Case Presentation: A 36 year old male with anorexia presented for weakness Due to concerns of being overweight, patient began to increasingly restrict his diet (ie eliminating carbs, smaller calorie goals) over the past three years and also began taking milk of magnesia daily over the past year, losing approximately 120 lbs over this time. For the past two months he become increasingly weak and fatigued and in the time period immediately prior to hospitalization, he began to struggle physically to complete basic tasks such as tying his shoes causing him to present to the hospital. In the emergency room, he was found to be afebrile with a heart rate of 52 and blood pressure of 95/60 mmHg. He was found to have a WBC of 2.3 K/uL, Hgb 11.4 g/dL, platelets 104 K/uL, alkaline phosphatase 97, ALT 1009 U/L, AST 551 U/L, direct bilirubin .1 mg/dL, INR 1.2 and glucose of 81 mg/dL. His BMI was found to be 15. Patient was not confused and able to converse logically. He denied further symptoms such as fevers, chills, dyspnea, cough, dysuria, abdominal pain. He also denied alcohol use, acetaminophen use or eating wild mushrooms. Testing for alternative causes of hepatitis including ceruloplasmin, anti-smooth muscle, anti-mitochondrial antibody, viral hepatitis panel, deep doppler RUQ US, EBV, CMV, HSV, and HIV were negative. He was subsequently diagnosed with starvation hepatitis. With fluid and nutrition intake, patient’s liver function tests (LFT’s) gradually improved and at discharge his LFTs improved to alkaline phosphatase 71, ALT 559 U/L, AST 150 U/L, and direct bilirubin of .6 mg/dL. He was amenable to increasing his nutritional intake and following up with his primary care physician regarding further follow up for his anorexia and elevated LFT’s.
Discussion: Anorexia Nervosa is a common psychiatric condition amongst adolescents and young adults that carries a significant risk of death from medical complications and suicide. Medical complications include hypotension, bradycardia, pancytopenia, hypoglycemia and starvation hepatitis, all of which was seen in this patient. Starvation hepatitis typically presents with elevated transaminases where ALT is greater than AST, and alkaline phosphatase and bilirubin are unaffected. Patients with starvation hepatitis often present with mild to moderate transaminase elevations but severe cases can result in transaminases in the thousands, and the risk of severe transaminase elevation in starvation hepatitis rises inversely with BMI. Fortunately, starvation hepatitis typically resolves with increasing nutrition intake.
Conclusions: Starvation hepatitis is characterized by elevated transaminases and normal alkaline phosphatase and bilirubin. Starvation hepatitis typically presents with mild to moderate elevations of AST/ALT’s but can be severe with AST/ALT’s in the thousands. Starvation hepatitis often resolves with treatment of anorexia and increasing nutrition intake.