Case Presentation:
A 25 year‐old female with chronic anorexia nervosa and depression presents with sudden weakness and fatigue. Psychosocial history is notable for binge‐starve cycles over the past year and a decline in overall well‐being. Vitals on presentation were notable for hypothermia, hypotension, and bradycardia. Initial exam was notable for emaciation, lethargy, and lower extremity edema. Laboratory work‐up revealed markedly elevated LFTs, hypoglycemia, thrombocytopenia, abnormal renal function, and elevated INR and lipase. Electrocardiogram showed sinus bradycardia, with prolonged QTc interval. Ultrasound revealed normal liver and biliary tree. Serum acetaminophen, alcohol level, and urinary toxicology were unremarkable. Work up for infectious, autoimmune, and genetic causes of hepatitis was negative. Echocardiogram revealed left ventricular hypokinesis and EF 10‐15%.
Due to identified malnutrition, nutritional support was begun slowly, however electrolyte derangements began to manifest on hospital day 2, with hypophosphatemia, hypokalemia, hypocalcemia, and hypomagnesemia. Multiple medical and psychiatric disciplines were consulted, and aggressive electrolyte monitoring and repletion was done. The patient’s overall clinical status improved slowly during her hospital course. Her liver enzymes trended down, and her QTc interval eventually returned toward the normal range. Repeat echocardiogram following treatment revealed improvement of her EF to 40%.
Discussion:
Anorexia nervosa is an eating disorder characterized by extremely low body weight, fear of gaining weight or distorted perception of body image, and amenorrhea. Although described mostly in the context of psychiatric illness, anorexia can nonetheless lead to devastating, and at times, life threatening medical complications, and thus constitutes a major challenge to manage. Central to the pathogenesis of the refeeding syndrome is a weakened cardiopulmonary system, which is incapable of accommodating the fluid and sodium load presented to the body during nutritional repletion. The resultant volume expansion and fluid retention can progress even to heart failure. Hepatic dysfunction is a common medical complication of anorexia nervosa and its treatment. Hypotension due to poor nutritional intake and secondary to cardiac dysfunction from chronic malnutrition can lead to liver hypoperfusion and, ultimately, ischemic hepatitis. Takotsubo cardiomyopathy, also known as stress‐induced cardiomyopathy, has been described as a rare complication in young women with anorexia nervosa and usually presents in a manner similar to acute myocardial infarction. The pathophysiology of takotsubo cardiomyopathy remains to be elucidated but is thought to involve catecholamine excess leading to myocardial stunning.
Conclusions:
Given the clinical presentation, this patient likely presented on the brink of developing frank refeeding syndrome, with cardiac dysfunction and hypovolemia, leading to hepatic hypoperfusion and ischemic hepatitis. Subsequently, she developed electrolyte disturbances characteristic of refeeding syndrome, which were managed without major complication. Her hospital course is encouraging not only for her recovery, but for the collaboration of the different teams involved in her care, and it highlights the importance of a multidisciplinary approach to caring for patients with the potential dire complications of a complex psychiatric illness.