It can be hard to know when to seek medical care, especially with subtle symptoms. Chest pain, sudden loss of vision or speech, and severe stomach pain need immediate medical attention. But what about more subtle symptoms? Losing weight without trying and experiencing a fever can be indicative of underlying health issues and warrant medical evaluation.
Understanding Unintentional Weight Loss
Unintentional weight loss is when you lose weight without dieting or increasing physical activity. It may occur following a loss of appetite or when you’re consuming the same amount of calories as usual. This unexplained drop in weight could be caused by many conditions. A doctor can help you find the right treatment option.
What is Considered Significant?
Doctors typically become concerned about involuntary weight loss only when people lose more than about 10 pounds (4 to 5 kilograms) or, in smaller people, 5% of their body weight. Because everyone's weight goes up and down slightly over time (such as during an illness). Such weight loss can be a sign of a serious physical or emotional or mental health condition. In addition to weight loss, people may have other symptoms, such as loss of appetite, fever, pain, or night sweats, due to the underlying disease.
Potential Causes of Unintentional Weight Loss
Unintentional weight loss can be extremely distressing, particularly when you lose a relatively significant amount and don’t know why. Unintentional weight loss could be a sign of serious illness or disease, or it could be something as minor as a stomach virus.
Unintentional weight loss is most prevalent in people with pre-existing medical conditions. Some people who experience this symptom suffer from a variety of diseases including cancer, AIDS, and depression.
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Unintentional weight loss is often the result of an underlying chronic medical condition. However, short-term illnesses such as influenza or the common cold can also cause weight loss due to abdominal discomfort.
Common causes of unintentional weight loss include:
- Depression
- Diarrhea
- Oral ulcers
- Viral infections, such as the common cold, that can affect appetite
- Cancer
- Hyperthyroidism (overactive thyroid gland)
- Abdominal infection
- Gastroenteritis
- Dementia
- Celiac disease
- HIV or AIDS
Most often, weight loss occurs because people take in fewer calories than their body needs. They may take in fewer calories because their appetite has decreased or because they have a disorder that prevents their digestive tract from absorbing nutrients (called malabsorption). Less often, people have a disorder that causes them to use more calories (for example, an overactive thyroid gland). Sometimes, both mechanisms are involved. For example, cancer tends to decrease appetite but also increases caloric expenditure, leading to rapid weight loss.
Almost any long-term illness of sufficient severity can cause weight loss (for example, severe heart failure or emphysema). However, these disorders have usually been diagnosed by the time weight loss occurs.
Causes can be divided by people who have increased appetite and people who have a decreased appetite.
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With increased appetite, the most common unrecognized causes of involuntary weight loss are:
- An overactive thyroid gland (hyperthyroidism)
- Uncontrolled diabetes
- Disorders that cause malabsorption
With decreased appetite, the most common unrecognized causes of involuntary weight loss are:
- Emotional disorders (for example, depression)
- Cancer
- Medication adverse effects
- Drug dependence
Symptoms Associated with Weight Loss
Depending on what caused the weight loss, symptoms vary widely. You may notice a change in the way your clothes fit, or in the shape of your face, since that is an area where many people can see initial weight loss effects. However, some people are unaware that they’ve lost weight until they weigh themselves.
Unintentional weight loss due to an illness may occur along with fever, loss of appetite, abdominal discomfort or pain, diarrhea, or constipation.
Children who have unintentional weight loss may also have changes in appetite, fussiness over certain foods, physically smaller stature (if over the long term), abdominal pain, or fever.
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Medications and Weight Loss
Certain medications can cause unintentional weight loss as a side effect. If you’re on any medication and experience noticeable weight loss, consult with your doctor.
Diagnosis and Evaluation of Unintentional Weight Loss
Unintentional weight loss is a symptom of several conditions. Your doctor must go over your symptoms and any recent lifestyle changes you’ve made to know exactly what’s causing the weight loss. Because many disorders can cause involuntary weight loss, doctors usually need to do a thorough evaluation.
Your doctor may ask the following questions:
- Have you changed your diet?
- Have you had a recent illness?
- Have you recently traveled out of the country?
- Are you less energetic than usual?
- Have you had any digestive problems, such as diarrhea or constipation?
- Have you started taking any new medications?
