Review Question - QID 106786

A 55-year-old Caucasian male with a history of hypertension who had just emigrated from Scotland to the United States comes in to your office to establish care. He has not seen a medical provider in almost fifteen years. His father had cirrhosis and died of liver cancer at age 61 while his mother is still alive and healthy. He does not smoke tobacco and has one alcoholic beverage per week. He takes multivitamins and herbal supplements for sleep. His review of systems is positive for fatigue and weakness, joint pain in his hands, decreased libido and states that he tans easily. His vital signs are within normal limits and his physical exam is notable for obesity, MCP joint swelling and tenderness bilaterally. He also has generalized skin hyperpigmentation (Figure A). His laboratory results are notable for a hemoglobin A1c of 7.9%, AST 156 U/L and ALT 190 U/L.

What is the most likely underlying mechanism for this patient’s presenting symptoms?