34 year old female, BW loss 10 kg to 45 kg the last weeks before
hemithyreoidectomi (claimed difficulty in swallowing) because of
a follicular adenoma (BMI 16). Preop.hypokalemia (K=2-3 mmol/l).
Later also low Zinc, low Erythr.folic acid and low Ferritin. Thorough
examination of endocrine status, kidney function, g-i absorption neg.
No indication of Bartter syndrome or use of laxatives. No proof of
anorexia. Later generalised prurigo nodularis. Fatigue, coldness,
increased demand of sleep. In periods moderately increased liver
enzymes, neg. Hepatitis serology.

Substituted with Potassium, Zinc and Folic acid without change in
symptoms.

Is this a known clinical syndrome ?

--
Thanks for any help. Arild

X.400: G=arild;S=ellingsen;O=hda;P=hydro;A=telemax;C=no

                                          Steve Harris, M.D.

IMHO a good doctor - scratching his head or not - would be a little bit
more cautious with such quick diagnoses without knowing the patient at
all and having very little information about him.
Making a diagnosis of anorexia on the grounds of refusing a nasogastric
tube is ... well, let's respect net policy rules here.
By the way - they are mostly NOT fools down there in Norway.

Gruss
Dietrich

   By the way, letting patients starve is not a matter of intelligence
or not, but rather a matter of sensitivity.  I've seen some very smart
doctors do it.  The skeleton in the hospital closet is often the
patient, a fact which has been known for years, and hasn't changed a
great deal.  Even, I have no doubt, in Norway.

                                                Steve Harris, M.D.

If the shoe doesn't fit you, don't worry, I know it fits many readers
of this thread.

--

   They did try to do it to my own father once (after a ICU admission
for multiple trauma) while I watched, but I made such a fuss that they
relented.  Helps to have a doc in the family.  He, for whatever
reasons, survived.  

 > Did you

   And yes (in case you're wondering), I'm a licensed M.D. (in two
states now-- groan), board-certified in medicine and geriatrics, and
have so far never been sued or subjected to disciplinary action of any
kind.  Not that I think this is some kind of guarantee-- I just thought
you'd like to know.

                                        Steve Harris, M.D.

An interesting case, 6 "replies" and only 1 tenable diagnosis
offered to the patient's brother... ('nuf said)

        Anorexia nervosa would account for this clinical
picture.  This patient is a little older than most of the cases
I've seen but I would not exclude a. nervosa on account of being 34
years of age.

        We don't have the benefit of a good history and physical
exam.  Nor do we know exactly what has been done to date but I'd
like to offer coeliac sprue as a differential diagnosis.  Crohn's
disease would also be a consideration.  (The skin condition and
reference to elevated liver enzymes is nudging me toward inflammatory
diseases).

        Confronted with this scenario, I'd like to see calorie
counts and have a pathologist take another look at the small
bowel biospies which I suspect would have been done in Norway.

Regards,

J.P. Schaefer

                           Steve Harris, M.D.

:    Whatever it is, her doctors are letting her starve to death.  I
: suggest you get her nutrition by nasogastric tube (if necessary) until
: you figure out what is wrong. ***Do not let patients starve while
: doctors scratch their heads***   This is the first rule of medicine
: (and more than occasionally forgotten by surgeons).  If she refuses the
: NG tube, your diagnosis has been made: anorexia.  The "proof" of
: anorexia is in the behavior-- there aren't any medical tests for it.
: Although all the signs of malnutrition which you've noted (low K, low
: ferritin, low body weight, "problems" swallowing, etc, etc) are all
: suggestive.

:                                           Steve Harris, M.D.

From a patient's persceptive, I was in a similiar situation 6 years ago,
with 35lb weight loss (normal weight 106), while several doctors
scratched their heads, I continued to lose weight. Finally an excellent
internal specialist - took my husband aside and said to him "I don't know
what is wrong with your wife and at this point my main concern is
stopping the weight loss, put me on Ensure Plus and continued to run
tests, stopped antibotic therapy. We found out later that our well water
was "not fit for human consumption - Ecoli). I keep saying to the doctors
- Look at me - an losing too much weight and I can't afford to lose
anymore! They just continued to say I was nuts, anorexic, etc,etc. I
thank my lucky stars for the excellent internal specialist who had the
common sense to address the weight loss. I went home, ate, and increased
my caloric intake to almost 4000 per day. All futher testing at that time
came back normal. I did not see a doc for 5 years after that. And when
symptoms returned, including "TMJ" and numbness I quickly got a referral
to a neuroligst in the US, and MS dx was confirmed in 2 days.  
Many dx were forwarded during the previous experience: the Yuppy Flu,
depression (I was - I felt sick and looked like a bag of bones!) TMJ,
anoxeric, stress, post-partum depression, etc. etc.

I second Dr. Harris's statement that while docs stratch there heads -
address the weight loss, but what ever means necessary. I continue to
supplement my diet with Ensure Plus, especially when my MS symptoms
worsen, and remain at a heathly (for me) 108lbs. (Just a little person!)

KMayson
--

Due to a server problem at the end of last week, my system manager
told me that I have lost an email. She can only figure out part
of the address (netaccess.on.ca) and nothing from the message.
Please email me again.

--
Thanks again. Arild Ellingsen, Oslo, Norway

X.400: G=arild;S=ellingsen;O=hda;P=hydro;A=telemax;C=no