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The role of medical history in the diagnostic process of unexplainable weight loss
  1. Antonio Mirijello,
  2. Maria Maddalena D’Errico,
  3. Stefano Notarangelo and
  4. Salvatore De Cosmo
  1. Department of Medical Sciences, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
  1. Correspondence to Dr Antonio Mirijello, antonio.mirijello{at}gmail.com

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Description

A 44-year-old man was admitted to our Internal Medicine Unit because of fatigue and weight loss (about 6 Kg in 10 months). Prior medical history included a personality disorder and polysubstance abuse (opioids, cannabis, benzodiazepines). The patient was being treated with methadone, diazepam and escitalopram.

Because of this symptomatology—fatigue and weight lossthe patient had already undergone several outpatient visits (psychiatric, neurological, nutritional) and a hospitalisation and discharged with a diagnosis of Helicobacter pylori infection, resolved.

At physical examination, the appearance was particularly thin (49 kg, body mass index 17.3 kg/m2). Vital signs, physical examination and lab test including thyroid function, vitamin B12, folates, iron, proteins, autoantibodies, anti-transglutaminase,  Venereal Disease Research Laboratory (VDRL) and Treponema Pallidum Haemagllutination Assay (TPHA) were normal. Complete blood count showed mild macrocytic anaemia (haemoglobin 12.4 g/dL, mean corpuscular volume 102 fl) and slight elevation of inflammatory indices (C-reactive protein 1.57 mg/dL; nv <0.290, erythrocyte sedimentation rate 27 mm; nv 2–15). ECG was normal. Chest X-ray (figure 1A) showed ‘pseudonodular image in the right apico-subclavicular region, which is connected with the ipsilateral hilum. In the absence of previous examinations, CT scan is required’. On the basis of this result, interferon-gamma release assay (Quantiferon) was performed, which resulted positive. Thus, the patient underwent lung CT scan documenting ‘the presence of coarse nodulations in the upper lobes of both lungs, with greater extension to the right, the greater of which on the right with axial diameters of 23×11 mm, formed by dense tissue, mostly with small contextual calcified nodules, some of which surrounded by spicules that penetrate into lung parenchyma and connected with the pleura’ (figure 1B–C). Although these findings could be nonspecific and related to a previous contact with mycobacterium tuberculosis (MTB), given the absence of a history of mycobacterial infection, and considering symptoms (persistent weight loss), they were considered suspicious for active tuberculosis. Bacteriological exam of the sputum was negative. Thus, bronchoscopy was performed: bacteriological exam for MTB was negative, PCR and, subsequently, cultural exam were positive for MTB complex. Anti-tubercular treatment was started with complete resolution of weight loss.

Figure 1

(A) Chest X-ray showing a pseudonodular image in the right apico-subclavicular region, connected with the ipsilateral hilum; (B–C) Chest CT scan showing coarse nodulations in the upper lobes of both lungs, formed by dense tissue, mostly with small contextual calcified nodules, some of which surrounded by spicules that penetrate into lung parenchyma and connected with the pleura.

Tuberculosis represents a re-emerging disease.1 Guidelines suggest to evaluate the presence of pulmonary tuberculosis in any patient presenting with cough of ≥2–3 weeks duration, with at least an additional symptom (ie, fever, night sweats, weight loss or haemoptysis), as well as in any patient at high risk for TB with an unexplained illness, including respiratory symptoms, of ≥2–3 weeks’ duration. Notably, patients with history of drug abuse (injection and non-injection) and weight >10% below ideal body weight should be considered at high risk for TB.2

Our patient, with a previous psychiatric diagnosis, presented with significant weight loss and a history of injective opioids and smoked cannabis. From a posteriori point of view, basing on anamnestic data, the patient should have been considered at high risk for TB. Moreover, tuberculosis outbreaks had been described in marijuana users,3 and psychiatric comorbidities represent a risk factor for delayed TB diagnosis.4

The present case, in the era of hyper-technological medicine, calls back physicians to the importance of medical history and physical examination to perform a correct diagnosis.

Learning points

  • Weight loss represents a common, nonspecific, symptom for Internal Medicine referral.

  • The diagnostic approach to unexplainable weight loss needs a careful evaluation of medical history and physical examination, in order to avoid unnecessary exams in the diagnostic workup.

References

Footnotes

  • Contributors AM and SN managed the patient. AM, MMD and SDC wrote the initial draft of the paper. All authors had full access, and revised and approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Obtained.

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