Case 1

A 21 year old English woman, whose parents had emigrated from Pakistan, presented to an accident and emergency department with fatigue and a painful, swollen leg. A venogram was negative. Investigations showed iron deficiency anaemia (haemoglobin 87 g/l, mean cell volume 69 fl), and she was treated with ferrous sulphate. She continued to have pains in the wrist and knee. She was not a vegetarian and ate a balanced diet that included fewer than three pieces of unleavened bread a week. She worked full time outside the home and wore dress that did not shade her face or always cover her arms. Serum levels of calcium (2.38 mmol/l), phosphate (0.91 mmol/l), and alkaline phosphatase (160 IU/l) were in the normal range, but a 25-hydroxycholecalciferol level was 6 µg/l (reference range 7-50). At a hospital outpatient clinic “Asian osteomalacia” was diagnosed. She was discharged to the Jericho Health Centre in Oxford with the recommendation to prescribe ergocalciferol and calcium.

Her pains improved, but she continued to complain of fatigue and developed a new problem of frequent loose stools. She was referred to a gastroenterologist, and a duodenal biopsy showed partial villous atrophy, consistent with coeliac disease.

Case 2

A 67 year old widow had emigrated from Pakistan to England 13 years …