Round-about way of diagnosing coeliac disease in a primary school student

• Iron deficiency can occur with underlying absorption problems, such as coeliac disease.
• Iron deficiency may be a differential diagnosis for children with learning problems at school.
• Using lidocaine cream and plastic wrap to numb the arm is a useful tip when doing blood tests in children.

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Make sure you tell parents… economising on the lidocaine cream is not a good long-term investment

It is July 2021. Wembley – full. Wimbledon – packed. My part of the world? Back in lockdown. Once again, the streets of Sydney are empty of people and the shelves are emptying of toilet paper. Forget gold and bitcoin – when the apocalypse hits, the world currency will be toilet paper.

Patient zero felt the need to go on a current affairs show, with his face blurred, to deny that he was patient zero for our latest outbreak. A vaccine and mask-agnostic chauffeur, driving foreign airline crew to hotel quarantine, trying to blame someone who allegedly sneezed in a cafe for him getting COVID-19, then spreading it? Great television, but lacking science – like a lot in this pandemic.

I have bronchiectasis and have survived my two Oxford–AstraZeneca vaccine doses, so I’m feeling a little safer. Notwithstanding my vaccination status, the Royal Australian College of General Practitioners has, of today, said telehealth is preferred, but any face-to-face consultations must be in full personal protective equipment until the outbreak is over.

My Mandarin-speaking medical student translated the piece of paper found in the PPE pack as attesting to the highest quality of the PPE, and I think she’s right – that plastic PPE raises my core temperature a degree or two every time I wear it. I have complete confidence that nothing gets in and nothing gets out.

Eight-year-old Olivia knows nothing of these things. She is a prolific hand sanitiser user and mask wearer but, otherwise, more interested in what her mum promised to buy her in exchange for doing a blood test. We decided to do the blood test more for her nail dystrophy, concentration problems and subtle bags under her eyes than matters COVID-19 related.

In fact, Olivia’s teachers reported that she was almost always more interested in anything that her mum was going to buy her than anything her teacher had to say at school, particularly when it came to sport. Olivia had developed an aversion to sport because it almost always seemed to bring on diarrhoea. Her PE teachers put it down to nerves and tried to convince her that the only way to conquer her nerves was to confront them.

So, a blood test was in order. Olivia and her mum followed my parental advice sheet, and Olivia came in with her arms smothered in lidocaine cream and wrapped in plastic wrap to avoid evaporation.

This isn’t the most elegant solution, but you lose trust when you apply a patch instead. The glue on lidocaine patches is Olympic standard, and painfully ripping one of those things off, straight after you’ve told the child that it numbs their arm, means you have no chance of getting them to believe that the needle won’t hurt.

On the other hand, the plastic wrap just slides off, and the white, bleached skin on the cubital fossa reassures you that they won’t feel a thing. Just make sure you tell parents to pick the most prominent vein as a starting point, and that economising on the lidocaine cream is not a good long-term investment.

Olivia also scored one of our lollipops on her way out, and I felt like one myself when I got the results back. They revealed the following: ferritin level 15µg/L (normal range: 20–200µg/L), serum zinc level 9µmol/L (normal range: 10–18µmol/L), deamidated gliadin immunoglobulin A 43U/ ml (normal range: <15U/ml) and deamidated gliadin IgG 47U/ml (normal range: <15U/ml).

“Come to think of it, Olivia’s aunt on her dad’s side has coeliac disease,” said Olivia’s mum at the follow-up. This is useful information, of course, although it probably would have been more so had we obtained it before the blood test.

Olivia thought this diagnosis warranted another lollipop and said that she much preferred them to the sandwiches they gave out before sport at school. The coach had said that carbohydrate loading helps performance, but in Olivia’s case, it only gave her diarrhoea.

Fortunately, going gluten free is a lot easier these days than when Olivia’s aunt was first diagnosed. And looking at Olivia’s new-found energy in the surgery, I can’t wait to see her cross-country times come down!

Jonathan Bentley is a GP in Double Bay, Sydney, NSW

Details of this case study have been changed to protect patient confidentiality

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