of anti-TG3 and
anti-TG6, like those of anti-TG2, are still poorly
understood, but probably involve gluten-specific T
cells. Furthermore, whether DH and gluten ataxia are
induced by anti-TG antibody deposits, which in turn
are dependent on the presence of anti-gluten T cells,
remains to be determined. It is also unclear whether
the site of gluten immunization is intestinal or extra-
intestinal in these pathologies. Because anti-TG anti-
bodies are of the IgG isotype and, particularly in cases
without enteropathy, no deamidated peptides are
 R. Troncone & B. Jabri
| Symposium: Coeliac disease and gluten sensitivity
present in gluten ataxia, it is likely that immunization
against gluten occurs outside the intestinal environ-
ment in these patients.
GS pathology without anti-TG antibodies or enteropathy
Definition
Gluten sensitivity has been defined by the presence of
morphological, functional and immunological disor-
ders that respond to gluten exclusion and yet lack the
characteristic features that define CD. This definition
encompasses a wide range of disorders that may have
very different underlying mechanisms but have in
common the regression of symptoms in response to a
gluten-free diet in the absence of anti-TG antibodies
and histological enteropathy. It is important to recog-
nize that disorders included under the term GS are
actually conditions for which a precise definition and
even rudimentary knowledge of the underlying mech-
anisms is lacking. However, we will attempt to clas-
sify GS disorders and discuss whether they are linked
to adaptive anti-gluten immunity or innate ⁄ stress re-
sponses to gluten. Attempting such a classification
even though it is somewhat speculative may help to
design studies to identify objective markers and bet-
ter delineate these disorders.
Irritable bowel syndrome-related GS
Recently, the relationships between irritable bowel
syndrome (IBS), CD and GS have received particular
attention. Both IBS and CD present with clinical
symptoms that are largely overlapping. It is likely that
many individuals with unrecognized CD are labelled
as IBS patients. In fact, recent evidence has sug-
gested that CD, as diagnosed by positive serology and
positive biopsy, is four times more prevalent in IBS
than in non-IBS populations. Patients with diar-
rhoea-predominant IBS are certainly amongst those
who should be actively screened for CD [36]. More
interestingly, CD may predispose to IBS. It is in fact
known that a persistent low-grade inflammation may
favour development of IBS. For instance, IBS may de-
velop following a gastrointestinal infection [37].
Hence, it is plausible that gliadin-induced mucosal
inflammation may also have a predisposing effect on
the insurgence of IBS. Another possibility is that
within the group of patients with IBS, there are those
who cannot be classified as patients with CD, but still
present a dysfunctional immune response to gluten
and symptomatic responses to gluten challenge or
withdrawal. Arranz and Ferguson found that a pat-
tern of intestinal antibodies (high intestinal AGA IgA
ª 2011 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 269; 582–590
and IgM antibody titres) was able to identify a group
of patients with gluten-sensitive diarrhoea in the ab-
sence of enteropathy [38]. At the time this study was
conducted, anti-TG antibodies were not identified;
thus, it remains to be shown that these patients have
anti-gluten antibodies in the absence of anti-TG anti-
bodies. In a later study by Wahnschaffe and col-
leagues [39], a subset of IBS patients was found to
have anti-gliadin IgA and IgG but not anti-TG2 IgA
antibodies. These authors also reported anti-gluten
antibodies in the absence of anti-TG2 antibodies in
patients with IBS. Thus, the question of whether a
group of patients with gluten-sensitive symptoms
and anti-gluten immunity in the absence of anti-TG2
antibodies can be recognized remains open. Induc-
tion of anti-gluten immunity in the absence of anti-
TG2 antibodies may define a very early stage of CD,
before TG2 becomes activated and an amplification of
the anti-gluten immune response occurs.
