DEAR DR. ROACH: I am 66 and have always been in good health. I walk four or five times a week and do mild weight training two or three times a week. I eat a very healthy diet.

I have low testosterone (339). My symptoms are insomnia, low sex drive, erectile dysfunction, anxiety and weight loss. I cannot maintain my weight. My normal weight is 175, and I weigh 154 after eating all day. Also, I have rashes on my face and legs. My doctor says my testosterone is normal, and says I should take trazodone for sleeping, but does not know why I have this rash and says it will go away in time. The doctor says I should eat more to gain weight. I eat 4,000-5,000 calories a day, including weight-gain shakes, but cannot gain enough to reach my normal weight. What do you think? Can you help? — D.L.

ANSWER: There are many issues here, but the one that jumps out at me is your inability to gain weight despite eating a truly enormous number of calories. It’s hard for me to believe, but if I take you at your word, then one of three things is going on. You could be unable to absorb the nutrients, due to a problem with the intestine or pancreas. You could have a revved-up metabolism, which usually comes from excess thyroid hormones. Finally, you could be losing calories somewhere else, the most common cause of which is uncontrolled diabetes.

I think the most likely scenario is malabsorption, the most common cause of which is celiac disease. This also can cause low testosterone levels, as well as rash. One rash, dermatitis herpetiformis, is very closely associated with celiac disease, but usually is found on the elbows and knees more often than the face.

Inability to sleep is classically associated with a high thyroid level, so I think you need an evaluation of your thyroid (via blood test) to see whether you are, in fact, unable to absorb nutrients (a stool test is an easy way to find out), and a blood sugar test, which is simple to get as well. I wouldn’t think about treating the testosterone until you find out why you lost weight and are unable to gain it back.

DR. ROACH WRITES: A few weeks ago, M.A. wrote to me about her low blood counts. She kindly wrote me back, and after a bone marrow biopsy, was diagnosed with a low-grade marginal zone B cell lymphoma. This particular type of blood cancer usually starts in the spleen, and the abnormal cells often can be found in the bone marrow, which I think is likely the case with M.A.

The bad news about low-grade lymphomas is that they often are not curable. The good news is that they grow very slowly. Half all people with this type of tumor live with this condition for longer than 10 years. Because the main reason M.A. was found to have this condition was abnormal blood test results, it may not be necessary to treat it right now. However, it’s likely that M.A. will require blood transfusions as the disease progresses.

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