Multiple sclerosis or neurological manifestations of Celiac disease
Our patient is a 37-years-old woman with a history of chronic abdominal pain since 2004. Anti-endomysial antibody (Ab) of isotype IgA (16 u/mL), and anti-gliadin antibody of isotype IgA (67 u/ml), and IgA tissue transglutaminase antibody (186 u/mL) was present in the serum. Gastric and duodenal biopsy documented chronic gastritis associated with Heliobacter pylori and chronic duodenitis, but not celiac disease-related pathological findings. Gluten-free diet (GFD) was started and her GI symptoms subsided, so diagnosis of celiac disease was made.\nIn her past history, about 18 years ago, her left-eye became ophthalmoplegic and without a definite diagnosis, after corticosteroid therapy, it was recovered completely within 1 month. Five years ago, she suffered from diplopia that was binocular and continued until now. Few months before, she became ataxic. She thought that it has been related to diet. Although, it evolved and established completely within a few days, so she met a neurologist and her brain MRI showed demyelinating plaques compatible with multiple sclerosis [], without any structural abnormality in cerebellum []. Her visual evoked potentials (VEP) were abnormal too (delayed responses with normal wave configuration). Oligoclonal band was seen in CSF examination. Therefore, the clinical diagnosis of MS was made and Avonex (Beta interferon 1-a, IM, weekly) was introduced to her. Till now, she has not had any relapse, and her neurological disability (EDSS) is fixed.\nNow, she has episodic ataxia and slurred speech especially whenever she is tired. On neurological examination, she has binocular diplopia and fine horizontal nystagmus when she looks to the left side. Her plantar reflexes are upward.\nAbdominal reflexes are not detectable and her deep tendon reflexes are symmetric and exaggerated (3+). Her gait is ataxic and she falls when turns rapidly. Other neurological examinations are not remarkable.