In our clinic, Institute for Specialized Medicine, we deal with various autoimmune diseases, including autoimmune diseases driven by gluten and those driven by chronic infections, for example chronic borreliosis also known as Lyme disease. Quite frequently, we see patients who have Lyme disease that can be affected by immunogenic foods, like gluten. Therefore, the issue of interconnection between Lyme disease and gluten sensitivity has been discussed numerous times with my patients.
Because this is a very complex topic, for ease of understanding, I typically divide it into three sub-topics:
1. Statistics on Lyme disease and gluten intolerance/celiac disease overlap
2. How Lyme disease affects the natural course of gluten intolerance/celiac disease
3. The role of a gluten-free diet in therapy of Lyme disease
Statistics on Lyme disease and gluten intolerance/celiac disease overlap
Gluten intolerance/celiac disease is an autoimmune enteropathy (disease of the intestine) with genetic, environmental, and immunologic components. It is characterized by an abnormal immune response to gluten that leads to inflammation and tissue damage in the small intestine. Gluten intolerance/celiac disease is strongly associated with genes for the specific class II human leukocyte antigens (HLAs) DQ2 and DQ8. It is estimated to affect close to 1% of the American population.
Lyme disease, also known as borreliosis, is caused by the Borrelia burgdorferi bacteria often found in ticks. Lyme disease is currently the most common vector-borne infection in the USA, where its incidence has been rapidly increasing in recent years. Although early aggressive antibiotic therapy resolves clinical symptoms in a significant number of cases, somewhere between 20-30% of patients will develop a persistent chronic infection requiring prolonged antibiotic therapy.
The potential of Borrelia to cause a late onset of celiac disease or gluten sensitivity has come into focus of several research studies. Studies from the United States and Sweden have demonstrated some similarity with the geographic distribution of celiac disease and Lyme disease. In the US, celiac disease is the most prevalent in the Northeast and the Midwest regions, where the great majority Borrelia infection also occur. In Sweden, the highest incidence of celiac disease has been associated with the southern region, where Lyme disease is endemic.
The joint US-Swedish study published in 2017 concluded that only a minor fraction of the celiac disease patient population had a prior diagnosis of Lyme disease. The association is similar between Lyme disease and celiac disease. Taken together, the data indicate that Borrelia infection is not a substantive risk factor in the development of celiac disease.
How Lyme disease affects the natural course of gluten intolerance/celiac disease
To understand the impact of Lyme disease on gluten intolerance/celiac disease we need to look at the basic science of this topic.
a. The inflammatory cascade triggered by gluten is a result of gluten interacting with class II human leukocyte antigens (HLAs) DQ2 and DQ8 expressed on the surface of immune cells.
b. The magnitude and effect of this interaction depend on the density of the molecules on the surface of these immune cells.
c. The surface density of these molecules is mediated by mechanisms controlling gene expression.
d. Inflammation triggered by various infectious agents (viruses, bacteria, fungi) is among the most powerful stimuli upregulating, or increasing, HLA DQ2/8 expression.
e. This means that various infections, including Lyme disease, can induce a transition from dormant gluten intolerance to a full-blown disease.
The following case demonstrates a typical example of how an infectious process can trigger a transition from being asymptomatic to symptomatic gluten intolerance.
A young man bitten by a tick developed a classical Lyme bulls eye rash. He was treated with antibiotics right after the tick bite and never developed classical symptoms of chronic Lyme disease. However, several months after the bite he started experiencing bloating, abdominal pain, and diarrhea. He was seen by a gastroenterologist and underwent upper endoscopy and colonoscopy with no abnormal findings. His stool analysis for gastrointestinal infections and parasites came back negative as well.
He then came to our clinic in order to get a second opinion regarding the nature of his symptoms. His lab test results revealed HLA DQ8 positivity. I put him on a gluten-free diet which relieved his symptoms by 70-80%. After being gluten-free for several months, he was not fully asymptomatic, so he eliminated cow’s milk-based dairy products resulting in a near complete resolution of his symptoms. Currently, he visits our clinic on annual basis and is still symptom free.
The role of a gluten-free diet in therapy of Lyme disease
In genetically-predisposed individuals, daily consumption of gluten results in a chronic low-grade inflammatory process affecting the gastrointestinal tract. This can interfere with the absorption of antibiotics and other remedies administered to patients with Lyme disease and therefore decrease the efficacy of therapy.
Another mechanism of Lyme disease and gluten interference is eliminating immunogenic foods (foods triggering immune response after their consumption) as a part of a complex therapy for chronic infections.
To understand the role of immunogenic foods in therapy of Lyme disease and chronic infections, let’s look at this from a prospective of classical immunology.
An immune response to one antigen is reduced by prior exposure to a second unrelated antigen. The phenomenon is called antigenic competition. From a practical standpoint it means that if your body is dealing with several unrelated immune-mediated illnesses, the efficacy of the immune system in resolving any given ailment will be significantly diminished. Therefore, a person suffering from a chronic infection and gluten intolerance will benefit from gluten elimination. This is true not only for gluten but also for a variety of immunogenic foods.
Here is an example of this from our clinic.
A middle age woman who was a patient in our clinic for several years due to several autoimmune problems triggered by Borrelia burgdorferi and Bartonella henselae infections demonstrated a significant clinical improvement after a year and a half of complex antibiotic therapy. However, she stated that her improvement had reached a plateau of 70-75% of her pre-illness health. Modifications of antibiotic therapies had not resulted in any significant symptomatic improvement. After a prolonged discussion of various therapeutic options, she agreed to be tested for food intolerances based on IgA, IgG and leukocyte-activation test systems. The common thread in every test showed the presence of prolamin intolerance. Prolamins are a group of plant storage proteins having high proline content—gluten is a prolamin. Continuation of the antibiotic therapy in a combination with prolamin elimination resulted in near complete symptom resolution.
The coexistence of Lyme disease and gluten intolerance/celiac disease is not uncommon. The treatment of Lyme disease and gluten intolerance are interconnected. In the treatment of Lyme disease, if symptom eradication is minimal or has reached a plateau, it is best to consider eliminating gluten as a part of therapy. Likewise, the therapy of chronic Lyme disease may benefit symptoms of gluten intolerance because the antibiotic treatment keeps the infection from increasing the expression of the genes found in gluten intolerance.
The connection is one that will continue to be studied especially as more cases of Lyme disease continue to increase.
This article was originally written for Simply Gluten Free magazine for their September – October 2018 edition.