COMMENT ON CASTELLANETA ET AL. High Rate of Spontaneous Normalization of Celiac Serology in a Cohort of 446 Children With Type 1 Diabetes: A Prospective Study. Diabetes Care 2015;38:760–766 Diabetes Care 2015;38:e188 | DOI: 10.2337/dc15-1208 We read with interest the data reported by Castellaneta et al. (1) about the spon- taneous normalization of autoantibody markers for celiac disease (CD) in a wide population of children and adolescents with type 1 diabetes mellitus (T1DM). The authors hypothesized that this phenome- non could be related to a state of tempo- rary positivity of celiac serology in children with T1DM. They concluded that a gluten- free diet should be delayed in the absence of clinical signs of CD and that these subjects should be carefully fol- lowed up with serological and histolog- ical tests for a con fi rmation of the diagnosis. We partially agree with the authors’ conclusions, and we would like to share our experience about the association of T1DM and CD, highlighting some differ- ences previously reported. We investi- gated the prevalence of CD in a cohort of 331 newly diagnosed subjects with T1DM (2) over an 18-year follow-up based on anti-endomysial antibody (EmA) screening. We found that 7 of 29 subjects (24%) showed positivity for EmA detected at T1DM onset or during routine follow-up. The laboratory find- ings were confirmed by subsequent evaluations. Three of them underwent biopsy before normalization and a nor- mal mucosa was found. In all of these subjects, EmA spontaneously serocon- verted and became negative during a follow-up of 2–8 years. Castellaneta et al. cited another study (3) on EmA screening in subjects with T1DM that reported that 30% of EmA-positive chil- dren were already found negative at the second assay. However, the authors confirmed that all these subjects had a weak EmA reactivity. In the study by Castellaneta et al. (1), the median time for tTG normalization was shorter than in our study, 1.3 years. We think it is unlikely that EmA can have a longer time for normalization than tTG, as the authors affirmed that they did not find any cases that were both EmA positive and tTG negative. A different interpreta- tion may be that this is not related to gluten consumption (all the children who normalized CD-related antibodies follow a gluten-containing diet), but it is simply an epiphenomenon of the autoim- mune activation shown in subjects with T1DM. In fact, Waisbourd-Zinman et al. (4) also reported a study on spontaneous normalization of tTG in subjects with T1DM; the data showed that up to one- third of subjects with positive tTG levels seroconverted within 1 year of follow-up. Surprisingly, they found that sometimes EmA did not normalize accordingly to tTG: in fact, 3 of 10 subjects with EmA- and tTG-positive levels not on a gluten-free diet showed only tTG normalization dur- ing the follow-up period. Therefore, the association between CD and T1DM still remains a fascinating field of study with many aspects still to be clearly under- stood. In subjects with a predisposition for autoimmune diseases, autoanti- bodies can appear even at a low titer, and their meaning needs to be carefully interpreted. Duality of Interest. No potential conflicts of interest relevant to this article were reported. References 1. Castellaneta S, Piccinno E, Oliva M, et al. High rate of spontaneous normalization of celiac se- rology in a cohort of 446 children with type 1 diabetes: a prospective study. Diabetes Care 2015;38:760–766 2. Salardi S, Volta U, Zucchini S, et al. Preva- lence of celiac disease in children with type 1 diabetes mellitus increased in the mid-1990 s: an 18-year longitudinal study based on anti- endomysial antibodies. J Pediatr Gastroenterol Nutr 2008;46:612–614 3. Barera G, Bonfanti R, Viscardi M, et al. Oc- currence of celiac disease after onset of type 1 diabetes: a 6-year prospective longitudinal study. Pediatrics 2002;109:833–838 4. Waisbourd-Zinman O, Hojsak I, Rosenbach Y, et al. Spontaneous normalization of anti-tissue transglutaminase antibody levels is common in children with type 1 diabetes mellitus. Dig Dis Sci 2012;57:1314–1320 Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy Corresponding author: Giulio Maltoni, giulio.maltoni2@unibo.it. © 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. Giulio Maltoni, Silvana Salardi, and Stefano Zucchini e188 Diabetes Care Volume 38, November 2015 e-LETTERS – COMMENTS AND RESPONSES