History Of Unintentional Weight Loss Research Articles

Abstract #1409027: Paraneoplastic Hyperthyroidism

Non-seminomatous germ cell tumors producing human chorionic gonadotropin (HCG) were first described in 1964. HCG is capable of inducing hyperthyroidism by stimulating the TSH receptor, due to its identical alpha subunit. We report a case of HCG-mediated hyperthyroidism in the setting of a choriocarcinoma. A 28-year-old man presented with a 3-week history of unintentional weight loss, cough, hemoptysis, palpitations, shortness of breath, nausea and vomiting. Chest x-ray showed a large pleural effusion and multifocal nodular opacities on lungs measuring up to 4 cm. CT abdomen/pelvis showed a 1.4 cm left renal mass concerning for metastasis, and hepatomegaly. CT chest demonstrated a 16 cm heterogeneous enhancing mass in the mediastinum, a large pericardial effusion, moderate left pleural effusion and metastatic pulmonary nodules. Laboratory results showed elevated HCG of 947,825 mIU/mL, AFP 25 ng/ml, LDH 1,394 U/L, TSH 0.011 mcIU/mL, FT4 2.0 ng/dL, Ferritin 2680 ng/mL, CRP 118 mg/L. Testicular ultrasound was unremarkable. Biopsy of mediastinal mass was consistent with choriocarcinoma. Endocrinology was consulted for evaluation of abnormal thyroid function. He was tachycardic, without other overt symptoms of hyperthyroidism and no clinical findings of Graves’ Disease. TRAB, TSI, TPO antibodies were negative. Propylthiouracil (PTU) 100mg every 8 hours and low dose propranolol were started. Chemotherapy with Etoposide, Ifosfamide, and Cisplatin was initiated. Thyroid function improved 5 days after initiation of therapy. After 3 cycles of chemotherapy, his TSH and Free T4 levels normalized and the HCG level decreased to 1,521 mIU/mL. His most recent thyroid function tests were TSH 5.8 mcIU/ml and Free T4 level 1.1 ng/dL and the decision was made to stop PTU. HCG is a heterodimer with an alpha subunit identical to that of TSH, LH and FSH. High HCG levels can stimulate the TSH receptor and cause hyperthyroidism. Hyperthyroidism has been reported in trophoblastic tumors when HCG levels are >200,000 mIU/mL. Initiation of chemotherapy produces rapid decline in HCG levels and improvement of Free T4 levels. Diagnosis of paraneoplastic hyperthyroidism is challenging, as symptoms of hyperthyroidism may overlap with those of metastatic disease. Symptomatic patients should be started on thianomide and beta blocker which improve well-being and tolerance to chemotherapy. We illustrated the challenge of diagnosing hyperthyroidism in HCG-secreting choriocarcinoma and the importance of initiating chemotherapy and anti-thyroidal medication in symptomatic patients to improve outcomes.

S1787 Steroid-refractory IgG4-Related Disease Presenting as Sclerosing Cholangitis

Introduction: IgG4-related disease (IgG4-RD) is characterized by tumefactive infiltration of IgG4-bearing plasmablasts and other lymphocytes, along with storiform fibrosis, into one or multiple organs, with resultant organ enlargement, fibrosis, and dysfunction. Although initial reports of IgG4-RD concerned involvement of the pancreas, other organs such as the biliary tract can be involved. We present a case of steroid refractory IgG4- RD sclerosing cholangitis (IgG4-SC). Case Description/Methods: A 67-year-old man with hypertension presented with a 2-week history of unintentional weight loss, painless jaundice, and pruritus. Exam showed jaundice and scleral icterus. Laboratory revealed elevated liver tests with an obstructive pattern, with ALP, GGT, & Bilirubin of 431 U/L, 438 IU/L, 17.6mg/dL, respectively. MRCP, ERCP, and subsequent EUS demonstrated diffuse pancreatic parenchymal hypo-echogenicity, long segment strictures at the distal common bile duct with proximal duct dilation, dilated common hepatic duct, and multiple segmental intrahepatic biliary duct strictures. Biliary sphincterotomy and stent placement resolved symptoms. Biopsy of the Ampulla of Vater revealed chronic inflammation with ulceration. Further work-up uncovered an elevated serum IgG4 of 266 mg/dL with a negative ANA, SMA, AMA, and tumor markers. He was then diagnosed with IgG4-SC and completed a course of prednisone. Relapse of symptoms prompted a repeat ERCP which uncovered biliary tree pruning and irregularity, necessitating biliary stent replacement. Due to poor tolerance with rituximab infusion, he was treated with Mycophenolate Mofetil which accomplished a year of disease quiescence. Discussion: The prime gastrointestinal manifestations of IgG4-RD include type 1 Autoimmune Pancreatitis and less commonly, IgG4-SC. Management involves high dose steroids for 4 weeks with a slow taper over years to prevent permanent fibrosis. Patients are at highest risk of relapse during steroid taper or within 6 months of completion, with a relapse rate of 15-60%. Although our patient did not have the classic predictive factors of relapse, such as proximal strictures or serum IgG4 >280 mg/dL, he had a suboptimal response to steroids which prolonged his clinical course and exposed him to repeated procedures. There is still a need for further studies regarding the role for possible combination therapy (steroids & immunosuppressive therapy) to prevent relapse in high-risk individuals.

