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A patient with severe late onset primary hypogammaglobulinaemia developed coeliac disease. The case illustrates that coeliac disease can occur in the virtual absence of local antibody production by plasma cells in the mucosa of the small bowel. Furthermore, our inability to demonstrate specific cellular immunity to a subfraction of gluten raises doubts about the relevance of immunological reactions in the pathogenesis of coeliac disease.

In an attempt to identify the nature of the active principle, Kveim reagent was exposed to chemical fractionating agents. Thirty-one patients with sarcoidosis underwent simultaneous intradermal injection with fractionated and unfractionated Kveim material. Kveim reagent was stable in the presence of DNAse, RNAse, pronase, 95% phenol, neutral detergent, and to lipid extraction with chloroform-methanol. Kveim reagent was also stable in the presence of both 8 M urea (8MU) and 2-mercaptoethanol (2ME) when used alone. When both these agents were used together, Kveim reagent was inactivated. Fourteen patients had a positive test to unfractionated Kveim reagent; of these, only 2 gave a positive response to material fractionated by exposure to 8MU and 2ME. Simultaneous exposure to 8MU and 2ME was more likely to inactivate Kveim reagent (10/10 tests) than sequential exposure to 8MU and 2ME (2/4 tests). Chemical analysis of the fractionated material showed that it retained granuloma-generating activity despite the lack of carbohydrates. Protein loss in terms of total and relative amino acid composition was progressive and nonspecific throughout processing. These results are consistent with a protein-active principle which is dependent on three-dimensional structure.

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