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Chest x-ray demonstrating large right pneumothorax on the day after placement of the central venous catheter.
Source publication
Of the many body systems adversely affected by severe anorexia nervosa (AN), the pulmonary system is relatively spared. However, in the face of severe malnutrition of AN, the lung may undergo architectural changes that adversely affect its integrity and healing capacity. We report herein a case of a pneumothorax in a patient with severe AN, in whic...
Context in source publication
Context 1
... procedure went smoothly and without apparent complication, and a post-procedure chest x-ray was unremarkable. How- ever, the next day an x-ray obtained for unrelated rea- sons demonstrated a sizable right pneumothorax ( Figure 1). Although the patient was asymptomatic, a 10-French pigtail thoracostomy catheter was inserted at the bedside and attached to 20 cm H 2 O suction to evacuate the pneumothorax and facilitate lung re-expansion. ...Similar publications
This case report describes a patient with a subacute right-sided tension hemopneumothorax following an occult stab. The patient's electrocardiogram (ECG), performed as part of a standardized triage process, demonstrated significant abnormalities that misguided initial resuscitation, but resolved following evacuation of the tension hemopneumothorax....
Aim: We have analyzed the chest tube thoracostomies (CTT) performed in our Thoracic Surgery clinics of our newly established medical school hospital. Material and Method: The medical records of 130 patients to whom CTT were performed by the Thoracic Surgery Clinics of the Çanakkale On-sekiz Mart University from December 2009 to July 2013 were retro...
Citations
... We identified two readmissions for severe outcomes that may have been precipitated by ARFID (pneumothorax and kidney failure), highlighting the severity of the disease and its potential for catastrophic consequences [37]. Prior studies of patients with anorexia nervosa have established links between eating disorders and these conditions, and severely malnourished patients with ARFID may be similarly at risk for organ failure and dysfunction [38,39]. However, we were unable to explore this further given the limitations of administrative data and we can only speculate that these readmissions are related to underlying ARFID rather than another etiology. ...
Background
Avoidant restrictive food intake disorder (ARFID) is a relatively new feeding and eating disorder added to the DSM-5 in 2013 and ICD-10 in 2018. Few studies have examined hospital utilization for patients with ARFID specifically, and none to date have used large administrative cohorts. We examined inpatient admission volume over time and hospital utilization and 30-day readmissions for patients with ARFID at pediatric hospitals in the United States.
Methods
Using data from the Pediatric Health Information System (PHIS), we identified inpatient admissions for patients with ARFID (by principal International Classification of Diseases, 10th Revision, ICD-10 diagnosis code) discharged October 2017–June 2022. We examined the change over time in ARFID volume and associations between patient-level factors (e.g., sociodemographic characteristics, co-morbid conditions including anxiety and depressive disorders and malnutrition), hospital ARFID volume, and hospital utilization including length of stay (LOS), costs, use of enteral tube feeding or GI imaging during admission, and 30-day readmissions. Adjusted regression models were used to examine associations between sociodemographic and clinical factors on LOS, costs, and 30-day readmissions.
Results
Inpatient ARFID volume across n = 44 pediatric hospitals has increased over time (β = 0.36 per month; 95% CI 0.26–0.46; p < 0.001). Among N = 1288 inpatient admissions for patients with ARFID, median LOS was 7 days (IQR = 8) with median costs of $16,583 (IQR = $18,115). LOS and costs were highest in hospitals with higher volumes of ARFID patients. Younger age, co-morbid conditions, enteral feeding, and GI imaging were also associated with LOS. 8.5% of patients were readmitted within 30 days. In adjusted models, there were differences in the likelihood of readmission by age, insurance, malnutrition diagnosis at index visit, and GI imaging procedures during index visit.
Conclusions
Our results indicate that the volume of inpatient admissions for patients with ARFID has increased at pediatric hospitals in the U.S. since ARFID was added to ICD-10. Inpatient stays for ARFID are long and costly and associated with readmissions. It is important to identify effective and efficient treatment strategies for ARFID in the future.
... Weight loss in AN can cause emphysematous changes to the lung parenchyma, increasing the risk of SBSP. AN can cause various complications due to weight loss and malnutrition, although only a small number of studies have described weight loss in AN causing changes in the lungs themselves [4]. SBSP is present in approximately 1.0% of cases of spontaneous pneumothorax and is associated with underlying disorders such as chronic obstructive pulmonary disease, malignancies, and pulmonary tuberculosis [1]. ...
Anorexia nervosa causes various complications accompanying weight loss and malnutrition. Although bilateral spontaneous pneumothorax (SBSP) is uncommon, caution is needed in anorexia nervosa because this complication can be fatal. We encountered a 17-year-old girl with SBSP from emphysematous pulmonary changes due to anorexia nervosa. She was hospitalized with SBSP during treatment for anorexia nervosa. Chest tube drainage was started on admission, but no improvement was achieved. Surgery was therefore performed. Lung lesions on surgical specimens demonstrated malnutrition-induced emphysematous changes, a risk factor for SBSP. Attention should be paid to the occurrence of SBSP during the clinical course of anorexia nervosa.
