So Much More than Bald and Bloated

A 44-year-old previously healthy semiprofessional male athlete presented with five days of nausea, vomiting, and abdominal pain. He had also experienced several months of decreased energy and new episodes of constipation three weeks prior to presentation.

At this point, we do not have sufficient information to completely determine the cause of his abdominal symptoms. Common causes of abdominal pain and vomiting in adults of his age group include peptic ulcer disease, pancreatic or hepatobiliary track disorders, small or large bowel processes, appendicitis, or even renal pathology. Further characterization may be possible by describing the location and quality of pain and factors that might relieve or exacerbate his pain. Despite the ambiguity, multiple clues might allow us to narrow the broad differential diagnosis of abdominal pain. In a previously healthy, vigorous, middle-aged man with subacute abdominal pain associated with constipation, the differential diagnosis should include disease states that may cause a bowel obstruction; these states include inflammatory bowel disease (IBD), gastrointestinal malignancy, or peptic ulcer disease. Mechanical obstruction due to volvulus or intussusception would be less likely in his age group. Given his history of several months of fatigue and several weeks of constipation, he should be evaluated for metabolic causes of abdominal pain and constipation, such as hypothyroidism or hypercalcemia. In addition to basic laboratory and imaging studies, obtaining additional history regarding prior abdominal surgeries, medication use, alcohol intake, and family and travel history will be the key in directing the evaluation.

Six months prior to admission, the patient began to feel more fatigue and exercise intolerance, reduced sweating, increased cold intolerance, and increased presyncopal episodes. He was diagnosed with hypothyroidism (TSH 6.69 μIU/mL; free T4 not done) and initiated on levothyroxine. One month prior to presentation, he developed constipation, loss of taste, reduced appetite, and weight loss of 30 pounds. He developed blurry vision and photophobia. He also complained of erectile dysfunction, urinary hesitancy and straining, which were diagnosed as benign prostatic hypertrophy.

Given the addition of numerous historical features in a previously healthy man, it is important to strive for a parsimonious diagnosis to unify his seemingly disparate features. His fatigue, constipation, and cold intolerance are consistent with his diagnosis of hypothyroidism but are nonspecific. Whether the degree of hypothyroidism caused his symptoms or signs is doubtful. The constellation of symptoms and signs are more likely to be representative of a nonthyroidal illness. His abdominal pain, unexplained weight loss, and presyncopal episodes should raise consideration of adrenal insufficiency. The combination of hypothyroidism and adrenal insufficiency suggest the possibility of an autoimmune polyendocrine syndrome or other pituitary pathology. In this case, history of headache, dysgeusia, and visual disturbances might support the diagnosis of pituitary adenoma. A cosyntropin stimulation test could establish the diagnosis of adrenal insufficiency. A low ACTH level would establish a diagnosis of pituitary or hypothalamic hypofunction. If pituitary hypofunction is documented, then a brain MRI would be needed to confirm the diagnosis of pituitary adenoma.