A 41-year-old man comes to the office for follow-up after a recent upper gastrointestinal endoscopy and small-bowel biopsy for suspected celiac disease. He initially presented 6 weeks ago with diarrhea and weight loss. The patient has followed a gluten-free diet since then and has noticed significant improvement in his bowel symptoms. He has no other medical problems and has started taking a multivitamin daily. The patient does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal, and examination shows no abnormalities.
Laboratory results today show hemoglobin of 12.8 g/dL (11.0 g/dL 6 weeks ago) and mean corpuscular volume of 88 µm³. Small-bowel biopsy results are consistent with celiac disease.
Which of the following additional interventions is needed at this time?

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11ec193a_9801_43af_853d_2941782a780f_MD0002_00 Patients with celiac disease are at risk of developing nutritional deficiencies, neuropsychiatric illness (eg, peripheral neuropathy, headache, depression), and skin disorders (eg, dermatitis herpetiformis). In addition, although the pathogenesis is unknown, hyposplenism has been reported and is believed to be relatively common. Therefore, pneumococcal vaccination is recommended in patients with celiac disease, regardless of age. Most of the complications of celiac disease can be prevented by strict lifelong adherence to a gluten-free diet; however, nutritional deficiencies and bone loss (primarily due to vitamin D deficiency) should be screened for and treated appropriately. (Choice A) Although upper gastrointestinal endoscopy with small-bowel biopsy is necessary to confirm the diagnosis of celiac disease and exclude other potential etiologies (eg, intestinal lymphoma, bacterial overgrowth), colonoscopy does not have a role in establishing the diagnosis. In addition, celiac disease does not increase the risk of colorectal cancer. (Choice B) Although Helicobacter pylori infection can lead to a lymphocytic infiltration of the duodenum, as occurs in celiac disease, biopsy would frequently demonstrate the bacteria. In addition, given this patient's gluten responsiveness, no further evaluation for H pylori is necessary. (Choices C and D) Patients with celiac disease are not at increased risk for herpes zoster or hepatitis A; therefore, screening and vaccination guidelines for these conditions are similar to the general population. Herpes zoster vaccination is recommended for patients age ≥60. Hepatitis A vaccine is recommended for adult patients at increased risk of infection or complications, such as those with liver disease or who travel to endemic areas. Educational objective: Celiac disease is associated with hyposplenism; therefore, pneumococcal vaccination is recommended at the time of diagnosis, regardless of patient age. Other common complications of celiac disease include dermatitis herpetiformis and nutritional deficiencies leading to impaired bone metabolism and neuropathy. Strict adherence to a gluten-free diet can minimize or prevent many of these of complications. __________ References: Clinical management of coeliac disease. (http://www.ncbi.nlm.nih.gov/pubmed/21443532)

A 41-Year-Old Man Comes to the Office for Follow-Up After