Worth a Second Look

A CLINICAL PROBLEM-SOLVING article by Tyler Berzin from Brigham and Women's Hospital, Boston.
A 72-year-old man presented to his primary care physician for evaluation of fatigue and weight loss. Over the prior 8 months, the patient had lost 16 kg from a baseline weight of 82 kg. During the same period, he began having up to 10 loose stools per day, which he described as voluminous and watery. The loose stools improved with fasting, and the urge to defecate did not awaken him from sleep. There was no history of blood in the stool, fever, chills, or rash.
The patient also reported a poor appetite, with early satiety and a reduced ability to taste foods.
On physical examination, the patient appeared thin and tired. The extremities were warm and well perfused, with 3+ soft, pitting edema of the legs bilaterally. The neurologic examination was notable for diminished sensation of pinprick and vibration in the distal lower extremities bilaterally as well as the absence of ankle reflexes.
The patient had deficiencies in iron, vitamin D, and zinc. Upper endoscopy revealed enlarged folds extending from the stomach to the beginning of the jejunum, with multiple nonbleeding erosions.
The patient preferred symptom management over additional diagnostic testing, and for the next several months, he was followed closely by a nutritionist and a gastroenterologist. His weight stabilized but did not increase, and his diarrhea improved only marginally. Follow-up evaluation by his gastroenterologist revealed new, patchy alopecia with depigmentation of the remaining scalp hairs, as well as onycholysis and yellow discoloration of his nails.[Original Article]