A middle-aged woman with nausea, weight loss, and orthostatic hypotension

Abstract

A 54-year-old, right-handed, Caucasian woman presented with intermittent nausea, vomiting, and orthostatic hypotension of 1 year duration. Following every meal, she would belch and vomit nonbloody undigested food. She reported constipation and fatigue and felt lightheaded and occasionally lost consciousness on standing. She denied visual changes, dysphagia, dysarthria, weakness, involuntary movement, or loss of urinary or fecal continence. She denied fever, chill, dysuria, diarrhea, or coughing. At one point, she was hospitalized for rehydration every 2 weeks. She had lost nearly 80 pounds over the prior year. She had a history of osteoarthritis with bilateral knee replacements. Her current medications were lansoprazole, midodrine hydrochloride, fludrocortisone acetate, and metoclopramide without significant relief. Her family history was remarkable for cancer and a brother had Down syndrome. She previously worked as a draftsman. She did not use tobacco or recreational drugs and rarely drank alcohol. General examination was significant for orthostasis. Supine blood pressure was 143/89 mm Hg with heart rate of 88 beats per minute. Upon standing, her blood pressure dropped to 63/44 mm Hg with heart rate increasing to 102 beats per minute. Mental status, language, and cranial nerve examination were normal. Sensation to vibration and pinprick was decreased distally in the lower extremities bilaterally. Light touch and temperature sensation were normal. Romberg sign was negative. Muscle strength and tone was normal in all extremities. Deep tendon reflexes were intact in biceps, triceps, brachioradialis, and patellar but absent at the Achilles. Plantar responses were flexor. Limb coordination was normal. She could stand without assistance for only under 1 minute before becoming lightheaded, requiring sitting. Extensive gastrointestinal workup at different hospitals including mesenteric lymph node biopsy led to the diagnosis of sclerosing mesenteritis. Treatment with prednisone provided only transient relief. Her endocrine evaluation did not reveal a cause for the orthostasis. Transthoracic …