A female patient with rapid weight gain!

A 36 years of age female patient was brought to the hospital with rapid weight gain.

The patient is an unmarried female with a history of the polycystic ovarian syndrome (and menstrual irregularities).

She had been obese since teenage that resulted in depression and psychosocial issues like fatigue, somnolence, staying at home most of the times, and unable to get married.

A Rapid Weight Gain Of 32 Kgs …

She had a weight of 117 kgs (258 pounds) two weeks prior to presentation and was alright except for easy fatigability, mild edema, and exertional shortness of breath.

Her attendants reported that she has excessive snoring at night and has difficulty in concentrating on her tasks. She also has been noted to sleep while sitting during the day time.

Over the past two weeks, she gained 32 kgs (her weight increased from 117 Kgs to 149 kgs). She also noticed worsening shortness of breath and excessive body swelling.

The patient could not lie flat and she could not complete sentences due to the shortness of breath.

BMI of 62 Kg/m² and sPO2 of 69% …

On examination, She was 149 kgs with a BMI of 62 Kg/m².

She had a pulse of 120/minute, a respiratory rate of 28/minute, and a BP of 140/105 mmHg.

She had an oxygen saturation (as measured by the pulse oximeter) of 69% and had central cyanosis.

She had gross body swelling as evidenced by bilateral pitting edema up to the thighs, abdominal wall swelling with redness, and periorbital puffiness.

Breath sounds were reduced bilaterally and heart sounds were muffled.

The following investigations were advised to the patient …

• Blood CBC
• ALT, Urea, Creatinine, and Uric Acid
• Serum Albumin, serum proteins
• Urinalysis
• Electrocardiogram (ECG)
• Echocardiogram with Pulmonary arterial pressure
• Chest X-ray
• Polysomnography
• Thyroid function tests
• Arterial Blood Gases

Before discussing the reports, can you enumerate a few important causes of rapid weight gain?

Causes of rapid weight gain:

1. Fluid retention:

   • Fluid retention can lead to rapid weight gain in days. Fluid retention mostly affects patients who have any of the following disorders:
     1. Kidney disease
     2. Liver Cirrhosis
     3. Heart failure
     4. Malabsorption syndrome
     5. Malnutrition
   • All these conditions result in the accumulation of excessive fluid in the extracellular compartments of the body. Patients may notice legs swelling, periorbital swelling, ascites (fluid in the abdominal cavity), pleural effusion (fluid in the pleural cavity), or fluid accumulation in the subcutaneous tissues.
   • Rapid weight gain occurs in these patients after excessive intake of salt and water or skipping their medicines (diuretics)

2. Hypothyroidism:

   • Hypothyroidism can result in rapid weight gain via any of the following mechanisms:
     1. A slow basal metabolic rate resulting in underutilization of the excess calories. Excess nutrients are then stored in the body as fats.
     2. Excess fluid retention occurs via leaky blood vessels and entrapment of water in the extracellular compartment by the excess glycosaminoglycans.

3. Hypercortisolism:

   • Steroids can cause rapid weight gain. Excess steroid in the body is called Cushing’s syndrome. Most patients notice weight gain after they are started on steroid pills for some reasons by their physicians. Other than that steroids may be excessively produced by the adrenal gland or the pituitary gland.
   • Steroids cause salt and water retention and also cause the redistribution of fats in the body resulting in a physical appearance called “lemon on a matchstick appearance”. This appearance is described when the patients have thin limbs and truncal obesity.
     

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Reports of our patient …

Our patient had normal blood counts, liver and renal functions. She had a TSH slightly above the upper limits of normal (6.65 uIU/ml) with normal T4 and T3.

Her Echocardiogram was suggestive of severe pulmonary hypertension and right heart failure.

She had compensated respiratory acidosis with a pCo2 of 48 mmHg and bicarbonate of 34 mEq/l.

Sleep studies could not be performed.

The patient was labeled as a case of Pickwickian syndrome with obstructive sleep apnea resulting in severe pulmonary hypertension and cor-pulmonale.

She was started on diuretics, anticoagulants, endothelin receptor antagonist, and CPAP (continuous positive airway pressure) ventilation.

Her weight dropped from 149 to 141 kilograms in two weeks, oxygenation improved from 69% to 87% on room air, and her swelling decreased.

Consultation with a bariatric surgeon was requested who differed surgery for the time being since the patient was not stable.

(Note: Actual photos have not been attached since the patient was not willing)

Comments and critiques are welcome …