A 19-Year-Old Man With Life-Threatening Obesity

Shahida Badsha, MBBS, FCPS, MCPS


April 09, 2018

Physical Examination and Workup 

Upon physical examination, the patient appears uncomfortable (Figure 2). He speaks very little, and his answers are appropriate but in monosyllables.

Figure 2.

He has gross, generalized obesity with no obvious differential fat distribution on the face, trunk, or limbs. His eyes may be considered almond-shaped, and he has a fullness in the forehead region and in the cheeks, giving a pear-shaped appearance. His mouth is somewhat fish-shaped, with a thin upper lip. He is alert, well-oriented, and communicative, although he seemingly resents doing so and replies in muffled monosyllables or by nodding. His hearing and vision are within normal limits.

His weight is 192 lb (87 kg), which puts him in the 90th percentile, and his height is 51.2 inches (130 cm), which puts him below the fifth percentile. His body mass index (BMI) is 51.5 kg/m2. His occipitofrontal head circumference (OFC) is 22 inches (56 cm). His blood pressure is 100/80 mm Hg. Taking his blood pressure required the largest available cuff. Although it is 100/80 mm Hg at presentation, a consultation note from another doctor recorded it as 183/109 mm Hg. A separate note from a different visit shows a blood pressure of 112/68 mm Hg in an outpatient setting. His pulse is regular at 80 beats/min. His respiration is audible, although not noisy, with 18-20 breaths/min. He cannot lie down on a couch due to the concern of respiratory distress from airway obstruction.

He has a plethoric face (Figure 2) and a low frontal hairline. No facial, axillary, or pubic hair is seen. He has some carious teeth; otherwise, the oral cavity and tongue are normal. No goiter is appreciated. Heart sounds and chest auscultation findings are normal. His liver and spleen cannot be satisfactorily palpated. However, liver function test results were reportedly normal on several occasions. CT scan and ultrasonography findings of the abdomen reveal the liver to be normal. Grossly examined, cranial nerves and sensations are intact. Tendon reflexes can be elicited, and plantars are downgoing. He has small hands and feet. A single transverse palmar crease is noted on the right hand.

Due to suprapubic fat, his external genitalia are difficult to observe. Palpation of the scrotum for testes is not permitted. His skin is erythematous, dry, and scaly. No pitting edema is noted. He has numerous ulcerative lesions scattered over the lower half of his body (Figure 3).

Figure 3.

Some ulcers are reported as painless, and some are reported as painful. His hands and feet are small, and his nails are discolored (Figures 4-6).

Figure 4.

Figure 5.

Figure 6.

Laboratory studies including complete blood count, peripheral smear, sodium, potassium level, blood urea nitrogen level, calcium level, creatinine level, alanine aminotransferase level, aspartate aminotransferase level, bilirubin level, phosphate level, and alkaline phosphatase level are all within normal limits.

Urinalysis reveals normal specific gravity, with no protein, glucose, or red or white cells. His fasting blood glucose level is 7.2 mmol/L, and his postprandial blood glucose level is 8.1 mmol/L. The postprandial glucose level was tested 90 minutes after breakfast.

MRI of the brain is performed to investigate the hypothalamic-hypophyseal axis as a cause of obesity and short stature. The MRI reveals mild cerebral atrophy. High-resolution CT scanning of the chest, abdomen, and pelvis are performed to investigate for a hormone-secreting tumor and reveal normal findings. An x-ray of the dorsal spine is unremarkable. His bone age assessed at age 14 years was reportedly delayed to 8-9 years. Skin biopsy reveals nonspecific dermatitis.

Hormonal studies reveal the following:

  • Serum cortisol (M) level, <50 nmol/L

  • Serum cortisol (E) level, <20 nmol/L

  • Urinary free cortisol level, 58 nmol/24 h

  • Thyroid-stimulating hormone level, 1.63 mIU/L

  • Free T4 level, 13.5 pmol/L

  • Adrenocorticotropic hormone (ACTH) level, 3.2 pmol/L

  • Fasting growth hormone level, 2.5 ng/mL


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