I appreciate if you can shed some light on possible causes for high albumin but low globulin in a 14-year-old girl presenting with weight loss and secondary amenorrhea but no psychological features of typical anorexia nervosa. She moved to the country at the beginning of the year and since then has lost almost 20 percent of her body weight, with changes in gut symptoms including constipation, fullness after meals, stomach aches. She has low T3 but normal TSH and T4, which left her conventional endocrinologist stumped because he can’t give thyroxine in a weight loss patient. I’m going through gut testing and other blood markers, but her previous doctors have already done some standard tests and found high chloride, low liver enzymes, raised albumin, low globulin, normal hemoglobin, which is why I’m curious as to why albumin is high in a patient with poor oral intake. She eats animal protein but can’t stomach the quantity as before.

Dr. Amy Nett: Good question. So in terms of the high albumin, I would think about dehydration, particularly given that you’re mentioning she has high chloride, so consider checking her creatinine. Even though you mentioned normal hemoglobin, it’s possible that since she does have poor nutrients or poor diet at this time, that hemoglobin could also look normal because of dehydration and hemoconcentration rather than actual normal, rather than a truly normal hemoglobin. So I think, I don’t know how many times you’ve drawn the albumin and it’s been elevated, but I would think most likely based on all the markers you’ve given, that high albumin is probably due to dehydration. So make sure she’s adequately hydrated and then consider repeating it.

Low globulin could be nutrient deficiencies but often low globulin and—or I should say, albumin and globulin seemed to track inversely. So I would expect with a high albumin, a lower globulin.

So maybe try hydration and see if that helps and I think you’re absolutely right to look at her gut. Again, that poor T4-to-T3 conversation could, to some extent, be due to underlying gut issues.