Doctors first ask about how much weight the person has lost and over what time period. Doctors may ask about:
- Changes in clothing size, appetite, and food intake
- Whether the person has difficulty swallowing
- Whether bowel patterns have changed
- What other symptoms the person has, such as fatigue, malaise, fevers, and night sweats
- Whether the person has a history of a disorder that causes weight loss
- What drugs, including prescription and over-the-counter medications, and illicit drugs and herbal products, the person is taking
- Whether there are any changes in the person's living situation (for example, loss of a loved one, loss of independence or job, loss of a communal eating routine)
During the physical examination, doctors check vital signs for fever, a rapid heart beat, rapid breathing, and low blood pressure. The general physical examination is very thorough because many disorders can cause involuntary weight loss. Doctors examine the heart, lungs, abdomen, head and neck, breasts, nervous system, rectum (including a prostate examination for men and testing for blood in the stool), genitals, liver, spleen, lymph nodes, joints, and skin. Doctors also assess the person's mood.
Weight is measured, and body mass index (a calculation that relates an individual's weight to their height) is calculated.
If your doctor feels that your diet or a digestive disorder is to blame, they may do a nutritional assessment. This may consist of a blood test that shows levels of specific vitamins and minerals. The results of this test will determine if you’re deficient in any of these or if you have anemia.
Anemia occurs when your level of red blood cells is lower than usual. Iron deficiency or deficiency in a specific B vitamin can cause anemia.
Blood tests can also determine if a hormonal condition is to blame.
People's symptoms and doctors' findings on physical examination suggest the cause of weight loss in about half of people, including many people eventually diagnosed with cancer.
Screening for common cancers (for example, colonoscopy for colon cancer or mammography for breast cancer) is often done. Other testing is done depending on what disorders the doctor suspects. When the history and physical examination do not suggest specific causes, some doctors do a series of tests, including a chest x-ray, blood tests, and urinalysis, to narrow down a cause. These tests are followed by more specific tests as needed.
If all test results are normal, doctors usually reevaluate the person within a few months to see if new symptoms or findings have developed.
Treatment for Unintentional Weight Loss
The underlying disorder causing involuntary weight loss is treated. If you have a nutritional deficiency, your doctor may refer you to a dietitian or devise a diet plan that helps to correct the deficiency. A deficiency due to a digestive disorder, such as inflammatory bowel disease, may require a specialized diet during times of inflammation to help you get the nutrients you need. This may include taking over-the-counter supplements.
Your doctor will likely prescribe medication if a hormonal disorder is causing the unintentional weight loss.
You can correct unintentional weight loss due to general illnesses such as influenza, the common cold, or food poisoning with bed rest, an increase in fluids, and medications used to settle the stomach, and by getting back on your normal diet when you are feeling better.
If your doctor suspects that your unintentional weight loss may be due to a more serious illness, such as cancer, you may undergo some tests to get more information.
To help people eat more, doctors often try behavioral measures, such as encouraging people to eat, assisting them with eating, providing favorite or strongly flavored foods, and offering only small portions. If behavioral measures are ineffective, high-nutrition food supplements can be tried. Feedings through a tube inserted into the stomach are a last resort, but may be worth the risk in certain situations. For example, tube feedings can be helpful if a person has a disorder that will eventually be cured or resolve, whereas tube feedings may not be worthwhile if a person stops eating because of severe Alzheimer disease.
Essentials for Older Adults: Involuntary Weight Loss
The frequency of involuntary weight loss increases with aging, often reaching 60% among nursing home residents. Older adults are more likely to have involuntary weight loss because diseases that cause weight loss are more common among older adults. There are also normal age-related changes that contribute to weight loss. Typically, many factors are involved. Normal age-related changes that can contribute to weight loss include the following:
- Decreased sensitivity to certain appetite-stimulating mediators and increased sensitivity to certain inhibitory mediators in the body
- A decreased rate of gastric-emptying (prolonging the feeling of fullness)
- Decreased sensitivities of taste and smell
- Loss of muscle mass (sarcopenia)
In addition, social isolation is common in older adults, which tends to decrease food intake. Depression and dementia are very common contributing factors, particularly among nursing home residents. Dental problems (for example, periodontitis) become more common with aging and can compromise nutrient intake and digestion. It is often difficult to sort out the exact contribution of specific factors.
Older adults may benefit from nutritional supplements to correct vitamin deficiencies (for example, of vitamins D and B12). However, supplements should be given between meals and at bedtime. Otherwise, supplements might decrease the appetite at mealtime.
When to Seek Medical Attention for Weight Loss
Try to keep track of your weight loss. Note when the weight loss started. Also, make a note of any other symptoms you experienced around the time of the weight loss. This will give your doctor useful information that can help in making a diagnosis.
In people with involuntary weight loss, certain symptoms and characteristics are cause for concern. They include:
- Fever and night sweats
- Bone pain
- Shortness of breath, cough, and coughing up blood
- Excessive thirst and increased urination
- Headache, jaw pain when chewing, and/or new vision disturbances (for example, double vision, blurred vision, or blind spots) in a person over 50
People who have warning signs should see a doctor right away. People who have no warning signs should see a doctor when possible. Typically a delay of a week or so is not harmful.
