Letter to the Editor
Response to: Fibromyalgia and Chronic Fatigue Syndrome Caused by Non-celiac Gluten Sensitivity
Respuesta a: Fibromialgia y fatiga crónica causada por sensibilidad al gluten no celíaca
a Unidad de Fibromialgia y Síndrome de Fatiga Crónica, Departamento de Reumatología, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
b Departamento de Reumatología, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
c Clínica del dolor, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
d Departamento de Psicología, Universitat Rovira i Virgili, Tarragona, Spain
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We would like to comment our experience with this attractive topic regarding patients with FM/CFS, which I hope will contribute to an improved knowledge of this association. The authors have reasonably ruled out celiac disease (CD) and have hypothesized that NGCD is the cause of FM and CFS in their patient; upon complete remission (CR) of symptoms, both digestive and musculoskeletal, with a gluten-free diet (GFD). CFS is characterized by intense fatigue in addition to cognitive, autonomic, neurroendocrine, immunoallergic and musculoskeletal symptoms, newly appearing and inexplicable, lasting for at least 6 months. In the criteria (C) from the most recent international consensus in 2011, gastrointestinal alterations were included (irritable bowel syndrome [IBS] as was sensitivity to foodstuff) as diagnostic criteria for CFS.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This new classification allows us to consider NGCD as a comorbid condition (CC), which perpetuates CFS and not unleashes it. In our series of 200 patients affected by CFS attended at the Unidad del Camp de Tarragona (2011–2013), we found the following CC: 101 patients (50.5%) with FM, 38 patients (19%) with chronic autoimmune thyroiditis, 31 patients (15.5%) with NGCD and 27 patients (13.5%) with IBS. At the onset of GFD, in addition to multidisciplinary treatment, most of our patients (up to 80%) had improvement of their intestinal symptoms (abdominal pain, diarrhea, flatulence, oral ulcers) and a very modest response to extra intestinal symptoms (fatigue, bone pain, alterations in concentration and depression) without reaching CR. Therefore, we have supported the theory of overlap between FM/CFS and NGCD without concluding that the latter is its cause in this patient population, but may aggravate its symptoms. This term was probably employed for the first time in 1978 by Ellis and Linaker. There is increasing evidence suggesting the existence of NGCD. This concept groups patients who do not comply with the criteria of CD but experiment intestinal symptoms and/or extra intestinal manifestations when consuming gluten. Recent studies have proposed that FODMAP (fermented oligo, di, monosacharides and polyols) as components of the wheat causing symptoms of NGCD, in addition to gluten.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Its prevalence is estimated to be 10 times greater than CD. In <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> we expose the diagnostic criteria used to define NGCD.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The gold standard for its diagnosis would be a double blind intervention controlled with placebo, because taking gluten out of the diet could lead to a placebo effect that may explain the improvement or remission of symptoms. In conclusion, we must take into account several considerations in the case presented by the authors. First, NGCD is a comorbid condition of FM/CFS, not the factor triggering it. Second, both FM and CFS are 2 chronic and complex diseases from the diagnostic and therapeutic standpoint, which require multidisciplinary management (adequate nutrition and dietary balance, symptom-based treatment, cognitive-conductual therapy and regulated gradual physical exercise) more than a simple GFD. Third, we believe that the case presented is a NGCD with extra intestinal affection (FM/CFS-like symptoms) more than FM/CFS per se.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Qanneta R, Fontova R, Castel A. Respuesta a: Fibromialgia y fatiga crónica causada por sensibilidad al gluten no celíaca. Reumatol Clin. 2015;11:185.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CD, celiac disease.