Restoration of the lamina propria duodenal immune infiltrate in gluten-free diet treated celiac patients despite persistent villous atrophy.

Introduction: Although celiac disease (CD) current and only treatment is a life-long strict gluten-free diet (GFD), some patients suffer from persistent duodenal lesions despite years into the diet. Hence, we aimed to study the effect that the GFD elicits on the mucosal immune infiltrate from these patients.

Method: To that end, duodenal biopsies were collected from non-celiac controls and CD patients, both at diagnosis and after at least one year into the GFD. The profile of duodenal intraepithelial lymphocytes (lymphogram) and the lamina propria immune infiltrate were determined by spectral cytometry.

Results: At diagnosis, all CD patients had mucosal atrophy, a compatible lymphogram, and an expansion of lamina propria NK cells, innate lymphoid cells, B-cells, Treg and Tγδ cells, all of them expressing high levels of Fas, and Integrins α4 and β7. However, despite all GFD-treated patients had negative serology, 68.4% of them displayed persistent villous atrophy (Marsh score ≥ 3), while 73.3% had a compatible lymphogram. Nevertheless, despite such persistent atrophy, the lamina propria mucosal immune infiltrate was normalized in all GFD-treated patients. Besides, time on the GFD, but not the persistence of mucosal atrophy, correlated with an increased expression of gut-homing migration markers on lamina propria effector T-cells from these patients.

Conclusion: Hence, we hereby have proved how the lamina propria immune infiltrate, as opposed to intraepithelial lymphocytes, is normalized in GFD-treated CD patients despite persistent villous atrophy, suggesting that the epithelial layer may be the driver of such paradoxical persistent mucosal inflammation.