Delayed severe rhabdomyolysis after taking 'ecstasy'.

Sir, Many patients with dermatitis herpetiformis also have a small bowel enteropathy which responds to withdrawal of gluten from the diet. However, in this setting, coeliac disease is usually mild and rarely results in clinical malabsorption. Both disorders have a high association with HLA, B8 and DR3 antigens and are suspected to have, at least in part, an immune pathogenesis. Some 1000 of patients with coeliac disease develop neurological complications (box). Cook' compiled a series of 16 patients and drew attention to the fact that these were the same neurological disorders that occur in paraneoplastic disease. Paraneoplastic cerebellar ataxia is most frequently associated with small cell lung cancer or carcinoma of the breast or ovary. Patients with breast or ovarian carcinoma have high titres of an IgG directed against a cytoplasmic antigen in cerebellar Purkinje cells.2 Whether this antibody is involved in the pathogenesis of the disorder or simply a epiphenomenon is not yet clear. The aetiology of cerebellar ataxia found with coeliac disease is equally obscure although vitamin deficiency, particularly of vitamin E, does not appear to be relevant.3 We were interested to look for the presence of an anti-Purkinje cell antibody in a patient with coeliac disease and anti-Purkinje cell antibody in a patient with coeliac disease and cerebellar ataxia. Our patient was a 65-year-old caucasian woman who presented with a 12-month history of progressive unsteadiness of gait and slurring of speech. She had a past history of reversible airways disease, dermatitis herpetiformis and, two years prior to her neurological presentation, had been found to have coeliac disease. Despite having no symptoms of malabsorption, investigations had revealed an abnormal xylose tolerance test (1 h plasma xylose 0.69 mmol/l; normal range 0.65-1.35 mmol/l), positive antigliaden and endomysial antibody and severe villous atrophy of the small bowel. She had been unable to tolerate a gluten-free diet. She smoked 10 cigarettes per day and she did not drink alcohol. At the time of investigation she was taking Becotide and salbutamol inhalers. There was no family history of note. General medical examination was normal. She had a cerebellar dysarthria, normal external ocular movements and an ataxia of limb and gait. Deep tendon reflexes were preserved, plantar responses flexor, and there were no sensory signs.