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

Shahida Badsha, MBBS, FCPS, MCPS

Disclosures

April 09, 2018

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 19-year-old man is transported by wheelchair to a clinic by his older brother due to difficulty with ambulation. His chief complaints are morbid obesity and oozing skin ulcers. The patient was born to consanguineous parents and had a normal, full-term delivery in the hospital, with no antenatal or perinatal complications. His birth weight was reportedly average, and he had no apparent dysmorphic features. When he was circumcised, the small size of his penis was documented. No absence of testis was documented at this time, despite the noted micropenis.

The mother reported an uneventful full-term pregnancy and delivery with no history of decreased fetal movements. He was initially exclusively breastfed and later given cow's milk and home food. His mother recalls frequent regurgitation and posseting in his infancy. Within the first 2 months, he developed redness and scaling of the skin; he received treatment but was never completely cured. He has three older siblings, all reportedly healthy. His mother does not report any hypotonia or failure to thrive in early infancy.

He has no reported history of seizures, cyanotic spells, or respiratory distress. His motor milestones were delayed when compared with his siblings. He walked and spoke short phrases by age 2 years. By age 4 years, he had a voracious appetite and was larger in size than his cousin, who was about the same age (Figure 1).

Figure 1.

As a young child, he could not run well and was unable to articulate Rs and Ss in his speech. He had no visual problems. He was admitted to school at age 6 years and was able to study until age 15 years, when he stopped going to school due to poor mobility secondary to his severe obesity. His mother reports that he had frequent outbursts at school as he progressed and attributed it to peers making fun of his obesity.

At age 8 years, he was reportedly not growing in height, and his testes were not palpable in the scrotum. Medical advice was sought; however, the family was not told a diagnosis or given treatment approaches. At age 14 years, the family became significantly worried about his gross obesity, snoring while sleeping, absence of facial and axillary hair, and short stature. His growth in height, as expected with a pubertal growth spurt, did not occur. The patient also became increasingly aggressive, which the family attributed to his peers making fun of his obesity. His unrelenting appetite had become a major problem.

To treat his irritated skin, topical creams and ointments had been applied. Additionally, three courses of oral antibiotics and steroids had been prescribed for his skin condition, which was diagnosed as a nonspecific dermatitis. He has no significant history of constipation or heat/cold intolerance. His parents and siblings remain healthy. His family history is negative for pubertal delay, short stature, morbid obesity, congenital anomalies, and developmental or learning disabilities. He has a positive family history of asthma among his uncles and aunts. His grandparents are both deceased, with no specific cause of death attributed.

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