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Hopper et al highlight the non-specific way in which coeliac disease can present in adults 1. Presentations to rheumatology services are not uncommon with symptoms including fatigue, weakness, non-specific arthralgia, muscle cramps, and myalgia. A good argument therefore exists for screening for this disease when patients present with what may seem initially to be fibromyalgia or chronic fatigue syndrome (CFS), using combined serological testing. Such screening for coeliac disease is included in the recently published NICE guidance on the management of CFS.2 A true arthritis has also long been recognised.3 4 Presentation in elderly people is rare but also described and deserves mentioning 4.
A gluten-free diet is the mainstay of treatment of the metabolic bone disease that may complicate coeliac disease. A mixture picture of osteomalacia and osteoporosis may be seen, and vitamin D replacement may have an additional role to improve both symptoms and to reduce the risk of fracture. A low serum measurement of vitamin D may be the only abnormality found on biochemical testing, and screening should be considered in patients with premenopausal and male osteoporosis. Presentation with mixed deficiency anaemia is also possible, rather than iron deficiency alone, a low serum concentration of folate in particular being a fairly sensitive early indicator of the disease. Finally, coeliac disease may develop in patients with primary autoimmune rheumatic disease such as systemic lupus erythematosus and Sjogren's syndrome, and vice versa.
Occasionally non-specific musculoskeletal presentations may lead to the erroneous prescribing of corticosteroids. This may lead to false negatives on subsequent duodenal biopsy. However, corticosteroids may improve both gastrointestinal and musculoskeletal symptoms, and may be used to treat refractory disease. Other forms of immunosuppression—such as azathioprine and infliximab—are also used in refractory cases.5
Competing interests: None declared.