Case Study  


Celiac disease: is it compatible with a career in gymnastics? 


September 2016: first presentation to primary care 

Clara, a 24-year-old woman with a love for gymnastics, presented to her GP complaining of frequent facial flushing over the preceding 12 months. She noticed that over time, these flushing episodes had increased in frequency and seemed to be lasting longer. During late summer, the skin on her face had been feeling tight and itchy, and pus-filled pimples had developed.

Based on her symptom profile, Clara was diagnosed with rosacea. To reduce the risk of flare-ups, the GP proposed a management plan which involved avoidance of potential triggers, including:

  • Alcohol
  • Hot drinks
  • Caffeine 
  • Cheese
  • Spicy food
  • Aerobic exercise

October 2016: 3-week follow-up appointment

For 3 weeks, Clara avoided the potential triggers that her GP mentioned, which involved stopping her gymnastics training. However, she still had several flare-ups of rosacea and developed further symptoms, including diarrhea, fatigue, and weight loss. 




Due to Clara’s ongoing facial flushing and her new symptoms, the GP decided to request a range of blood tests to investigate other potential underlying pathologies, aside from rosacea: 

  • Vitamin D: low (15 nmol/L)
  • Vitamin B12: low (140 pg/mL)
  • Tissue transglutaminase (tTG) IgA: positive (52 U/mL, 5x ULN)
  • Total IgA: normal (1.8 g/L)
  • Specific IgE to a panel of food allergens: negative (<0.1 kAU/L)
  • Tryptase: mildly elevated (16 mcg/L)

Clara tested negative for food allergy but was deficient in vitamins D and B12, despite having a balanced diet including meat and fish. In light of the unexplained vitamin B12 deficiency, the GP decided to test for pernicious anemia with blood tests for antibodies against parietal cells and intrinsic factor, which later returned negative.

Unexplained iron, vitamin B12, or folate deficiency can be a sign of celiac disease.1




Refined Diagnosis

Following a repeat tTG IgA test (51 U/mL, 5x ULN), Clara’s GP had a high suspicion of celiac disease, based on her symptoms, unexplained vitamin B12 deficiency, and elevated tTG IgA. The GP referred her to a gastroenterologist who confirmed the diagnosis.

tTG IgA is the recommended first-line test for celiac disease, together with total IgA to check for IgA deficiency.2




Management Plan

  • Cholecalciferol (1,600 IU) for 6 months
  • Intramuscular hydroxocobalamin (1 mg) three times a week for 2 weeks
  • Gluten-free diet
  • 3-monthly follow-up to assess response to treatment, including tTG IgA level 

It is common practice for tTG IgA to be tested every 3 months, until normalized, and once a year as an indicator of diet adherence.2




January 2017: 3-month follow-up appointment 

After 3 months of strict adherence to a gluten-free diet, Clara’s rosacea and celiac disease symptoms had markedly improved. She no longer had troublesome diarrhea and had regained the weight she previously lost. However, despite Clara’s skin no longer feeling tight or itchy, she still had occasional bouts of facial flushing.

Clara told the GP that she now had much more energy and had been able to return to her gymnastics training; she felt that her quality of life had improved to near-normal.


Clara’s repeat blood test results:

  • Vitamin D: normal (70 nmol/L)
  • Vitamin B12: normal (350 pg/mL)
  • tTG IgA: falling (39 U/mL, 4x ULN)
  • Tryptase: still mildly elevated (15 mcg/L) 

Due to the elevated tryptase, Clara’s GP referred her to a specialist in mast cell disorders.

Early diagnosis and treatment of celiac disease with a gluten-free diet implemented in coordination with a dietitian, could:

  • Decrease the risk of some cancers,3 complications in type 1 diabetes,4 low birth weight of babies,3 and delayed puberty3,5
  • Improve bone mineral density (if diagnosed at a young age),3,6 dermatitis herpetiformis,7 condition of intestinal mucosa,7 anemia,5 and disease symptoms3,7
  • Resolve infertility,3,5,8 spontaneous abortions,3 and menstrual problems3





March 2017: 3-month follow-up appointment 

3 months later, after consultation with a specialist in mast cell disorders, it was revealed that Clara had hereditary alpha-tryptasemia syndrome. This explained the chronically elevated tryptase, and Clara’s trouble with persistent facial flushing.

Clara was still adhering to a strict gluten-free diet, and her tTG IgA level had dropped to 31 U/mL (3x ULN).


April 2020: 3 years later 

Clara’s tTG IgA level returned to normal in 2019, and she now had annual check-ups with the GP, to monitor diet adherence and symptoms associated with hereditary alpha-tryptasemia syndrome. 


Her bowel symptoms and fatigue had entirely resolved on a gluten-free diet, and she was enjoying national success as a gymnast. She decided to leave her full-time office job to pursue a career in gymnastics.

In April 2020, her younger brother was diagnosed with celiac disease at the age of 25 years, after living with intermittent abdominal pain and bloating for several years.

First-degree relatives have a 10 percent chance of developing celiac disease.

Screening for first-degree relatives, and case-finding in second-degree relatives, can help identify patients earlier, thus reducing the risk of complications.10,11





Do you routinely screen first-degree relatives for celiac disease?  

Yes No

This is a fictional case study, and the image used is of a model.
IgA: immunoglobulin A; IgE: immunoglobulin E; ULN: upper limit of normal

1. Halfdanarson T R, Litzow M R, Murray J A. Hematologic manifestations of celiac disease. Blood 2007;109(2):412-421

2. Al-Toma A, Volta U et al. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J 2019;7(5):583-613

3. Murch S, Jenkins H et al. Joint BSPGHAN and Coeliac UK guidelines for the diagnosis and management of coeliac disease in children. Arch Dis Child 2013;98(10):806-811

4. Elfström P, Sundström J, Ludvigsson J F. Systematic review with meta-analysis: associations between coeliac disease and type 1 diabetes. Aliment Pharmacol Ther 2014;40(10):1123-1132

5. Bozzola M, Meazza C, Villani A. Auxo-endocrinological approach to celiac children. Diseases 2015;3(2):111-121

6. Grace-Farfaglia P. Bones of contention: bone mineral density recovery in celiac disease--a systematic review. Nutrients 2015;7(5):3347-3369

7. Ciacci C, Ciclitira P et al. The gluten-free diet and its current application in coeliac disease and dermatitis herpetiformis. United European Gastroenterol J 2015;3(2):121-135

8. Shah S, Leffler D. Celiac disease: an underappreciated issue in women's health. Womens Health (Lond) 2010;6(5):753-766

9. Lewis D, Haridy J, Newnham E D. Testing for coeliac disease. Aust Prescr 2017;40(3):105-108

10. Bonamico M, Ferri M et al. Serologic and genetic markers of celiac disease: a sequential study in the screening of first degree relatives. J Pediatr Gastroenterol Nutr 2006;42(2):150-154

11. Singh P, Arora S et al. Risk of celiac disease in the first- and second-degree relatives of patients with celiac disease: a systematic review and meta-analysis. Am J Gastroenterol 2015;110(11):1539-1548