The possibility that a subset of IBS patients may be
characterized by an innate immune response to glia-
din is strengthened by other observations suggesting
that such an innate response to gliadin may be disso-
ciated from the adaptive specific immune response:
(i) rectal gluten challenge studies showed a response
characterized by infiltration of T cells similar to that
observed in CD patients in six of 13 siblings of chil-
dren with CD [40]. Interestingly, the positivity was
not associated with the presence of the haplotypes
present in the great majority of patients CD [40]; (ii)
gluten peptides that are not recognized by T cells may
activate epithelial cells; and (iii) epithelial stress, as
assessed by the presence of IL-15 and heat shock pro-
tein, was found in the absence of anti-gluten immu-
nity and anti-TG antibodies in family members of CD
patients (B. Jabri, personal observations). In this
form of IBS-related GS, innate and not adaptive anti-
gluten immunity would play a role and epithelial cells
would be the targets.
Understand the different forms of IBS-related IBS
would require in-depth clinical, biological and immu-
nological phenotyping. For instance, the presence
of anti-TG antibodies, signs of epithelial distress and
T-cell activation before and after a gluten-free diet
should be investigated.
Extraintestinal GS
The presence of gluten-sensitive extraintestinal man-
ifestations in patients with anti-gluten antibodies
has been suggested. For instance, 16% of patients
with psoriasis have been found to present high levels
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 R. Troncone & B. Jabri
| Symposium: Coeliac disease and gluten sensitivity
of IgA and ⁄ or IgG antibodies to gliadin [41]. This
observation was considered a possible sign of GS and
prompted the evaluation of the effect of a gluten-free
diet on the manifestations of psoriasis. A significant
improvement was observed in patients with elevated
AGAs when they were put on a gluten-free diet,
whereas lesions deteriorated when the ordinary diet
was resumed in 18 ⁄ 30 patients [41]. Similar observa-
tions have been made in patients with recurrent oral
ulceration. Indeed, it is interesting that 85% of pa-
tients with oral ulceration who responded to gluten
withdrawal had high serum levels of AGAs [42]. The
immunological basis for these pathologies is un-
known. There are two key immunologically related is-
sues that need to be addressed to better understand
this disease entity. The first is related to the presence
of anti-gluten antibodies in the absence of anti-TG
antibodies. Possible explanations for this are that the
site of immunization against gluten may be extrain-
testinal and ⁄ or that TG may not be activated. The sec-
ond is related to what mediates extraintestinal GS.
Are anti-gluten T cells and ⁄ or anti-gluten antibodies
directly involved in the disease process? Do they have
a direct role by inducing local inflammation? And if
so, why do they induce inflammation only at certain
sites?
Autoimmune (Type 1 diabetes) GS
Type 1 diabetes (T1D) is considered to be an organ-
specific autoimmune disease mainly precipitated in
genetically susceptible individuals in whom T lym-
phocytes infiltrate the islets of the pancreas and
destroy the insulin-producing b-cell population [43].
Environmental factors such as food antigens and
viruses have been associated with T1D [44]. There is
much indirect evidence of a role for the intestinal im-
mune system in humans: enhanced immune respon-
siveness to food antigens occurs in patients with T1D
[44], and a close association between CD and T1D
has been reported [45]. In fact, a dysfunctional im-
mune response to gliadin is likely to be a feature of
T1D patients (who do not present anti-EMA and anti-
tissue TG antibodies in their serum). Indeed, it has re-
cently been reported that a subset of these patients
react with lymphocyte infiltration to rectal instillation
of gliadin [46], and it was demonstrated that jejunal
biopsies from T1D patients mount an inflammatory
response to gliadin in an organ culture system [47].
However, we were unable to grow gliadin-specific T-
cell lines from the jejunal mucosa of such patients,
suggesting that mechanisms other than those of
adaptive anti-gluten immunity were responsible for
the inflammation elicited by gliadin. It is presently
588 ª 2011 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 269; 582–590
unclear whether in some of the patients gluten may
play a causal role in the development of T1D. It is also
possible that patients with T1D have nongluten-re-
lated intestinal inflammation and that the abnormal
response to gluten is a by-product of mucosal inflam-
mation. This, however, does not exclude the possibil-
ity that gluten may contribute to disease development
by further amplifying intestinal inflammation. In
agreement with a role for gluten in the development of
T1D and autoimmune diseases in general, the sooner
a gluten-free diet is started in patients with active CD
the lower their risk of developing an autoimmune dis-
order [48]. Conversely, intestinal inflammation as
found in T1D [47] may favour development of CD. It is
impossible to draw firm conclusion, given how little
we know at present about the nature and cause of
intestinal inflammation and its relationship to gluten
in T1D and other autoimmune disorders. Depending
on whether intestinal inflammation in T1D is influ-
enced by gluten should determine whether T1D is
included amongst GS disorders.