... Patients typically do not require specific treatment, though they should be admitted for observation. Spontaneous pneumothorax may also occur in people with AN [50]. However, pneumothorax may be difficult to resolve in people with AN as the lung may remain collapsed for an extended period of time until their state of malnutrition resolves [51]. ...
Plain English summary
People with anorexia nervosa frequent emergency departments to obtain their medical care. It is thus important for emergency department personnel to be familiar with this increasingly common and serious disorder. As opposed to most other mental illnesses, anorexia nervosa is associated with many dangerous medical complications, which become more problematic as the malnutrition and weight loss become more severe. All body systems are adversely affected. The mortality rate of anorexia nervosa is the second highest of all mental disorders, with medical complications and suicide being the top two causes of death. Mandated medical care may occasionally be required to obtain ongoing treatment for people with anorexia nervosa when they present to the emergency department with severe malnutrition and other emergent complications.
... Non-cardiac chest pain may be musculoskeletal, psychogenic, gastrointestinal or pulmonary in origin [76]. AN may predispose individuals to spontaneous pneumothorax and this should therefore be considered as a rare but serious differential for chest pain among this group [77,78]. ...
Background
Eating disorders (EDs) are serious conditions predominantly affecting adolescents and young adults (AYAs) and pose a considerable threat to their health and wellbeing. Much of this increased morbidity and mortality is linked to medical compromise, especially cardiovascular abnormalities. Rates of presentation to both community and inpatient medical settings have increased in all age groups following the Covid-19 pandemic and subsequent “lockdowns”, with patients presentations being more medically compromised compared to previous years. This has implications for clinicians with regard to the performance of competent cardiovascular assessments and management of findings.
Aims
This paper is a practical resource for clinicians working with AYAs in whom EDs may present. It will provide a brief summary of the physiological context in which cardiovascular complications develop, systematically outline these complications and suggest a pragmatic approach to their clinical evaluation.
Methods
Relevant literature, guidelines and academic texts were critically reviewed. Conclusions were extracted and verified by a Child and Adolescent Psychiatrist and Adolescent Paediatrician, with suitable expertise in this clinical cohort.
Conclusions
The cardiovascular complications in EDs are primarily linked to malnutrition, and patients presenting with Anorexia Nervosa are most often at greatest risk of structural and functional cardiac abnormalities, including aberrations of heart rate and rhythm, haemodynamic changes and peripheral vascular abnormalities. Other cardiovascular abnormalities are secondary to electrolyte imbalances, as seen in patients with Bulimia Nervosa. More recently defined EDs including Avoidant/Restrictive Food Intake Disorder and Binge Eating Disorder are also likely associated with distinct cardiovascular complications though further research is required to clarify their nature and severity. Most cardiovascular abnormalities are fully reversible with nutritional restoration, and normalisation of eating behaviours, including the cessation of purging, though rare cases are linked to cardiac deaths. A detailed clinical enquiry accompanied by a thorough physical examination is imperative to ensure the medical safety of AYAs with EDs, and should be supported by an electrocardiogram and laboratory investigations. Consideration of cardiovascular issues, along with effective collaboration with acute medical teams allows community clinicians identify those at highest risk and minimise adverse outcomes in this cohort.
... The increased severity of COVID-19 in these patients may have increased the likelihood of pneumothorax. Malnutrition was associated with a higher risk of pneumothorax, which may result from poor healing which can produce prolonged air leakage in the pleural cavity (24,25). Pre-existing lung conditions can also be risk factors for pneumothorax. ...
... The risk of developing subsequent contralateral spontaneous pneumothorax is higher among underweight patients; malnutrition of pneumocytes may be a possible mechanism leading to pneumothorax development. 100,101 A higher blood level of aluminum has been noted among patients with spontaneous pneumothorax 102 leading to the postulation that aluminum might play a role in formation of subpleural blebs and bullous lesions and pneumothorax development. 102 ...
Pneumothorax is a common problem worldwide. Pneumothorax develops secondary to diverse aetiologies; in many cases, there may be no recognizable lung abnormality. The pathogenetic mechanism(s) causing spontaneous pneumothorax may be related to an interplay between lung-related abnormalities and environmental factors such as smoking. Tobacco smoking is a major risk factor for primary spontaneous pneumothorax; chronic obstructive pulmonary disease is most frequently associated with secondary spontaneous pneumothorax. This review article provides an overview of the historical perspective, epidemiology, classification, and aetiology of pneumothorax. It also aims to highlight current knowledge and understanding of underlying risks and pathophysiological mechanisms in pneumothorax development.
