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Dr Benbow and her colleagues (November 2001 JRSM, pp. 578-580) draw attention to the fact that ‘chronic, nondiabetic medical disease’ could be a contributory factor to instability in elderly patients, brittle diabetes being in some instances characterized by recurrent hypoglycaemia. Unrecognized coeliac disease proved to be one such chronic disorder in a woman who in 1963 was diagnosed with diabetes at the age of 21, being stabilized on lente insulin from March 1964. During the subsequent 37 years she had had four distinct episodes of microcytic and/or hypochromic anaemia, responsive to iron supplements, but barium studies, undertaken in 1984, failed to reveal the underlying cause. Recurrent hypoglycaemic episodes, associated with what was thought to be infective diarrhoea, occasioned an admission in September 1990, and the bowel symptoms subsequently remitted spontaneously. When the hypoglycaemic episodes recurred in March 2001 (her body weight being 48.8 kg at the time), further investigations showed that she had coexisting coeliac disease. Coexisting colorectal disease was ruled out by barium enema and colonoscopy. After eight months of a gluten-free diet she had gained weight and her haemoglobin had risen from 8.5 to 13.7 g/dL. In that time there had been no recurrence of hypoglycaemic episodes.
This case history resonates with a report by Bhattacharyya and others1 of a woman with coeliac disease and brittle diabetes whose recurrent hypoglycaemia was ameliorated by adherence to a gluten-free diet. Although the onset of coeliac disease was possibly during young adulthood in the present case, the fact that 19% of patients with adult coeliac disease could be in the > 60 age group2 should alert us to the possibility of an association with diabetes in old age as well. Furthermore, in the presence of otherwise unexplained brittle diabetes, the coexistence of iron-deficiency anaemia should heighten suspicion, since this haematinic deficiency is the commonest extraintestinal manifestation of coeliac disease3.