Refractory Sprue
By Ron Hoggan, Ed. D.

There are a number of reports of coexisting intolerance to milk proteins among celiac patients. One recent report was of an investigation for cross-reacting antibodies. They found none, but a number of these patients displayed antibodies against gliadin and parallel anti-casein antibodies(1). Another group reports that 36% to 48% of celiac patients demonstrate antibody reactions to milk proteins (2). Some investigators indicate that the frequency of such antibodies diminishes over time on a gluten-free diet but they also report a higher initial frequency of reactions to milk proteins (3).

A case report of a celiac patient thought to have refractory sprue describes a full recovery following dietary exclusion of egg, chicken, and tuna in addition to the gluten-free diet (4). The patient became *very* ill before the possibility of immune reactions to other dietary proteins was considered.

These reports suggest to me that we need for increased awareness of additional food sensitivities in the context of celiac disease, especially when symptoms persist. Investigation for additional food sensitivities should be conducted prior to the prescription of steroids or other drugs for symptom management, as the therapeutic use of systemic steroids is not entirely benign. Dietary exclusion of allergenic proteins, on the other hand, is simply an inconvenience - one that most celiac patients are already well versed in.

ELISA or similar testing for common food allergies should be conducted *prior* to beginning steroids as such testing, along with dietary exclusion, may make such drugs unnecessary. Steroids may also compromise the accuracy of food allergy/delayed food sensitivity testing so there are many good reasons for objective food sensitivity testing before beginning any treatment strategy.

Sources:
  1. Paranos S, et al. Lack of cross-reactivity between casein and gliadin in sera from coeliac disease patients. Int Arch Allergy Immunol. 1998 Oct;117(2):152-4.
  2. Volta U, et al. Antibodies to dietary antigens in coeliac disease. Scand J Gastroenterol. 1986 Oct;21(8):935-40.
  3. Scott H, et al. Immune response patterns in coeliac disease. Serum antibodies to dietary antigens measured by an enzyme linked immunosorbent assay (ELISA). Clin Exp Immunol. 1984 Jul;57(1):25-32.
  4. Baker AL, et al. Refractory sprue: recovery after removal of nongluten dietary proteins. Ann Intern Med. 1978 Oct;89(4):505-8.