Invasive giant pituitary macroadenoma causing Cushing disease; a case report

Introduction: Cushing disease is a rare entity, and among them, giant pituitary adenomas causing Cushing disease is rarer. Here we present a case of Cushing disease secondary to a giant pituitary macroadenoma. Case report: A 41-year-old female with poorly controlled diabetes mellitus and hypertension diagnosed for six months presented with a history of unintentional weight loss, polyuria and polydipsia for the same duration. There was change in her facial appearance with increased pigmentation, frontal balding and she also noted increase in the size of her abdomen. There were features of proximal muscle weakness. Symptoms of hypothyroidism, hypoadrenalism or hyperprolactinemia were absent, and she was amenorrhoeic following hysterectomy done a year back. Visual impairment, headache, abdominal pain, features suggestive of internal malignancy, especially lung and renal, including features of pheochromocytoma were absent. She denied a family history of similar illness. Her BMI was 20.44 kg/m–2. She had a prominent abdomen, round facies, hirsutism, male pattern hair loss, facial plethora and generalized pigmentation and thinning of skin. She also had hypertension and proximal muscle weakness. Rest of the examination was normal. Investigations revealed hypokalaemia, poorly controlled hyperglycaemia and, non-suppressed overnight dexamethasone suppression test. She had a elevated ACTH level, and a high dose dexamethasone suppression test showed suppression. Pituitary imaging with MRI revealed a 51x 62x 41 mm size sellar and a para sellar mass with heterogeneous echogenicity extending to the right temporal lobe. Further imaging for ectopic ACTH secretion was negative.She underwent transcranial surgery which was unsuccessful due to intraoperative bleeding, and radiotherapy was given postoperatively. Conclusion: Cushing disease due to giant pituitary macroadenomas are rare and may require secondary therapeutic measures in controlling the disease in case of failed surgery.

S1724 Colonic Histoplasmosis: An Uncommon Presentation of Disseminated Histoplasmosis in an Immunocompetent Patient

INTRODUCTION: Histoplasmosis is an invasive mycosis caused by inhaling the spores formed by the environmental mold Histoplasma capsulatum. It occurs commonly in immunodeficient patients however, healthy hosts can be affected if a large number of conidia is inhaled. Here we present an intricate case of disseminated histoplasmosis in an immunocompetent patient. CASE DESCRIPTION/METHODS: An 83-year-old man with a history of coronary artery disease, atrial fibrillation, diabetes complicated by gastroparesis, and COPD who presented with a 6-month history of unintentional weight loss, normocytic anemia, abdominal crampings, and chronic non-bloody diarrhea. Previous studies included an upper endoscopy 9 years prior, showing hiatal hernia but otherwise normal with a negative H pylori test at that time. Colonoscopy 7 years prior evidencing internal hemorrhoids, diverticulosis, and one tubular adenoma in the ascending colon.He underwent extensive workup upon admission, including negative stool culture, ova and parasites, HIV screen, Giardia ELISA, and C. difficile PCR; normal C reactive protein, stool lactoferrin, TSH and celiac panel. Colonoscopy showed one 9 mm polyp in the ascending colon (Figure A), 1 polyp in the transverse colon, diverticulosis coli, and internal hemorrhoids. Biopsy of the ascending polyp revealed fragments of tubular adenoma and focally eroded colonic mucosa with mixed histiocytes-rich mucosal inflammation including intracellular organisms, favoring Histoplasma capsulatum (Figures B and C). Computed tomography (CT) abdomen showed 1.7 cm left adrenal nodule, concerning for disseminated infection. CT neck was performed for evaluation of jaw pain and swelling that showed parotitis and multiple brain lesions, confirmed by MRI. The diagnosis of disseminated histoplasmosis was confirmed with a positive urinary Histoplasma antigen. The patient was started on liposomal amphotericin B but given advanced age, multiple comorbidities, and progressive disease at the time of diagnosis, the patient opted for comfort care measures. DISCUSSION: Histoplasmosis is the most common endemic fungal disease in both healthy and immunocompromised patients with more than several thousand infections reported yearly. GI histoplasmosis is unusual in immunocompetent hosts accounting for 0.05% of cases however in 50% to 70% of cases, it occurs in disseminated form. We believe that early diagnosis and proper management prevents the progression of the disease and potentially death.Figure 1Figure 2Figure 3