... The risk of developing subsequent contralateral spontaneous pneumothorax is higher among underweight patients; malnutrition of pneumocytes may be a possible mechanism leading to pneumothorax development. 100,101 A higher blood level of aluminum has been noted among patients with spontaneous pneumothorax 102 leading to the postulation that aluminum might play a role in formation of subpleural blebs and bullous lesions and pneumothorax development. 102 ...
Pneumothorax is a common clinical problem worldwide. Pneumothorax is defined as presence of air in the pleural cavity. It can develop secondary to diverse etiologies including traumatic, inflammatory, infective, malignant, genetic, and hormonal causes; in many cases, the lung appears normal and there may be no recognizable underlying lung abnormality. The severity of clinical manifestations in a patient with pneumothorax ranges from asymptomatic to life-threatening, and may be disproportionate to pneumothorax size. In this review, we provide an overview of the historical perspective, epidemiology, classification, and etiology of pneumothorax. We also explore current knowledge and understanding of underlying risks and pathophysiologic mechanisms that lead to development of pneumothorax
... In particular, bilateral pneumothorax and respiratory failure due to respiratory muscle weakness were characteristic complications in the present case. Biffl et al. described in their report regarding anorexia nervosa that prolonged starvation led to reductions in the total lung protein content, connective tissue, hydroxyproline, and elastin, and malnutrition was a well-known impediment to normal wound healing (25). Furthermore, ventilators can cause secondary pneumothorax (26). ...
We encountered a 47-year-old woman with polycystic liver disease (PLD) and severe malnutrition successfully treated by living-donor liver transplantation (LDLT). Her PLD became symptomatic with abdominal distension and appetite loss. Transcatheter arterial embolization and percutaneous cyst drainage failed to improve her symptoms. ABO-incompatible LDLT from her husband was performed after rituximab administration and mycophenolate mofetil introduction. Although she showed severe postoperative complications, she ultimately regained the ability to walk and was discharged. Because advanced PLD cases are difficult to treat conservatively or with surgery, like fenestration and hepatectomy, liver transplantation should be considered before it becomes too late.
... A very recent study demonstrated reduced peak expiratory flow rate in adult patients with AN which improved rapidly with weight restoration [43]. Additionally, there have been multiple case reports of spontaneous pneumothorax in adult patients with AN [44][45][46]. A thin body habitus is also recognized as a risk factor for pneumothorax in the general patient population. ...
Purpose of Review
Avoidant/restrictive food intake disorder (ARFID) is a relatively new psychiatric and eating disorder diagnosis that most often emerges in childhood. Due to ARFID’s diagnostic infancy, its medical complications are just starting to be delineated in the literature, and some are extrapolated from the medical manifestations of malnutrition in anorexia nervosa, restricting subtype (AN-R). Pediatric patients with ARFID can have a myriad of physical complaints, most commonly gastrointestinal, that prompt them to seek medical evaluation; thus, familiarity with its medical manifestations is important for all physicians.
Recent Findings
Electrolyte abnormalities may be more common in ARFID compared to patients with AN, while bradycardia has been shown to be comparatively less common. ARFID has been found to be associated with low bone density in both males and females. Addressing nutritional deficits and weight issues are paramount. Cognitive behavioral therapy for ARFID (CBT-ARFID) and several psychotropic medications have been found to be acceptable treatment modalities, but randomized controlled trials are needed.
Summary
ARFID has numerous reported and theoretical medical complications due to the resulting malnutrition that can last until adulthood if left untreated.
... However, literature on the topic is scarce and little data exists to fully explain the mechanism behind those changes. Some authors have also noted that the decreased strenghth of respiratory muscles in anorexia nervosa patients affects the residual volume of the lungs, which may promote the development of emphysema [8,9]. Furthermore, severe weight loss has been associated with impairment of the diaphragm' functioning, which may exacerbate dyspnea and respiratory failure during a respiratory tract infection [10]. ...
... Many studies and case reports point towards the conclusion that AN patients are more susceptible to infections due to a weakened immune system [4,12]. Furthermore, they are at a greater risk of rare complications, such as anatomical changes in the lungs [8]. ...
Background
Persistent structural changes of the lungs in anorexia nervosa (AN) patients are rarely described in contemporary medical literature. The objective of our paper is to report a rare case of severe bronchiectasis and inflammatory changes to the lungs resulting from chronic malnutrition in a AN patient.
Case presentation
We describe a patient with severe inflammatory lung disease caused by malnutrition, resulting in persistent bronchiectasis accompanying AN. We performed an analysis of the patient’s medical records including radiological findings and laboratory results. A review of available literature shows very little data available on this topic.
Conclusion
Bronchiectasis and other structural changes of the lungs are rare, but severe complications of severe, chronic malnutrition. As exemplified by our case report, they may require extensive differential diagnosis and pose a significant clinical challenge due to their non-reversible character. A successful treatment relies heavily on the patient’s compliance and may be hard to achieve. Clinicians managing patients with anorexia nervosa should be wary of early respiratory tract dysfunction-related symptoms and always consider malnutrition bronchiectasis as a differential diagnosis option.
