Reduced febrile response to bacterial infection in anorexia nervosa patients

Pulmonary complications of eating disorders: a literature review

The medical complications of eating disorders (EDs) have been described in the literature; however, the pulmonary system has historically been described as relatively spared from the ravages of eating disorders and thus neglected in the literature. Here we review the pulmonary complications that have been described in the literature, including the effects of starvation on the lungs of nutritionally deprived animals and patients with anorexia nervosa. There is clear evidence of weakness of respiratory muscles with starvation in both groups. However, there is discordance in the literature as to whether starvation results in "nutritional emphysema," and if so, by what mechanism and at what degree of malnutrition it develops. We also explore the growing concern for the risk of non-tuberculosis mycobacterium infection as well as risk for pneumomediastinum and pneumothorax in patients with restrictive EDs. From the limited literature, it is clear the lungs, in fact, are not spared and that further research is needed to fully understand the full extent of pulmonary complications instigated by EDs.

Risk of somatic diseases in patients with eating disorders: the role of comorbid substance use disorders

AIMS

Eating disorders (EDs) and substance use disorders (SUDs) often co-occur, and both involve somatic diseases. So far, no study has considered whether comorbid SUDs may impact somatic disease risk in patients with EDs. Therefore, this study aimed to examine the impact of comorbid SUDs on the risk of 11 somatic disease categories in patients with anorexia nervosa (AN), bulimia nervosa (BN) and unspecified eating disorder (USED) compared to matched controls.

METHODS

A retrospective cohort study was conducted using Danish nationwide registries. The study population included 20 759 patients with EDs and 83 036 controls matched on month and year of birth, sex and ethnicity. Hazard ratios (HRs) were calculated to compare the risk of being diagnosed with a somatic disease (within 11 categories defined by the ICD-10) following first ED diagnosis (index date) between ED patients and controls both with and without SUDs (alcohol, cannabis or hard drugs).

RESULTS

The ED cohort and matched controls were followed for 227 538 and 939 628 person-years, respectively. For ED patients with SUDs, the risk pattern for being diagnosed with different somatic diseases (relative to controls without SUDs) varied according to type of ED and SUD [adjusted HRs ranged from 0.95 (99% CI = 0.57; 1.59) to 4.17 (2.68, 6.47)]. The risk estimates observed among ED patients with SUDs were generally higher than those observed among ED patients without SUDs [adjusted HRs ranged from 1.08 (99% CI = 0.95, 1.22) to 2.56 (2.31, 2.84)]. Abuse of alcohol only had a non-synergistic effect on six disease categories in AN patients and five in BN and USED patients. Abuse of cannabis (with/without alcohol) had a non-synergistic effect on five disease categories in AN and BN patients and two in USED patients. Abuse of hard drugs (with/without alcohol or cannabis) had a non-synergistic effect on nine disease categories in AN patients, eight in BN patients and seven in USED patients.

CONCLUSIONS

The present study documents non-synergistic but not synergistic harmful somatic consequences of SUDs among patients with different EDs, with AN and hard drugs being the most predominant factors. Hence, EDs and SUDs did not interact and result in greater somatic disease risk than that caused by the independent effects. Since EDs and SUDs have independent effects on many somatic diseases, it is important to monitor and treat ED patients for SUD comorbidity to prevent exacerbated physical damage in this vulnerable population.

Anorexia nervosa and COVID ‐19 infection: Clinical case report

The true risk of COVID‐19 infection in anorexia nervosa (AN) including the duration of viral RNA shedding and infectivity is still unclear. We report on a case of a patient with severe AN with a mild course of COVID‐19 and prolonged viral RNA shedding for at least 39 days after symptom onset. A careful evaluation of long‐term infectivity must include viral load, live virus isolation, and viral genome sequencing.

We report on a case of a patient with severe anorexia nervosa (AN) with unusually prolonged viral clearance, despite a mild course of COVID‐19. Careful evaluation and preventive actions should be tailored to each patient with AN requiring hospitalization considering the potential for disease transmission and viral mutation.

In patients with anorexia nervosa, myokine levels are altered but are not associated with bone mineral density loss and bone turnover alteration

Objectives

The two-fold aim of this study was: (i) to determine the effects of undernutrition on the myokines in patients with restrictive anorexia nervosa (AN) and (ii) to examine the potential link between myokines and bone parameters.

Methods

In this study, 42 young women with restrictive AN and 42 age-matched controls (CON) (mean age, 18.5 ± 4.2 years and 18.6 ± 4.2 years, respectively) were enrolled. aBMD and body composition were determined with DXA. Resting energy expenditure (REEm), a marker of energy status, was indirectly assessed by calorimetry. Bone turnover markers and myokines (follistatin, myostatin and irisin) were concomitantly evaluated.