A 17-Year-Old Girl With Weight Loss and Elevated Inflammatory Markers

A 17-year-old girl presented to her primary care physician with a history of unintentional weight loss and vague sensory symptoms, including tingling of her lower extremities. She had a nonrevealing neurology workup and a largely normal rheumatology workup apart from mild elevation in her inflammatory markers. She also had a nonfocal examination apart from a posterior cervical lymph node (2 × 1 cm). Given that she was well appearing, with a nonfocal examination and only mild laboratory abnormalities, she was told to follow-up with rheumatology in 3 months. Around that time, she re-presented to her medical home for a well-child visit, during which she was noted to have continued weight loss, now amounting to 17 lb in 1 year, and marked further elevation in her inflammatory markers. Her laboratory results were also significant for a profound microcytic anemia requiring inpatient admission for blood transfusion. During her admission, she was seen by the rheumatology, gastroenterology, and oncology subspecialty teams. Despite imaging studies and extensive laboratory workup, there was no unifying diagnosis at the time of her hospital discharge. Ultimately, an outpatient imaging study revealed the etiology.

Pulmonary Complication following Drug-Eluting Bead Hepatic Chemoembolization

A 70-year-old man with a history of essential hypertension presented to his gastroenterologist with a 6-month history of unintentional weight loss. After an unremarkable colonoscopy, a computed tomographic (CT) scan of the abdomen was performed demonstrating a 6.2-cm arterially enhancing hepatic mass with delayed washout and extension into the hepatic vein ([Fig. 1a], [b]). The patient was found to have no associated liver disease or serologic evidence of viral hepatitis. A biopsy of the mass was performed demonstrating poorly differentiated hepatocellular carcinoma (HCC), and the patient was referred to interventional radiology for locoregional therapy. Prior to liver-directed therapy, imaging demonstrated a small pleural effusion felt to be related to venous invasion and narrowing of inferior vena cava (IVC). The drug-eluting beads transarterial chemoembolization (DEB-TACE) was performed with 100- to 300-µm drug-eluting beads loaded with 75 mg of doxorubicin (LC Beads, BTG, West Conshohocken, PA) followed by 300 to 500 µm “bland” particle (Embosphere; Merit Medical, Salt Lake City, UT) embolization. An angiographic endpoint of 5-beat stasis was reported. No angiographic images were stored demonstrating arteriovenous shunting; however, in retrospect, shunting could have been suspected based on attenuation of caval blood surrounding the tumor on arterial phase imaging on both CT and angiography ([Fig. 1c], [d]). Approximately 48 hours after discharge, the patient presented to his primary care physician with fevers and mild dyspnea. This was attributed to an increased right pleural effusion following DEB-TACE, which was managed conservatively without thoracentesis. The patient's oxygen saturation was incidentally noted to be decreased at 92%; however, patient was judged not to be symptomatic enough to require treatment and as such was discharged from medical care with instructions to follow up if symptoms worsened. The patient improved over the course of the next month, but follow-up imaging demonstrated a minimal response of the treated HCC. After discussion with the patient, repeat DEB-TACE was performed.

