Case 25-2021: A 48-Year-Old Man with Fatigue and Leg Swelling

The patient had been well until 8 months before the current admission, when fatigue and lethargy developed.He thought the fatigue was associated with alcohol consumption and reduced his intake to 12 beers weekly; before this, he had consumed 24 beers weekly for 15 years.Three months before the current admission, the patient's weight had decreased by 9.1 kg.However, 3 weeks before this admission, the weight had increased by 9.6 kg and swelling developed in both legs.He thought the weight gain was related to diet changes, including consumption of pizza, pasta, and soup, during the coronavirus disease 2019 pandemic.One week before the current admission, the patient was evaluated by his primary care physician.He was instructed to elevate his legs, wear compression stockings, and decrease dietary sodium to 2 g daily.On the day of the current admission, the leg swelling had not abated and new abdominal distention occurred.He called the primary care clinic and was instructed to seek evaluation at the emergency department of this hospital.On evaluation, a review of systems was notable for fatigue, lethargy, decreased appetite, abdominal bloating, constipation, penile swelling, decreased libido, intolerance of cold temperatures, and ankle and knee pain in both legs that was worse when the patient was climbing stairs.There was no fever, shortness of breath, chest pain, or hematochezia.Sixteen months before the current evaluation, the patient had been admitted to this hospital with pneumonia involving the right upper and middle lobes that was due to Mycoplasma pneumoniae.During that admission, he received diagnoses of diabetes and normocytic anemia.After discharge from the hospital, laboratory evaluation revealed a glycated hemoglobin level of 6.1% (reference range, 4.3 to 6.4).Metformin was prescribed, and follow-up evaluation was recommended; however, the patient had not returned to the primary care clinic before the current illness. Copyright © 2021 Massachusetts Medical Society.