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Severe Small Heart Syndrome in a Patient with Anorexia Nervosa

Published:December 07, 2020DOI:https://doi.org/10.1016/j.amjmed.2020.10.033
      A 40-year-old woman with a 6-year history of anorexia nervosa and no other comorbidities presented to our hospital with fatigue. Her height was 164 cm, weight was 28.3 kg, body mass index was 10.5 kg/m2, blood pressure was 72/45 mm Hg, pulse rate was 82 beats per minute, and body temperature was 36.4°C. She was pale, and her oral mucosa and skin were dry. Blood tests revealed the following: total protein 7.6 g/dL, albumin 4.5 g/dL, blood urea nitrogen 54.9 mg/dL, creatinine 1.27 mg/dL, sodium (Na) 120 mmol/L, potassium (K) 3.5 mmol/L, chloride (Cl) 91 mmol/L, and blood sugar levels 96 mg/dL. A diagnosis of dehydration with electrolyte abnormalities was established. Chest x-ray study showed a significantly small cardiothoracic ratio (CTR) of 0.24 (Figure, A). Echocardiography revealed good cardiac contractility, but in the mitral valve, the early passive filling wave velocity/late active filling wave velocity decreased to 0.71, indicating diastolic dysfunction. However, she refused medical treatment, including electrolyte infusion therapy, because she refused to believe that her condition was due to anorexia nervosa. On day 168 from first admission, she was hospitalized for sepsis secondary to a urinary tract infection. Chest x-ray study indicated a slight increase in the CTR (from 0.27 to 0.33), and echocardiography revealed features of Takotsubo cardiomyopathy with pericardial effusion. There were no features suggestive of refeeding syndrome nor hypoglycemia. Antibiotics and intravenous fluids were administered; however, infusions of ≥1000 mL of fluids were refused. On hospitalization day 10, echocardiography revealed improvements in the features of Takotsubo cardiomyopathy. On hospitalization day 14, her albumin was 1.8 g/dL, blood urea nitrogen 19.0 mg/dL, creatinine 0.92 mg/dL, Na 138 mmol/L, K 4.0 mmol/L, and Cl 102 mmol/L. Dehydration and hyponatremia had reduced; however, hypoalbuminemia became apparent due to administration of 500-700 mL of intravenous fluids per day. Chest x-ray study revealed a CTR of 0.43 with bilateral pleural effusion (Figure, F). She also had pitting edema of the limbs. After successful treatment of the infection, the pleural effusion gradually reduced after hospitalization day 16; intravenous fluid treatment was completed on day 30 and edema improved on day 32; subsequently, the patient was discharged on day 52. One month after she was discharged, chest x-ray study showed a reduced CTR of 0.28 (Figure, J), and blood tests revealed the following: albumin 4.2 g/dL, blood urea nitrogen 64.4 mg/dL, creatinine 1.60 mg/dL, Na 127 mmol/L, K 5.1 mmol/L, and Cl 95 mmol/L, again indicating dehydration and electrolyte abnormalities. Echocardiography revealed no significant changes in cardiac function.
      Figure
      FigureChest x-ray studies showing changes in cardiothoracic ratio (CTR). (A, J) The upright posterior-anterior view. (B-I) Erect anterior-posterior view. (A) At the first visit, CTR: 0.24. (B) On admission due to infection (day 1), CTR: 0.33. (C) Day 3, CTR: 0.36. Pleural effusion appeared. (D) Day 7, CTR: 0.39. (E) Day 10, CTR: 0.41. (F) Day 13, CTR: 0.43. (G) Day 16, CTR: 0.42. (H) Day 21, CTR: 0.40. (I) Day 49, CTR: 0.30. Pleural effusion disappeared. (J) Day 94, CTR: 0.28.
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