A 40-year-old male presents to the clinic with complaints of persistent diarrhea, generalized edema, and unexplained weight loss over the past few months. He also reports fatigue, abdominal discomfort, and a history of chronic, low-grade fever. His medical history is significant for a previous diagnosis of rheumatoid arthritis, for which he is on long-term methotrexate therapy.

Physical examination reveals moderate peripheral edema, particularly in the legs and abdomen. Laboratory investigations show hypoalbuminemia, low protein levels, and normal liver function tests. Stool studies and imaging are unremarkable for any infectious cause or obstruction. Further work-up reveals a decreased serum immunoglobulin A (IgA) level and mild lymphopenia. An upper gastrointestinal endoscopy is performed, which shows prominent villous atrophy in the duodenum and signs of malabsorption.

The diagnosis of protein-losing enteropathy (PLE) is suspected, which may be secondary to his underlying autoimmune condition and methotrexate use. The patient is advised to follow up with a specialist for management and further evaluation, including possible biopsy and monitoring of protein loss.

Key Points:

• Chronic diarrhea and edema in a patient with rheumatoid arthritis and methotrexate use raise suspicion for protein-losing enteropathy.

• The diagnosis of PLE is supported by low serum albumin and protein levels, with malabsorption findings on endoscopy.

• Management includes addressing the underlying condition and supportive care to correct protein loss and manage edema.