Lipodystrophy look-alikes: navigating diagnostic overlap with endocrine diseases

Lipodystrophy syndromes are rare and heterogeneous disorders characterized by partial or generalized absence of subcutaneous adipose tissue. These conditions are associated with severe metabolic complications, including insulin resistance, diabetes, dyslipidemia, and hepatic steatosis. Because of their rarity and clinical variability, lipodystrophies are often under-recognized and may be mistaken for more common endocrine disorders, leading to misdiagnosis and delayed treatment. Several endocrine diseases share overlapping clinical manifestations with lipodystrophy, such as abnormal fat distribution, hyperandrogenism, growth disturbances, or metabolic dysfunction. Such overlap poses significant diagnostic challenges, especially for nonspecialist clinicians. A precise differential diagnosis is crucial as management strategies differ substantially between lipodystrophies and other endocrine conditions. This review explores the main diagnostic pitfalls encountered when assessing patients with suspected lipodystrophy and offers practical guidance on the clinical, biochemical, and imaging features useful for distinguishing these conditions from other endocrinological disorders. Recognizing lipodystrophy early is crucial to prevent severe complications and initiate targeted treatments, including lifestyle interventions, insulin-sensitizing drugs, lipid-lowering therapies, and, when appropriate, recombinant leptin (metreleptin) therapy. By outlining key clinical clues and common areas of overlap, this review aims to help clinicians avoid misdiagnoses and ensure timely, accurate identification of lipodystrophy syndromes.