What medical conditions could present with anxiety‑like symptoms in a middle‑aged adult with non‑alcoholic fatty liver disease, metabolic syndrome, intermittent chest pain, neutrophilic leukocytosis, and blurred vision?

Medical Conditions Mimicking Anxiety in Your Clinical Context

In a middle-aged adult with NAFLD, metabolic syndrome, intermittent chest pain, neutrophilic leukocytosis, and blurred vision presenting with anxiety-like symptoms, you must systematically exclude cardiovascular disease, hyperthyroidism, hypoglycemia, pheochromocytoma, and recognize that NAFLD itself independently increases anxiety risk by 23%.

Cardiovascular Causes (Highest Priority Given Chest Pain)

Cardiac ischemia must be excluded first given the combination of metabolic syndrome, chest pain, and anxiety-like symptoms (palpitations, dyspnea, sense of doom). 1

• Metabolic syndrome components—hypertension, dyslipidemia, insulin resistance, and visceral obesity—collectively increase cardiovascular mortality risk through multiple mechanisms 1
• NAFLD patients have substantially elevated cardiovascular disease risk independent of traditional metabolic factors, making cardiac evaluation mandatory 1
• Obtain ECG, troponin, and consider stress testing or coronary CT angiography based on pretest probability 2
• The AST:ALT ratio <1 suggests metabolic rather than alcoholic liver disease, but does not exclude cardiac pathology 3

Endocrine Disorders

Hyperthyroidism presents with anxiety, tremor, palpitations, heat intolerance, weight loss, and can cause blurred vision from thyroid eye disease:

• Check TSH, free T4, and free T3 immediately 1
• Thyroid dysfunction commonly coexists with NAFLD and metabolic syndrome 1

Hypoglycemia from diabetes medications or insulinoma causes anxiety, tremor, diaphoresis, blurred vision, and confusion:

• Obtain fasting glucose, HbA1c, and consider continuous glucose monitoring if diabetic 1
• Hypoglycemia episodes can mimic panic attacks with identical autonomic symptoms

Pheochromocytoma (rare but critical) presents with episodic hypertension, palpitations, diaphoresis, headache, and anxiety:

• Consider 24-hour urine or plasma fractionated metanephrines if hypertension is paroxysmal 1

Hematologic Causes of Neutrophilic Leukocytosis

Infection or inflammatory process can cause anxiety-like symptoms through cytokine-mediated effects:

• Evaluate for occult infection (pneumonia, urinary tract infection, dental abscess) with chest X-ray, urinalysis, and focused examination 1
• Check CRP and ESR to assess inflammatory burden
• Chronic inflammation from NAFLD itself can contribute to leukocytosis 1

Malignancy (particularly hepatocellular carcinoma given NAFLD) can present with constitutional symptoms and paraneoplastic anxiety:

• NAFLD with advanced fibrosis increases hepatocellular carcinoma risk even without cirrhosis 1
• Obtain abdominal ultrasound or MRI and alpha-fetoprotein 1

Ophthalmologic Causes of Blurred Vision

Diabetic retinopathy from uncontrolled diabetes causes progressive vision changes:

• Dilated fundoscopic examination is mandatory given metabolic syndrome 1
• Retinopathy presence predicts increased all-cause and cardiovascular mortality 1

Hypertensive retinopathy from uncontrolled hypertension causes vision changes and indicates end-organ damage:

• Fundoscopy to assess for arteriovenous nicking, hemorrhages, exudates 1

NAFLD as Direct Cause of Anxiety

NAFLD independently increases anxiety risk through bidirectional pathophysiologic mechanisms, not just shared metabolic factors:

• Women with NAFLD have 43% increased odds of depression (adjusted OR 1.43,95% CI 1.14-1.80) 4
• NAFLD increases anxiety incidence by 23% (HR 1.23, P<0.001) even after controlling for metabolic comorbidities 5
• Severe hepatic steatosis significantly correlates with both state anxiety (adjusted OR 1.84) and trait anxiety (adjusted OR 2.45) in women 4
• The pooled prevalence of anxiety in NAFLD patients is 37.2% (95% CI 21.6-54.3%) 6
• Depression in NAFLD associates with more severe hepatocyte ballooning in a dose-dependent manner (adjusted COR 3.6 for clinical depression) 7

Metabolic Syndrome Components

Obstructive sleep apnea causes daytime anxiety, fatigue, and cognitive impairment:

• Present in high frequency with obesity and metabolic syndrome 1
• Obtain STOP-BANG score and consider polysomnography 1

Polycystic ovary syndrome (if female) causes anxiety, metabolic dysfunction, and is strongly associated with NAFLD:

• Check testosterone, DHEA-S, and pelvic ultrasound 1

Critical Pitfalls to Avoid

• Do not attribute anxiety solely to psychiatric causes without excluding organic disease in patients with multiple metabolic risk factors 1
• Do not overlook cardiovascular disease because the patient is "anxious"—metabolic syndrome patients have high pretest probability for coronary disease 1
• Do not dismiss the bidirectional relationship between NAFLD and mental health—treat both simultaneously 6, 4, 5
• Do not forget that 60-80% of NAFLD patients are asymptomatic from liver disease itself, so symptoms likely represent comorbid conditions 8

Systematic Diagnostic Algorithm

1. Immediate cardiac evaluation: ECG, troponin, consider stress test given chest pain and metabolic syndrome 1
2. Endocrine screening: TSH, free T4, fasting glucose, HbA1c 1
3. Infection/inflammation workup: CBC with differential, CRP, chest X-ray, urinalysis for neutrophilic leukocytosis 1
4. Ophthalmologic assessment: Dilated fundoscopy for diabetic/hypertensive retinopathy 1
5. NAFLD severity stratification: FIB-4 or VCTE to assess fibrosis risk, as advanced fibrosis increases all complications 1
6. Sleep apnea screening: STOP-BANG questionnaire given obesity and metabolic syndrome 1
7. Hepatocellular carcinoma surveillance: Ultrasound and AFP if cirrhosis or advanced fibrosis present 1