‘Missed’ coeliac disease in type 1 diabetes mellitus with fatal consequences

Our patient is a 40-year-old man with a 22-year history of type 1 diabetes. His control had been consistently poor but he had minimal end organ damage. There was no significant past medical history or family history. He was a C1 driving licence holder, and the DVLA was aware of his diagnosis of type 1 diabetes. In January 2007 he unexpectedly lost 8kg in weight and found he required less insulin. He had frequent hypoglycaemic episodes, but did not seek medical attention. Five months later he was involved in a road traffic accident that was fatal to the other driver. The paramedics found him to be hypoglycaemic. This resulted in a custodial sentence, and lifetime driving ban. He was subsequently admitted to hospital to investigate his hypoglycaemia. Thyroid function and synacthen tests were normal. Coeliac serology was negative and he was mildly anaemic. His HbA1c was elevated at 10.4% (90mmol/mol). He was discharged without cause found. A month later he was readmitted with breathlessness. He was severely anaemic with an Hb of 7.8g/dl, and was referred for gastroscopy. This demonstrated hyperplastic gastritis of the stomach, with altered blood present. Duodenal biopsies were taken and showed subtotal villous atrophy with a patchy increase in intraepithelial lymphocytes and crypt hyperplasia. The findings were consistent with coeliac disease. The patient was referred to a dietitian for advice on a gluten-free diet. His haemoglobin normalised and a DEXA scan excluded osteoporosis. Copyright © 2011 John Wiley & Sons.