Dr. Mahak Bhasin, Dr. Sajitha Nair, Dr Sindhu, Dr Sreya, Dr C. Jayakumar, Department of Pediatrics, AIMS, Kochi
Seventeen year old child developmentally normal and immunised for age k/c/o hypothyroidism on treatment for the same had complaints of infrequent bowel movements with painful passage of hard stools ~once in two weeks.
Weight was 55kgs at this time.
She was evaluated for these complaints and a colonoscopy was done which was found to be normal. She was thus prescribed laxatives and asked to follow a strict diet avoiding eggs, sugar, meat etc. and engage in exercises due to obesity.
Initially, she had difficulty in restricting her diet but as her constipation improved, she started noticing aversion towards foods like eggs, non vegetarian foods and oily foods. Her appetite reduced and she started losing weight. She lost 17 kgs in 9 months and was brought here for evaluation of the same. Weight at admission was 37kgs.
No history of cough, low grade fever, evening rise of fever, night sweats.
No history of blood in stools, joint pain, rashes, perianal fistula, oral ulcers
No history of increased frequency of micturition, increased thirst
No history suggestive of bone pains, recurrent respiratory infections, oral thrush
No history of self induced vomiting, laxative abuse or distorted body image.
Normal antenatal and post natal history and no previous hospital admissions in the past.
No history of TB contact in the past 2 years
Paternal grandmother and father’s sister were treated for depression
On examination, she was was tired looking and emaciated in appearance with bradycardia, pallor and bilteral pitting pedal edema. 2*1 cm non tender firm swelling was noted in the anterior surface of lower neck below thyroid gland
No skin rashes, mucocutaneous bleeds, oral ulcer, arthritis, bony tenderness
SMR stage 5
Anthropometry:
Weight: 36.2kgs (below 3rd centile)
Height:170cm(on 97th centile),
BMI – 12.6kg/m2(below 3rd centile)
Systemic examination was normal except bradycardia.
Differentials Considered
• Tuberculosis
• Inflammatory Bowel Disease
• Type 1 Diabetes
• HIV
• Malignancy
• Psychological
Labs showed anemia with normal counts and negative inflammatory markers.
LFT/RFT. Peripheral Smear showed microcytic hypochromic anemia.
GRBS 150mg/dL and HbA1c 5.3%
Culture Urine Negative
25 OH Vitamin D low 23.19ng/ml
Vitamin B12 highly elevated >>2000pg/ml
Anti HCV, HBsAg, p24 Ag and HIV 1 AND 2 Ab Negative
TTG IgA and Total IgA to rule out Celiac disease were normal
Iron profile showed low serum iron and TIBC levels with elevated serum ferritin (460.30ng/ml) and low TIBC (173.8mcg/dl)
USG Abdomen showed mild fatty liver, significant urinary bladder debris, prominent left extrarenal pelvis with uroepithelial thickening.
USG Pelvis was normal
USG Neck was suggestive of ?dermoid cyst just inferior to the thyroid with no focal thyroid lesions.
USG Bilateral ankles only mild subcutaneous edema around the bilateral ankle joints.
2D Echo showed localised pericardial effusion measuring 9mm around postero inferior region
HRCT Chest showed a midline cystic lesion below the thyroid liked dermoid cyst. Multiple centrilobular nodules in the left lower lobe with adjacent groundglass opacity-possibility of aspiration to beconsidered. Pericardial effusion.
CT Abdomen showed mild diffuse periportal edema. Mild free fluid in pelvis and mesenteric stranding. Mild pericardial effusion. Ground glass opacity in left lower lobe- likely infective etiology.
Bronchoscopy- was normal. BAL Fungal KOH, GneXpert, AFB Smear, BAL Culture, Fungal Culture, AFB Culture negative
BAL Cytopathology- alveolar macrophages with lymphocytes. Bronchial epithelial cells seen. Suggestive of chronic inflammation, no malignant cells seen.
Colonoscopy normal
OGDscopy normal. Histopathological specimens were suggestive of very mild chronic inactive gastritis,
NBT DHR negative
Angiotensin Converting Enzyme to rule out Sarcoidosis was normal.
Immunoglobulin profile normal. Extended lymphocyte subset normal.
ANA IFA and Anti dsDNA negative
Serum Cerruloplasmin levels mildly low(15.71) (16-45mg/dl) Rheumatology consultation sought and Autoimmune liver panel done as advised was negative
Gynaecology review was sought for secondary amenorrhoea and Serum Prolactin values and Beta HCG done as per their advice. Values were found to be normal
After ruling out all the organic causes of her symptoms, child was evaluated for a psychogenic cause for her illness.
Psychiatry consultation was sought. Since there was no history of self induced vomiting/laxative abuse/distorted body image, possibility of anorexia nervosa was ruled out.
Child was hence diagnosed with F50.89 – Psychogenic Loss of Appetite
Child was started on psychotherapy and after that child started gaining weight
Eating disorders are characterised a persistent disturbance of eating behaviour that impairs health or psychosocial functioning.
Eating Disorders- ICD 10 Classification
• F50.0 Anorexia Nervosa
• F50.00 unspecified, F50.01 restricting type, F50.02 binge eating/purging
• F50.2 Bulimia nervosa
• F50.8 Other eating disorders
• F50.81 Binge eating disorder
• F50.82 Avoidant/restrictive intake disorder
• F50.89 other specified eating disorder
• F50.9 Eating disorder, unspecified
Management includes psychotherapy and nutritional rehabilitation, management of an acutely ill patient.
Pharmacotherapy may be needed for such critical patients but does not have a role in long term management except for the depressed patient.
Children and teenagers, especially females are highly susceptible to developing these disorders and require careful screening for the same.