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">1. Consumption of gluten rapidly produces intestinal and extra intestinal symptoms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">2. These clinical manifestations disappear earlier after the onset of a gluten free diet and reappear after its reintroduction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">3. Immediate type hypersensitivity to wheat and gluten has been ruled out (gluten and wheat specific IgE and negative skin testing) and CD (negative serology: antiendomisial IgA antibodies, antitransglutaminase IgA and gliadin deaminated antipeptide IgG) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">4. Antigliadin antibodies, especially IgG, may be positive (they are positive in approximately 50% of patients) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">5. Histopathology: normal intestinal mucosa or mild increase in intraepithelial lymphocytes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">6. HLA-DQ2 and/or HLA-DQ8 may be positive (they are positive in approximately 40% of patients) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab784600.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Criteria of Non-celiac Sensitivity to Gluten.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fibromyalgia and chronic fatigue syndrome caused by non-celiac gluten sensitivity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Isasi" 1 => "E. Tejerina" 2 => "N. Fernández-Puga" 3 => "J.I. Serrano-Vela" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.reuma.2014.06.005" "Revista" => array:2 [ "tituloSerie" => "Reumatol Clin" "fecha" => "2014" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Myalgic encephalomyelitis: international consensus criteria" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.M. Carruthers" 1 => "M.I. van de Sande" 2 => "K.L. de Meirleir" 3 => "N.G. Klimas" 4 => "G. Broderick" 5 => "T. 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| 2024 August | 50 | 38 | 88 |
| 2024 July | 45 | 29 | 74 |
| 2024 June | 68 | 28 | 96 |
| 2024 May | 46 | 25 | 71 |
| 2024 April | 41 | 23 | 64 |
| 2024 March | 45 | 30 | 75 |
| 2024 February | 30 | 27 | 57 |
| 2024 January | 34 | 15 | 49 |
| 2023 December | 22 | 32 | 54 |
| 2023 November | 37 | 30 | 67 |
| 2023 October | 44 | 28 | 72 |
| 2023 September | 64 | 33 | 97 |
| 2023 August | 36 | 8 | 44 |
| 2023 July | 33 | 28 | 61 |
| 2023 June | 40 | 21 | 61 |
| 2023 May | 44 | 26 | 70 |
| 2023 April | 29 | 4 | 33 |
| 2023 March | 42 | 38 | 80 |
| 2023 February | 45 | 24 | 69 |
| 2023 January | 39 | 19 | 58 |
| 2022 December | 47 | 28 | 75 |
| 2022 November | 65 | 24 | 89 |
| 2022 October | 48 | 41 | 89 |
| 2022 September | 46 | 41 | 87 |
| 2022 August | 40 | 46 | 86 |
| 2022 July | 30 | 41 | 71 |
| 2022 June | 40 | 31 | 71 |
| 2022 May | 37 | 32 | 69 |
| 2022 April | 50 | 40 | 90 |
| 2022 March | 45 | 47 | 92 |
| 2022 February | 42 | 32 | 74 |
| 2022 January | 58 | 47 | 105 |
| 2021 December | 69 | 44 | 113 |
| 2021 November | 37 | 51 | 88 |
| 2021 October | 59 | 44 | 103 |
| 2021 September | 50 | 42 | 92 |
| 2021 August | 37 | 43 | 80 |
| 2021 July | 34 | 44 | 78 |
| 2021 June | 38 | 37 | 75 |
| 2021 May | 58 | 41 | 99 |
| 2021 April | 110 | 82 | 192 |
| 2021 March | 68 | 46 | 114 |
| 2021 February | 57 | 35 | 92 |
| 2021 January | 53 | 25 | 78 |
| 2020 December | 60 | 23 | 83 |
| 2020 November | 48 | 23 | 71 |
| 2020 October | 36 | 17 | 53 |
| 2020 September | 60 | 28 | 88 |
| 2020 August | 53 | 20 | 73 |
| 2020 July | 35 | 25 | 60 |
| 2020 June | 53 | 31 | 84 |
| 2020 May | 51 | 27 | 78 |
| 2020 April | 37 | 17 | 54 |
| 2020 March | 29 | 9 | 38 |
| 2020 February | 1 | 0 | 1 |
| 2018 December | 2 | 0 | 2 |
| 2018 May | 6 | 3 | 9 |
| 2018 April | 38 | 7 | 45 |
| 2018 March | 46 | 12 | 58 |
| 2018 February | 20 | 5 | 25 |
| 2018 January | 34 | 5 | 39 |
| 2017 December | 23 | 8 | 31 |
| 2017 November | 26 | 18 | 44 |
| 2017 October | 33 | 6 | 39 |
| 2017 September | 23 | 10 | 33 |
| 2017 August | 27 | 7 | 34 |
| 2017 July | 28 | 8 | 36 |
| 2017 June | 45 | 27 | 72 |
| 2017 May | 41 | 16 | 57 |
| 2017 April | 31 | 14 | 45 |
| 2017 March | 25 | 8 | 33 |
| 2017 February | 40 | 12 | 52 |
| 2017 January | 36 | 11 | 47 |
| 2016 December | 52 | 23 | 75 |
| 2016 November | 41 | 2 | 43 |
| 2016 October | 54 | 16 | 70 |
| 2016 September | 55 | 16 | 71 |
| 2016 August | 46 | 6 | 52 |
| 2016 July | 26 | 10 | 36 |
| 2015 December | 2 | 0 | 2 |
| 2015 November | 1 | 22 | 23 |
| 2015 October | 1 | 28 | 29 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 2 | 26 | 28 |
| 2015 July | 34 | 11 | 45 |
| 2015 June | 44 | 16 | 60 |
| 2015 May | 64 | 28 | 92 |
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