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An 80 year old man with no previous medical history was referred to our hospital with progressive weight loss of 24 kg in the past 12 months. There were no episodes of diarrhoea, fever, night sweats, nausea, or vomiting in the past 12 months. Physical examination revealed a significant reduction in the patient’s general and nutritional status (weight 56 kg, size 178 cm, body mass index 17.6 kg/m2), symmetrical oedema of the forearms and lower legs, and pleural effusions. Pathological laboratory findings included: erythrocyte sedimentation rate 82 mm/h; C reactive protein 3.8 mg/dl (normal 0.8 mg/dl); serum protein 5.6 g/dl (normal 6.5–8.5 g/dl); serum albumin 1.8 g/dl (normal 3.6–5.0 g/dl); serum iron 3.3 μmol/l (normal 10.6–26.0 μmol/l); haemoglobin 10.7 g/dl (normal 14–18 g/dl); MCV 119.7 fl (normal 86–101 fl); and vitamin B12 74 pg/ml (normal 199–730 pg/ml). Computed tomography scans of the chest and abdomen showed symmetrical pleural effusions but no signs of a solid tumour. Upper endoscopy, including histological examination of the stomach and duodenum, revealed no pathological findings. Total colonoscopy and ileoscopy demonstrated a diverticulosis of the sigmoid colon. Histological examination of colonic biopsies did not reveal any pathological findings. Radiographic enteroclysis was performed (fig 1).
What is the diagnosis? What additional investigations are necessary?
See page 436 for answer
This case is submitted by:
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