Conclusion
There is still a long way to go before all forms of GS
can be accurately defined and their underlying
mechanisms determined. Perhaps to progress, it is
important to acknowledge how little we know and
how confusing the terminology is. Indeed, in the
term gluten sensitive is the word gluten and sensi-
tive, and hence by definition classical CD, potential
CD, wheat allergy and dermatitis herpetiformis
should all be part of GS. The fact that these condi-
tions all have specific terms, rather than simply
GS, is because they are better defined than other
pathological manifestations that have been dis-
cussed under the term GS in this review. Stringent
clinical phenotyping to determine whether anti-TG
antibodies can be pathological and mediate extra-
intestinal manifestations, and assess whether in-
nate epithelial stress is a reality and can exist inde-
pendently from adaptive intestinal immunity will
help define gluten-induced or gluten-dependent
pathologies. In future, GS may be replaced by a set
of well-defined gluten pathologies.
Conflicts of interest
The authors have no conflicts of interest to declare.
References
1 Jabri B, Sollid LM. Tissue-mediated control of immunopathology
in coeliac disease. Nat Rev Immunol 2009; 9: 858–70.
 R. Troncone & B. Jabri
| Symposium: Coeliac disease and gluten sensitivity
2 Di Sabatino A, Corazza GR. Coeliac disease. Lancet 2009; 373:
1480–93.
3 Battais F, Richard C, Jacquenet S, Denery-Papini S, Moneret-
Vautrin DA. Wheat grain allergies: an update on wheat allergens.
Eur Ann Allergy Clin Immunol 2008; 40: 67–76.
4 Verdu EF, Armstrong D, Murray JA. Between celiac disease and
irritable bowel syndrome: the ‘‘no man’s land’’ of gluten sensitiv-
ity. Am J Gastroenterol 2009; 104: 1587–94.
5 Ferguson A, Arranz E, O’Mahony S. Clinical and pathological
spectrum of coeliac disease: active, silent, latent, potential. Gut
1993; 34: 150–1.
6 Lundin KE, Nilsen EM, Scott HG et al. Oats induced villous atro-
phy in coeliac disease. Gut 2003; 52: 1649–52.
7 Silano M, Agostoni C, Guandalini S. Effect of the timing of gluten
introduction on the development of celiac disease. World J Gas-
troenterol 2010; 16: 1939–42.
8 Troncone R, Auricchio S. Rotavirus and celiac disease: clues to
the pathogenesis and perspectives on prevention. J Pediatr Gas-
troenterol Nutr 2007; 44: 527–8.
9 Nisticò L, Fagnani C, Coto I et al. Concordance, disease progres-
sion, and heritability of coeliac disease in Italian twins. Gut 2006;
55: 803–8.
10 Karell K, Louka AS, Moodie SJ et al. HLA types in celiac disease
patients not carrying the DQA1*05-DQB1*02 (DQ2) heterodi-
mer: results from the European Genetics Cluster on Celiac Dis-
ease. Hum Immunol 2003; 64: 469–77.
11 Vader W, Kooy Y, Van Veelen P et al. The gluten response in
children with celiac disease is directed toward multiple
gliadin and glutenin peptides. Gastroenterology 2002; 122:
1729–37.
12 Arentz-Hansen H, McAdam SN, Molberg Ø et al. Celiac lesion T
cells recognize epitopes that cluster in regions of gliadins rich in
proline residues. Gastroenterology 2002; 123: 803–9.
13 Vader LW, de Ru A, van der Wal Y et al. Specificity of tissue trans-
glutaminase explains cereal toxicity in celiac disease. J Exp Med
2002; 195: 643–9.