Analysis of the practice and the reasons for under documentation of body mass index and unintentional weight loss in adult hospitalized patients in Indian set up

Background: The present study analyzed the practice of documentation of BMI and history of unintentional weight loss in adult hospitalized patients on admission by the health care staff and the causes for their under documentation. Methods: A cross-sectional study was conducted among 600 healthcare workers, 150 duty medical officers and 450 nurses attending to adult hospitalized patients in both public and private hospitals of Lucknow, U.P., India and nearby districts. Information was collected on the basis of a self-administered questionnaire, on the practice of recording of weight, height, BMI and history of unintentional weight loss in past three months in patient records and also for the reasons for the under-documentation. Results: Only 54.16% of the staff admitted documenting BMI of the patients regularly in their case notes. Similarly, only 60% of the staff documented history of unintentional weight loss in past three months in patient case notes. Documentation was omitted more by nurses as compared to medical officers. The main reasons for under-documentation were work overload and time constraints, lack of training, confusion regarding responsibility and mistaken opinion for malnutrition screening. Conclusions: BMI and weight loss are often not recorded by health staff, more so by nurses. They need to be provided sufficient time to perform nutritional assessment of patient; moreover we should make them competent and delineate roles to them as well as develop a nutrition culture in our health facilities.

Hepato-bronchial fistula secondary to perforated sigmoid diverticulitis: a case report

BackgroundPatients with diverticulitis are predisposed to hepatic abscesses via seeding through the portal circulation. Hepatic abscesses are well-documented sequelae of diverticulitis, however instances of progression to hepato-bronchial fistulization are rare. We present a case of diverticulitis associated with hepatic abscess leading to hepato-bronchial fistulization, which represents a novel disease course not yet reported in the literature.Case PresentationA 61-year-old Caucasian man presented with a history of unintentional weight loss and dyspnea both at rest and with exertion. He had a significant tobacco and alcohol misuse history. A massive right-sided pleural effusion was found on chest X-ray, which responded partially to chest tube insertion. A computed tomography scan of his thorax confirmed the presence of innumerable lung abscesses as well as a complex pleural effusion. An indeterminate tiny air pocket at the dome of the liver was also noted. A follow-up computed tomography scan of his abdomen revealed a decompressed hepatic abscess extending into the right pleural space and the right lower lobe. A sigmoid-rectal fistula was also revealed with focal colonic thickening, presumed to be the sequelae of remote or chronic diverticulitis. An interventional radiologist inserted a percutaneous drain into the decompressed hepatic abscess and the instillation of contrast revealed immediate filling of the right pleural space, lung parenchyma, and bronchial tree, confirming a hepato-bronchial fistula. After two concurrent chest tube insertions failed to drain the remaining pleural effusion completely, surgical lung decortication was conducted. Markedly thickened pleura were seen and a significant amount of gelatinous inflammatory material was debrided from the lower thoracic cavity. He recovered well and was discharged 10 days post-thoracotomy on oral antibiotics. The percutaneous liver abscess tube was removed 3 weeks post-discharge from hospital after the drain check revealed that the fistula and abscess had entirely resolved.ConclusionsRefractory right-sided pleural effusion combined with constitutional symptoms should alert clinicians to search for possible hepatic abscess, especially in the context of diverticulitis. The rupture of an untreated hepatic abscess could lead to death from profound sepsis or rarely, as in this case, a hepato-bronchial fistula. Timely investigation and a multidisciplinary treatment approach can lead to improved patient outcomes.

Outcome of preoperative weight loss in colorectal surgery

BackgroundThere are limited data regarding the outcomes of patients with preoperative weight loss. We sought to identify complications associated with preoperative weight loss in colorectal surgery. MethodsThe National Surgical Quality Improvement Program database was used to examine the clinical data of patients undergoing colorectal resection from 2005 to 2012 who had unintentional preoperative weight loss (more than 10% in 6 months of surgery). Multivariate analysis was performed to quantify the association of weight loss with postoperative complications. ResultsWe sampled a total of 79,696 patients who were admitted nonemergently for colorectal resection. The rate of preoperative unintentional weight loss was 3%. There were associations between preoperative weight loss with preoperative hypoalbuminemia (serum albumin level < 3.5 g/dL) (adjusted odds ratio [AOR] 2.58, P < .01). Postoperative mortality (AOR 1.74, P < .01) and complications of myocardial infarction (AOR 1.97, P = .03) and ventilator dependency (AOR 1.54, P = .03) had strong associations with weight loss. ConclusionsA history of unintentional weight loss can be used to predict mortality and morbidity rates and as a marker for nutritional assessment in colorectal surgery. Cardiopulmonary complications have significant association with preoperative weight loss.

