Weight Loss (Case 41)
Case: A 34-year-old woman with a history of HIV infection presents complaining of an unintentional weight loss of 20 pounds in 3 months despite an increased appetite. She also has been experiencing diaphoresis, heat intolerance, palpitations, fatigue, hair loss, and a gritty feeling in her eyes. Before 3 months ago her weight had been stable. She denies difficulty swallowing or breathing, mood changes, voice changes, or difficulty concentrating. She has noted that her menses are lighter than usual, but they are regular, occurring every 28 days without skipping months. She is compliant with her antiretroviral medications. She has a 15 pack-year history of smoking cigarettes, but denies alcohol or illicit drug use. She does not get any regular exercise.
Infection (e.g., HIV, tuberculosis)
Gastrointestinal causes (e.g., malabsorption, hepatitis)
Endocrine (e.g., uncontrolled diabetes, thyrotoxicosis)
Psychiatric (e.g. depression, anorexia, bulimia)
Cardiac (e.g., advanced heart failure)
Pulmonary (e.g., chronic obstructive pulmonary disease [COPD])
Substance abuse (e.g., opiates, cocaine, amphetamine, cannabinoids)
Heavy cigarette smoking
Medications (e.g., antidepressants, antiepileptics, exenatide, metformin, pramlintide, topiramate, digoxin, nonsteroidal anti-inflammatory drugs [NSAIDs])
Upon initially encountering a patient who reports weight loss, I first quantify the amount of weight lost over a specified time frame and determine whether this was intentional or unintentional weight loss. Clinically significant weight loss is defined as over 10 pounds or greater than 5% of body weight in 6 to 12 months. I like to know what kind of appetite the patient has. Causes of unintentional weight loss with an increased appetite usually involve either an underlying medical cause or a significant increase in rigorous exercise, leading to calorie loss despite increased appetite. Examples in this category include malabsorption, uncontrolled diabetes mellitus, and hyperthyroidism. I also like to find out if there is any history of cancer, if patients are up to date on their general medical screenings (e.g., Papanicolaou test, or PAP smear; mammogram; colonoscopy), and if there are gastrointestinal symptoms, fever, psychiatric symptoms, substance abuse or heavy smoking, rigorous exercise, medications, and chronic illnesses. As there is a broad differential diagnosis, the key is to narrow down the possible causes with a thorough history and physical exam.
• If the weight loss is intentional—as, for example in an obese patient (BMI > 30) who is now exercising and modifying the diet—then this patient should be encouraged and the weight loss is not concerning.
• If the patient is overly concerned about the weight loss and exhibits a distorted self-image, excessive exercise, decreased food consumption, laxative abuse, or induced vomiting, one should be concerned about psychiatric conditions such as anorexia nervosa or bulimia.
• I then want to know if appetite is increased or decreased. Since the majority of causes of weight loss are associated with decreased appetite, if the patient’s appetite is increased, this can help narrow down the potential underlying pathologies.
• When performing the abdominal exam, look for jaundice, ascites, hepatomegaly, or any abdominal pain or masses on palpation, as some of these findings can be seen in patients with hepatitis, colon cancer, or inflammatory bowel disease.