14 Dørum S, Qiao SW, Sollid LM et al. A quantitative analysis of
transglutaminase 2-mediated deamidation of gluten peptides:
implications for the T-cell response in celiac disease. J Proteome
Res 2009; 8: 1748–55.
15 Nilsen EM, Jahnsen FL, Lundin KE et al. Gluten induces an intes-
tinal cytokine response strongly dominated by interferon gamma
in patients with celiac disease. Gastroenterology 1998; 115: 551–
63.
16 Fina D, Sarra M, Caruso R et al. Interleukin 21 contributes to the
mucosal T helper cell type 1 response in coeliac disease. Gut
2008; 57: 887–92.
17 Monteleone G, Pender SL, Alstead E et al. Role of interferon alpha
in promoting T helper cell type 1 responses in the small intestine
in coeliac disease. Gut 2001; 48: 425–9.
18 Maiuri L, Ciacci C, Auricchio S et al. Interleukin 15 mediates epi-
thelial changes in celiac disease. Gastroenterology 2000; 119:
996–1006.
19 Salvati VM, MacDonald TT, Bajaj-Elliott M et al. Interleukin 18
and associated markers of T helper cell type 1 activity in coeliac
disease. Gut 2002; 50: 186–90.
20 Ferguson A, Murray D. Quantitation of intraepithelial lympho-
cytes in human jejunum. Gut 1971; 12: 988–94.
21 Jabri B, de Serre NP, Cellier C et al. Selective expansion of intra-
epithelial lymphocytes expressing the HLA-E-specific natural
killer receptor CD94 in celiac disease. Gastroenterology 2000;
118: 867–79.
ª 2011 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 269; 582–590
22 Roberts AI, Lee L, Schwartz E et al. NKG2D receptors induced by
IL-15 costimulate CD28-negative effector CTL in the tissue
microenvironment. J Immunol 2001; 167: 5527–30.
23 Meresse B, Chen Z, Ciszewski C et al. Coordinated induction by
IL15 of a TCR-independent NKG2D signaling pathway converts
CTL into lymphokine-activated killer cells in celiac disease.
Immunity 2004; 21: 357–66.
24 Hüe S, Mention JJ, Monteiro RC et al. A direct role for
NKG2D ⁄ MICA interaction in villous atrophy during celiac dis-
ease. Immunity 2004; 21: 367–77.
25 Dieterich W, Ehnis T, Bauer M et al. Identification of tissue trans-
glutaminase as the autoantigen of celiac disease. Nat Med 1997;
3: 797–801.
26 Tosco A, Salvati VM, Auricchio R et al. Most children with poten-
tial celiac disease are healthy but one third of them develop vil-
lous atrophy at 3-years follow-up. Clin Gastroenterol Hepatol
2011; 9: 320–5.
27 Bourgey M, Calcagno G, Tinto N et al. HLA related genetic risk for
celiac disease. Gut 2007; 56: 1054–9.
28 Vader W, Stepniak D, Kooy Y et al. The HLA-DQ2 gene dose effect
in celiac disease is directly related to the magnitude and breadth
of gluten-specific T cell responses. Proc Natl Acad Sci U S A 2003;
100: 12390–5.
29 Tiittanen M, Westerholm-Ormio M, Verkasalo M et al. Infiltration
of forkhead box P3-expressing cells in small intestinal mucosa in
celiac disease but not in type 1 diabetes. Clin Exp Immunol 2008;
152: 498–507.
30 Hull CM, Liddle M, Hansen N et al. Elevation of IgA anti-epidermal
transglutaminase antibodies in dermatitis herpetiformis. Br J
Dermatol 2008; 159: 120–4.
31 Marietta EV, Camilleri MJ, Castro LA et al. Transglutaminase
autoantibodies in dermatitis herpetiformis and celiac sprue.
J Invest Dermatol 2008; 128: 332–5.
32 Dahlbom I, Korponay-Szabó IR, Kovács JB et al. Prediction of
clinical and mucosal severity of coeliac disease and dermatitis
herpetiformis by quantification of IgA ⁄ IgG serum antibodies to
tissue transglutaminase. J Pediatr Gastroenterol Nutr 2010; 50:
140–6.