Unintentional Weight Loss Predicts Decline in Activities of Daily Living Function and Life-Space Mobility Over 4 Years Among Community-Dwelling Older Adults

The relationship between body mass index (BMI), weight loss, and changes in activities of daily living (ADL) function and mobility in older adults is not clear. We sought to study the relationship between BMI and weight loss on the rate of decline in ADL function and life-space mobility over a 4-year period among older African Americans and whites. The participants were 983 enrollees in the University of Alabama at Birmingham (UAB) Study of Aging, a longitudinal study of mobility among community-dwelling older adults stratified to achieve a balanced sample in terms of sex, race, and residence. Primary outcome measures were changes in ADL function and mobility assessed by the UAB Study of Aging Life-Space Assessment (LSA) which were measured every 6 months. Relative to normal weight participants, those with BMI levels in the obese range did not show more rapid ADL functional decline, but a history of unintentional weight loss predicted more rapid decline. Relative to normal-weight participants, other BMI categories were not associated with more rapid decline in LSA scores. However, unintentional weight loss predicted more rapid declines in LSA. Intentional weight loss had no relation to ADL function or LSA decline. In this population of community-dwelling older African Americans and whites, neither BMI nor intentional weight loss had an association with rate of functional decline. Unintentional weight loss had a negative relation with rate of functional decline, regardless of baseline BMI. Whether this is causal remains to be determined.

Detection of Patients at Increased Risk of Pancreatic Cancer Utilizing Electronic Databases

Purpose: Pancreatic cancer is the four and fifth most common cancer in men and women respectively and has the lowest five-year survival rate of any cancer. Surgical resection offers the only hope for cure; however 52% of patients have stage IV disease at the time of diagnosis. The current problem is there are no means to identify patients who are at risk of developing pancreatic cancer at an early resectable stage. We hypothesize that there may be certain risk factors which predispose patients for pancreatic cancer. If a combination of these factors could be determined then screening exams could be offered to these patients with endoscopic ultrasonography. Methods: A retrospective review of our tumor registry was used to identify 638 patients with pancreatic cancer diagnosed between the years of 1995–2005. Patients that were referred from an outside institution or not routinely followed at Scott & White were excluded. The remaining 397 patients had their electronic medical records reviewed to determine if the incidence of certain factors or combination of factors portend a higher risk of pancreatic cancer. The factors reviewed included: the presence of an elevated amylase or lipase, new onset diabetes, chronic pancreatitis, family history of pancreatic cancer, history of unintentional weight loss, and abnormal pancreatic radiographic imaging. In addition, we also reviewed the same criteria of age/sex matched controls seen at the GI clinic during this same period. Results: Multiple factors on univariate analysis including elevated amylase and lipase, family history of pancreatic cancer, alcohol use, elevated CEA, new onset diabetes as well as use of diabetic medications are present more commonly in patients with pancreatic cancer as compared to their age/sex matched controls. Multivariate analysis revealed family history of pancreatitis, use of diabetic medications, and history of weight loss or abdominal pain were significantly increased in pancreatic cancer patients versus controls. Conclusion: Conclusions: Our results indicate a combination of the above factors are more common in patients with pancreatic cancer. Patients with these risk factors should be identified while asymptomatic and offered a screening exam, either with CT scan or endoscopic ultrasound depending on local expertise, to find potentially resectable pancreatic cancers.

Prevalence of malnutrition on admission to four hospitals in England

Aims: The primary objective was to estimate prevalence of malnutrition on admission to four hospitals. Secondary objectives included assessing the relationship between nutritional status and length of hospital stay, numbers of new prescriptions, new infections and disease severity.Methods: We entered eligible patients according to predefined quotas for elective and emergency admissions to 23 specialities. We measured height, weight, Body Mass Index and anthropometrics, and recorded history of unintentional weight loss. Patients who had lost ≧10% of their body weight, had a Body Mass Index ⪡20, or had a Body Mass Index ⪡20 with one anthropometric measurement ⪡15th centile were considered malnourished.Results: Of 1611 eligible patients, 761 did not participate; 269 were too ill; 256 could not be weighed; and 236 refused consent. Eight hundred and fifty were subsequently evaluated. Prevalence of malnutrition on admission was 20%. Length of stay, new prescriptions and infections and disease severity were significantly higher in the malnourished.Conclusions: One patient in every five admitted to hospital is malnourished. Although this figure is unacceptably high, it may underestimate true prevalence. Malnutrition was associated with increased length of stay, new prescriptions and infections. Malnutrition may also have contributed to disease severity.