Summary
Celiac disease, epilepsy and cerebral calcification syndrome (CEC) is a rare disorder characterized by the combination of auto-immune intestinal disease, epileptic seizures and cerebral calcifications.
CEC was first described in 1992 and less than 200 cases have been reported so far.
Celiac disease (CD, see this term) and epilepsy manifest at a variable age, and diagnosis of CD is frequently done in late childhood, when specific investigations are led secondary to observation of epileptic seizures and cerebral calcifications (CC). CD can present with a typical form characterized by onset in the first 2 years of life, chronic diarrhea, weight loss, short stature, anorexia, and, in some cases, irritability and vomiting. CD may also present as silent or latent form, which are characterized - in absence of gastrointestinal symptoms - by dermatitis herpetiformis, dental enamel defects or autoimmune thyroiditis. In CEC patients, CD usually evolves in latent, silent or paucisymptomatic forms. Epilepsy's onset is between infancy and adulthood; most cases occur in early childhood. Most patients present with occipital epileptic seizures, the evolution being highly variable, with benign, drug-resistant, or epileptic encephalopathy forms. In the latter, severe mental deterioration and/or learning disorders have been reported while a mild mental deterioration is observed in only one third of all CEC cases. CC are seen in subcortical parieto-occipital regions. CC size does not change significantly over time, but in several cases, new CC appeared in other regions. Patients with CC and CD without epilepsy are considered as having an incomplete form of CEC. Some patients with epilepsy and CC without CD are supposed to have a CEC with latent CD.
Etiology of CEC is unclear. It is not known if epilepsy and/or CC are a consequence of CD. CD is an immune auto-inflammatory reaction occurring in predisposed gluten-intolerant individuals. It originates from the jejunal mucosa and spread to the lamina propria, leading to the observed histopathological features (crypt hyperplasia, jejunal villous atrophy and inflammatory infiltrate in the lamina propria). CD may induce autoimmune responses outside the gastrointestinal tract. Circulating activated T cells may cross the blood-brain barrier and be toxic to myelin or myelin-producing cells. As for isolated CD, CEC is associated with HLA-DQ2 and HLA-DQ8 genes.
Diagnosis relies on anamnestic investigation and EEG to characterize epileptic seizures. Computing tomography (CT) imaging reveals CC. Laboratory findings (antiendomisium antibodies, antigliadin antibodies, anti-tissue-transglutaminase type 2 antibodies, HLA phenotype), and histopathological analysis of small bowel biopsy (jejunal mucosa villous atrophy) identify a silent or latent CD in a patient with epileptic seizures and CC.
Differential diagnosis of CEC includes Sturge-Weber syndrome (see this term) without nevus flammeus and other conditions such as congenital folate malabsorption or adverse effects of methotrexate, antifolate agents and radiotherapy of leukemic children.
CD requires a life-long observance of a gluten-free diet (GFD), leading to clinical and histopathological resolution of symptoms. A study revealed that early CD diagnosis and treatment by GFD could prevent or reverse the epileptic disorder.
Early diagnosis and good compliance of GFD greatly improve patients' outcome. On the contrary, if treatment is delayed, epilepsy may be more severe and epileptic encephalopathy may develop.
Expert reviewer(s)
Last update: April 2012