33 Hadjivassiliou M, Sanders DS, Grünewald RA et al. Gluten sensi-
tivity: from gut to brain. Lancet Neurol 2010; 9: 318–30.
34 Hadjivassiliou M, Mäki M, Sanders DS et al. Autoantibody target-
ing of brain and intestinal transglutaminase in gluten ataxia.
Neurology 2006; 66: 373–7.
35 Stamnaes J, Dorum S, Fleckenstein B et al. Gluten T cell epitope
targeting by TG3 and TG6; implications for dermatitis herpetifor-
mis and gluten ataxia. Amino Acids 2010; 39: 1183–91.
36 Spiegel BM, DeRosa VP, Gralnek IM et al. Testing for celiac sprue
in irritable bowel syndrome with predominant diarrhea: a cost-
effectiveness analysis. Gastroenterology 2004; 126: 1721–32.
37 Rodrı́guez LA, Ruigómez A. Increased risk of irritable bowel syn-
drome after bacterial gastroenteritis: cohort study. BMJ 1999;
318: 565–6.
38 Arranz E, Ferguson A. Intestinal antibody pattern of celiac dis-
ease: occurrence in patients with normal jejunal biopsy histol-
ogy. Gastroenterology 1993; 104: 1263–72.
39 Wahnschaffe U, Schulzke JD, Zeitz M et al. Predictors of clinical
response to gluten-free diet in patients diagnosed with diarrhea-
predominant irritable bowel syndrome. Clin Gastroenterol Hepa-
tol 2007; 5: 844–50.
40 Troncone R, Greco L, Mayer M et al. In siblings of celiac children,
rectal gluten challenge reveals gluten sensitization not restricted
to celiac HLA. Gastroenterology 1996; 111: 318–24.
589
 R. Troncone & B. Jabri
| Symposium: Coeliac disease and gluten sensitivity

41 Michaëlsson G, Gerdén B, Hagforsen E et al. Psoriasis patients
with antibodies to gliadin can be improved by a gluten-free diet.
Br J Dermatol 2000; 142: 44–51.
42 O’Farrelly C. Wheat protein sensitive disease may be indepen-
dent of intestinal structural changes. In: Feighery C, O’Farrelly
C, eds Gastrointestinal Immunology and Gluten-Sensitive Dis-
ease. Dublin: Oak Tree Press, 1992; 169–80.
43 Mallone R, van Endert P. T cells in the pathogenesis of type 1 dia-
betes. Curr Diab Rep 2008; 8: 101–6.
44 Vaarala O, Atkinson MA, Neu J. The ‘‘perfect storm’’ for type 1 dia-
betes: the complex interplay between intestinal microbiota, gut
permeability, and mucosal immunity. Diabetes 2008; 57: 2555–
62.
45 Maki M, Hallstrom O, Huupponen T et al. Increased prevalence of
coeliac disease in diabetes. Arch Dis Child 1984; 59: 739–42.
46 Troncone R, Franzese A, Mazzarella G et al. Gluten sensitivity in a
subset of children with insulin dependent diabetes mellitus. Am
J Gastroenterol 2003; 98: 590–5.
47 Auricchio R, Paparo F, Maglio M et al. In vitro-deranged intestinal
immune response to gliadin in type 1 diabetes. Diabetes 2004;
53: 1680–3.
48 Ventura A, Magazzù G, Greco L. Duration of exposure to gluten
and risk for autoimmune disorders in patients with coeliac dis-
ease. SIGEP Study Group for Autoimmune Disorders in Coeliac
Disease. Gastroenterology 1999; 117: 297–303.
Correspondence: Riccardo Troncone, Department of Pediatrics and
European Laboratory for the Investigation of Food-Induced
Diseases, University Federico II, via S Pansini 5, I-80131 Naples,
Italy.
(fax: +39 081 5469811; e-mail: troncone@unina.it).

590 ª 2011 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 269; 582–590