My husband has been feeling very unwell. He is having nausea and dry retching in the morning, loss of appetite, weight loss, and muscle loss. His blood work shows elevated ferritin of 537 and low sodium of 132.
He has had a normal colonoscopy, endoscopy, abdominal ultrasound, and CT scan. I have attached all the reports for your reference. He takes Synthroid 75 mcg, but thyroid levels appeared normal.
Increased serum ferritin (attachment removed to protect patient identity) is usually a sign of chronic inflammation. Here the symptoms of nausea, loss of appetite and morning symptoms indicate possible gastric cause.
Chronic gastritis associated with mild esophagitis could be the cause. It is difficult to explain with a normal endoscopy.
Weight loss and muscle loss is additionally due to reduced intake secondary to the symptoms of nausea and loss of appetite.
Reduced calorie intake will make the body use the muscle proteins as energy, hence resulting in muscle loss and weight loss. This reduced intake has also affected his sodium levels too.
If his thyroid hormone levels are normal now after taking Synthroid (Levothyroxine), then Synthroid is working. If they are abnormal now and TSH is low and T3, T4 is high, then Synthroid dose needs reduction. I would like to know these levels to comment further.
Low thyroid hormone levels can cause few of the mentioned symptoms, so do check it.
As Propecia (Finasteride) is discontinued, I do not expect it to have affected in any way.
At present, I am strongly thinking of chronic inflammation possibly in stomach or esophagus. Gastric acidity control is necessary. As Omeprazole is recently started, it will take another two to three weeks for it to completely control the acidity and to notice any improvement.
Also, additionally he will need a regular diet for at least four to six times per day and on same time it may take a week or two to regularize. You need to avoid spicy or sour type of foods.
Diet should be protein rich. Increased hydration for at least 25 to 33 cups of water per day is also essential along with moderate physical activity.
Need to reduce stress, as it will affect acidity severely. Meditation and counseling will be necessary. Also, sleep should be regular and minimum eight to nine hours at night.
Do get his blood workup done to identify the level of malnutrition as reduction in hemoglobin levels will cause further weakness.
Reduced WBC (white blood count) can increase the risk of infection. Also, do get an erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels done to identify the amount of inflammation. If they are elevated, further evaluation will be necessary.
Do get a stool examination done to rule out any malabsorption or parasitic infection in gut. Hopefully, his blood sugar is normal.
Most importantly check the thyroid levels and improve the nutrition. You need to reduce acidity.
As all signs are pointing towards chronic inflammation, possibly acidity in stomach and esophagus. Even though endoscopy is negative, you need to continue on Omeprazole 20 mg twice daily. If necessary, Domperidone can be taken to reduce nausea feeling and also vomiting.
1. Omeprazole, if necessary you can have Domperidone.
2. Diet and lifestyle modification to reduce acidity in stomach is essential.
Regarding follow up:
Revert back with the investigation results to a hematologist.
Thank you so much for taking time to explain and give your advice and knowledge. His thyroid levels appear normal but maybe not the best level for him? T4 is 1.07 (ref range 0.58-1.64), TSH is 0.89 (0.4-3.0), T3 is 138 (87-178).
The GI doctor did note mild inflammation but no other findings. The only other thing of note is his testosterone has always been low (200-300). So it is hard to tell if this is a thyroid hormone issue or chronic inflammation.
Would something like Crohn's disease have showed on endoscopy?
I went through the values attached. Based on given laboratory values and query, my opinion is as follows:
The thyroid hormone levels are all in normal range. This means Synthroid is necessary. If it is within the normal range, then it should not be a problem.
As the TSH and T4 levels are good, I would think the thyroid hormone levels are good and not worry about it further.
For the testosterone, numerous variations are seen. As the muscle mass and energy was good before the present onset of symptoms, I would not look much into it.
If there is any infertility or impotence issue then he might require exogenous testosterone. His values are near the lower limit of normal and in few individuals it is normal.
However, everything depends on symptoms, before deciding, whether it is low or adequate. If necessary, exogenous testosterone can be started, based on symptoms and after discussion with your doctor.
Mild inflammation could be the cause and hence you need to continue him on Omeprazole and also make diet and lifestyle changes.
Yes, Crohn's disease would have been identified on endoscopy. Most of the symptoms presently are fitting for upper gastrointestinal tract (GIT) and Crohn's suspicion should be less. If the symptoms persist, then biopsy from any inflammation (if still present after therapy) to look for any signs of Crohn's.
If Crohn's is involving the upper GIT (based on inflammation suspicion), then he would have had more signs in the lower GIT first and oral lesions are also more frequent. I strongly would not think of Crohn's at this point of time and think of it only as chronic gastritis due to acidity.
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