Case Presentation: A 42-year-old Hispanic female with no significant medical history presented to the ED with chest pain, nausea, vomiting and poor oral intake for 2 days. She had similar symptoms in the past in the setting of emotional stress but never sought medical care. Physical examination was unremarkable. EKG showed no ischemic changes and CXR was normal. Her chest pain resolved without intervention. However, initial chemistries were notable for troponin <0.02 ng/ml, sodium 130 mmol/L, potassium 3.6 mmol/L, chloride 104 mmol/L, bicarbonate 7 mmol/L, phosphorus 3.6 mg/dL, glucose 79 mg/dL and anion gap 20 mmol/L. Arterial blood gas showed a partially compensated metabolic acidosis (pH 7.18, pCO2 21 mmHg, HCO3 8 mmol/L, pO2 91 ). Lactate and serum osmolar gap were normal. Urinalysis was positive for ketones. Urine toxicology and BAL were negative. Serum Beta-hydroxybutarate was markedly elevated (45 mg/dL). She was given 1 liter NS bolus and was started on D5W maintenance IVFs. Hours later on recheck her phosphorus was 0.7 mg/dL, consistent with refeeding syndrome. The patient subsequently disclosed that she had been engaging in a 4 day water-only fast in order to “be closer to God” and “receive guidance” on life stressors. She was started on a restricted calorie diet and received aggressive electrolyte repletion and monitoring. Her acidosis and hypophosphatemia improved within 48 hours. Additional workup revealed evidence of chronic malnutrition.
Discussion: Differential diagnoses in this case included a primary eating disorder, psychiatric disease such as depression or psychosis, or an unintended consequence of religious fasting. Accordingly, the hospital chaplain was consulted early in the patient’s hospital course. The patient revealed that fasting was encouraged within her non-denominational Christian religion, with variable rates of participation and duration among church members. After continued discussion with the medical team, the chaplain and her own pastor, the patient was able to recognize the detrimental effects of prolonged and frequent fasting on her health, and agreed to modify her fasting practices to shorter time periods with caloric supplementation.
Conclusions: Fasting for religious reasons is common within Judeo-Christian and Islamic religions. However, there is a paucity of medical literature regarding such practices and thus many physicians are unfamiliar with them. As illustrated by this case, patients may be reluctant to inform their treating physician of their fasting practices, fearing misunderstanding and admonishment. Early involvement by the chaplain and/or other members of a patient’s faith community can be instrumental in understanding the patient’s practices within the context of religious norms, gaining patient’s trust, and aligning patient and provider goals.