deal with it the way he always dealt with things. With a charming smile and a little extra distance.
He looked through the files while he waited for Rosie to turn up.
‘Sorry, sorry,’ she said, rushing in. ‘I was held up this morning.’
‘You’re not late,’ he pointed out, though he was pleased that she didn’t seem quite so defensive with him today.
‘No, but...’ She flapped a dismissive hand. ‘Has anyone told you about today’s clinic?’
‘Kathleen said it was the allergy and immunology clinic, so I’m assuming some of these patients have been coming here for a while.’
‘They have,’ she confirmed.
‘Then at least they have some continuity with you,’ he said with a smile. ‘Are you happy to call our first patient in?’
Their first patient was an eighteen-month-old girl, Gemma Chandler. ‘The doctor asked me last time to keep a food diary with a symptom chart,’ her mother said.
‘May I see them, please?’ Leo asked.
She took it out of her bag and handed it to him; he read the document carefully. ‘So she tends to get tummy pain, wind and diarrhoea, and sometimes her tummy feels bloated to you.’
Mrs Chandler nodded. ‘And sometimes she’s come out in a rash on her face and it’s been itchy. It’s really hard to stop her scratching it.’
‘There are some lotions that help with the itch and last a bit longer than calamine lotion,’ Leo said. ‘I can write you a prescription for that. And you’ve done a really good job on the diary—I can see a very clear link between what she’s eating and her symptoms.’
‘It’s dairy, isn’t it?’ Mrs Chandler bit her lip. ‘I looked it up on the Internet.’
‘The Internet’s useful,’ Leo said, ‘but there are also a lot of scare stories out there and a lot of wrong information, so I’m glad you came to see us as well. Yes, I think it’s an allergy to dairy—more specifically lactose intolerance. What that means is that Gemma’s body doesn’t have enough of the enzyme lactase to deal with any lactose in the body—that’s the sugar in milk. What I think we need to do is try an exclusion diet for the next fortnight to confirm it. So that means I’d like you to check the labels for everything and make sure there’s no milk in anything she eats or drinks. If you can keep doing the food diary and symptom chart, we can review everything in a fortnight.’
‘We can give you some information leaflets about substitutes and vitamin supplements,’ Rosie said. ‘You can give Gemma rice milk instead of cow’s milk, and sunflower margarine instead of butter.’
‘Gemma’s meant to be going to her cousin’s birthday party, next week.’ Mrs Chandler sighed. ‘So that’s going to be difficult—she won’t be able to have any of the sandwiches or any of the cake, will she?’
‘You could do a special packed lunch for her,’ Rosie suggested. ‘And I’m sure if you tell your family and friends, they’ll help you work things out.’ She handed Mrs Chandler a leaflet. ‘Eating out with a toddler can be tricky enough, but having to take a food allergy into account can make it seem overwhelming.’
Was she talking from personal experience? Leo wondered. Or was it because she’d worked with so many patients in the allergy clinic? Not that he could ask without being intrusive, and he didn’t want to give Rosie any excuse to back away from him.
‘There are some good websites on the back of the leaflet for helping you to find places where they offer dairy-free options,’ Rosie said.
‘Thank you,’ Mrs Chandler said.
‘And we’ll see you and Gemma again in a fortnight to see how things are. If her symptoms are better,’ Leo said, ‘I’ll refer you to a dietitian so you can get proper support with a long-term exclusion diet. And in the meantime, if you have any questions or you’re worried about anything, give us a call.’
Mrs Chandler nodded. ‘Will she ever grow out of it? I’ve heard that some children do.’
‘We really can’t tell, right now,’ Leo admitted. ‘I think this is something we’ll need to take one step at a time.’
Once the Chandlers had gone, while Leo was writing up the case notes, Rosie got out the next patient’s notes. ‘Sammy Kennedy. He’s a sweetheart.’
‘What’s he seeing us about?’ Leo asked.
‘He has CAPS.’
Cryopyrin-Associate Periodic Syndrome. Leo knew it was an auto-inflammation disorder where the immune system was overactive and caused prolonged periods of inflammation, rather than the body producing antibodies against itself. ‘That’s rare,’ he said. ‘About one in a million. Actually, I’ve only seen one case before.’
‘Sammy’s my only case, too,’ she said. ‘Most patients with CAPS in the UK have Muckle-Wells Syndrome, and that’s the variant Sammy has.’
‘Tell me about him,’ Leo invited. Sure, he could read the file, but this way he got the chance to interact with Rosie. And he liked how quick her mind was.
‘He’s eight years old and he’s been coming here for nearly a year. He comes to clinic with his mum roughly every eight weeks. We check his knees and ankles and do bloods to measure the inflammation levels, and then we give him an injection of the drug that keeps his MWS under control,’ she explained.
‘That’s the drug that blocks interleukin 1β, yes?’ he checked.
‘Yes,’ she confirmed. ‘The treatment’s still new enough that we don’t know the long-term effects, but we’re hoping that it will stop more severe problems developing as he grows older.’
‘Such as deafness?’
‘Exactly,’ she said. ‘Are you ready to see him now?’
He nodded. ‘Absolutely.’
Rosie went out into the reception area and came back with Sammy and his mother.
Leo smiled at them. ‘Hello. I’m Dr Marchetti—you can call me Dr Leo, if you prefer. And you’re Sammy?’
The little boy nodded.
‘Tell me how you’re doing, Sammy,’ Leo invited.
‘Sometimes I have good days, and sometimes I get bad days,’ Sammy said, shrugging.
‘OK. What happens when you have a bad day?’
‘Mum says it’s a flare-up. It affects my tummy, my knees and my head. I get a rash, and it’s always at night.’ Sammy grimaced. ‘Show him, Mum.’
Mrs Kennedy took out her phone and showed them a picture of the nettle rash on Sammy’s stomach.
‘How often do you get flare-ups?’ Leo asked.
‘Every couple of weeks. But it’s not been so bad, lately.’