Understanding Fever
Fever seems to play a key role in fighting infection. Persistent fever can mean you have an infection, including COVID-19. A fever can also be a symptom of many other infectious diseases, from a urinary tract infection to tuberculosis.
When to Seek Medical Attention for Fever
If you have a fever and other symptoms, such as cough and fatigue, contact your health care provider right away for medical advice. Your health care provider will likely recommend that you get tested for COVID-19. If you have emergency COVID-19 symptoms, such as trouble breathing, seek care immediately. If you need to go to a hospital, call ahead. Call your health care provider if your temperature is 103 F (39.4 C) or higher.
Case Study: Fever and Weight Loss in a Child
A 12-year-old boy was referred to a paediatric clinic for assessment of persistent fever, weight loss, and hematuria. He initially presented to his primary care physician with 3 days of fever and an erythematous, maculopapular rash of the lower body. There were no respiratory symptoms, sore throat, or gastrointestinal symptoms. Physical examination revealed mild erythema of the right tympanic membrane. Despite compliance with antibiotics, the patient remained febrile. He was seen in the emergency room for re-evaluation, 3 days after starting antibiotics. The family endorsed constitutional symptoms, including fatigue and documented weight loss over the last month. His tympanic membranes appeared normal. He was subsequently seen in paediatric clinic and had defervesced 1 day after completing a 1-week course of antibiotics. He had been febrile for 12 days total. His weight loss and fatigue were ongoing. He had a persistent rash, but no other signs of Kawasaki disease. There was no lymphadenopathy or hepatosplenomegaly. He had a loud diastolic murmur in keeping with his known history of aortic regurgitation. Despite defervescence, a transthoracic echocardiogram (TTE) was requested.
Diagnostic of infective endocarditis by TTE Parasternal long-axis view. On the left, diastole with aortic valve closed. One the right, systole with aortic valve opened. Large mobile vegetation attached to the subaortic ridge (echogenic mass).
Due to the size of the vegetation (>10 mm) and its location (left-sided heart), the patient underwent emergency cardiac surgery for resection of the vegetation and Ross’ intervention. His postoperative course was uneventful. Numerous blood cultures remained negative, but polymerase chain reaction (PCR) of the infected tissue identified Streptococcus oralis as the causative organism.
IE is rare in children but carries significant morbidity and mortality (1). Risk factors include congenital heart disease, indwelling central venous catheters, and rheumatic heart disease (2). Subacute IE presents nonspecifically with fever, malaise, and weight loss for several weeks. Other findings may include a new or changing murmur, glomerulonephritis, hematuria, splenomegaly, a nonspecific rash, elevated inflammatory markers, and septic emboli resulting in extracardiac infection. Paediatric patients rarely have the classic stigmata of IE, such as Janeway lesions, Osler nodes, and splinter hemorrhages (2).
Blood cultures are recommended for all paediatric patients with fever of unknown origin, and especially in those with a pathological heart murmur, history of heart disease, or previous IE (2). If the diagnosis of IE is suspected, three blood cultures of adequate blood volume for age and weight should be obtained. In acute IE, blood cultures should be collected within about one hour so that antibiotics may be initiated, but may be spaced further apart in subacute IE. Blood cultures in patients with IE may be persistently negative in approximately 5% of cases.
In children with suspected IE, with or without positive blood cultures, TTE is an important diagnostic tool, as highlighted in the modified Duke criteria. While TTE is more sensitive in children than in adults, the absence of vegetation or intracardiac abscess does not rule out IE.
Diagnostic Challenges
Our patient was diagnostically challenging for several reasons. He presented nonspecifically with fatigue, fever, and weight loss. The presence of weight loss in a child with unexplained fevers is a red flag for serious pathology and is what prompted a thorough diagnostic workup. While a diastolic murmur was noted, it was attributed to his known structural heart disease.
Importance of Collaboration and Management
Due to the variable presentation and significant mortality of IE, collaboration between paediatricians, cardiologists, and infectious disease specialists is recommended throughout diagnosis and management. Once a diagnosis is made, management includes a prolonged course of intravenous antibiotics, tailored to the causative organisms, if known. Surgical intervention is an important consideration in those with large vegetations, uncontrolled infection, prosthetic valve endocarditis, and heart failure (2).
PCR in this case identified Streptococcus oralis and highlights the importance of dental hygiene in children with valvulopathy. Recently, there has been a shift away from antibiotic prophylaxis before dental procedures and toward an emphasis on prevention of oral disease (2).