Chronic Insomnia as an Uncommon Manifestation of Celiac Disease: A Case Report

Abstract

Background Celiac disease is an immune-mediated enteropathy with well-established gastrointestinal manifestations; however, its extraintestinal and neuropsychiatric presentations are increasingly recognized. A possible association between celiac disease and neuropsychiatric or sleep-related symptoms, including insomnia, has been described in observational studies, systematic reviews, and population-based analyses. Nevertheless, chronic insomnia as a principal presenting symptom remains an atypical and underreported presentation in the published literature. Case Presentation A 42-year-old male presented to an outpatient neurology clinic in Mogadishu, Somalia, with a primary complaint of chronic insomnia lasting five months. The patient reported severe nocturnal restlessness, an inability to initiate or maintain sleep, and considerable psychological distress. Prior attempts at sleep hygiene optimization and over-the-counter pharmacotherapy had yielded no improvement. His personal and family history were unremarkable, except for chronic but mild abdominal distension and discomfort, which the patient had long tolerated. Dietary history revealed a predominantly wheat-based diet. A high index of clinical suspicion prompted referral for gastroenterological evaluation. Serological testing demonstrated borderline elevated tissue transglutaminase IgG (tTG IgG: 0.70 kU/L). Upper gastrointestinal endoscopy revealed erythematous and edematous mucosa in the first and second portions of the duodenum (D1 and D2). Histopathological examination of duodenal biopsies confirmed Marsh-Oberhuber type 3a changes, including partial villous atrophy, crypt hyperplasia, flattened enterocytes, and increased intraepithelial lymphocytes (42 IEL/100 enterocytes), consistent with celiac disease. Following the institution of a strict gluten-free diet, the patient experienced marked resolution of both insomnia and gastrointestinal symptoms within weeks. Notably, the insomnia was assessed clinically without objective sleep studies (eg, polysomnography or actigraphy), validated insomnia rating scales, or a formal psychiatric evaluation, and the symptomatic improvement following dietary intervention should therefore be interpreted as a temporal association rather than confirmation of a direct causal relationship. Conclusion This case highlights the value of considering celiac disease in the differential diagnosis of chronic, otherwise unexplained insomnia, particularly when subtle gastrointestinal symptoms or dietary risk factors are present. Given that insomnia is common in the general population and that this report lacks objective sleep and psychiatric assessment, the observed association remains suggestive rather than definitive. Neurologists may benefit from maintaining clinical awareness of this possible association and pursuing collaborative evaluation with gastroenterology to ensure timely diagnosis and treatment.