Results

AN patients presented low aBMD at all bone sites. REEm, bone formation markers, myostatin and IGF-1 were significantly lower, whereas the bone resorption marker and follistatin were higher in AN compared with controls. No difference was observed between groups for irisin levels. When the whole population was studied, among myokines, only myostatin was positively correlated with aBMD at all bone sites. However, multiple regression analyses showed that in the AN group, the independent variables for aBMD were principally amenorrhoea duration, lean tissue mass (LTM) and procollagen type I N-terminal propeptide (PINP). For CON, the independent variables for aBMD were principally LTM, age and PINP. Whatever the group analysed, none of the myokines appeared as explicative independent variables of aBMD.

Conclusion

This study demonstrated that despite the altered myokine levels in patients with AN, their direct effect on aBMD loss and bone turnover alteration seems limited in comparison with other well-known disease-related factors such as oestrogen deprivation.

Candida brain abscesses in a patient with anorexia nervosa receiving total parenteral nutrition

A 28-year-old woman with anorexia nervosa (AN) and Candida brain abscesses was transferred to our hospital for intensive treatment. On admission, she had a low-grade fever but no clinical neurological abnormalities were observed, even though she had a high-grade fever in the previous hospital. These clinical findings did not suggest a serious disorder in the brain. However, magnetic resonance imaging showed mass lesions in bilateral lentiform nuclei in addition to several abscesses in the whole body. The fungal cultures of specimens from abscesses on the anterior chest wall and iliopsoas muscle detected Candida albicans. She was treated with antifungal therapy (fosfluconazole, fluconazole, liposomal amphotericin B, and flucytosine) and two emergent craniotomies for drainage of the intracranial fluid. Thereafter, antifungal medications (voriconazole and flucytosine) were administered for six months as a longterm treatment, which abolished most abscesses. However, severe frontal lobe dysfunction persisted as a residual symptom. This case suggests that AN can mask clinical manifestations of infection. We should always consider the possibility of infectious complications in these patients.

COVID-19, anorexia nervosa and obese patients with an eating disorder - some considerations for practitioners and researchers

Since COVID-19 is a global health emergency, there is an urgent need to share experiences on decision-making with regard to safety recommendations and for hypotheses that can inform a more focused prevention and treatment. Moreover, combining research into eating disorders and obesity with research into COVID-19 may provide a unique opportunity to shed light on the susceptibility to COVID-19.

Severe bronchiectasis and inflammatory lung disease in a patient with anorexia nervosa and severe and enduring malnutrition - a case report

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.

Coping strategies and stress-induced natural killer cell redistribution in women with eating disorders

BACKGROUND

Patients with eating disorders (ED) are very sensitive and responsive to psychosocial stress. Stress response includes changes in immune cell distribution and may be modulated by the capability to cope with stressors. Thus, the present study sought to analyze the association between coping strategies and immune response (natural killer [NK] cell redistribution following psychosocial stress) in patients with anorexia nervosa (AN) and bulimia nervosa (BN) and healthy controls (HC).

METHOD

Twenty-four AN patients, 29 BN patients, and 58 HC were studied. A multidimensional assessment tool, the COPE Inventory, was used to assess coping strategies. The number of NK cells was quantified in peripheral blood before and after the application of the Trier Social Stress Test (TSST). Potentially mediating variables, such as weight status, severity of eating pathology, depression, anxiety, and impulsivity were controlled.

RESULTS

The three groups differed in intensity and direction of cell redistribution: The TSST was followed in BN patients by a significant decrease in the number of NK cells, whereas HC displayed a moderate decrease and AN a clear increase. Specific correlations between coping strategies and NK cell mobilization were found, especially in BN patients (positive for "planning" and negative for "substance abuse").

CONCLUSION

Recognition and subsequent modification of the dysfunctional coping strategies used by patients with ED could contribute to improving their immune status, strengthening their resilience and increasing their ability to overcome the disease.

The adolescent onset anorexia nervosa study (ANABEL): Design and baseline results

The anorexia nervosa adolescent longitudinal biomarker assessment study (ANABEL) is a 2-year longitudinal study.

OBJECTIVE

Evaluate several clinical, biochemical, immunological, psychological, and family variables and their interactions in adolescent onset eating disorders (EDs) patients and their 2-year clinical and biological outcome. This article illustrates the framework and the methodology behind the research questions, as well as describing general features of the sample.

METHODS

A longitudinal study of 114 adolescents with EDs seeking treatment was performed. Only adolescents were selected during 4 years (2009-2013). The variables were collected at different times: baseline, 6, 12, 18, and 24 months of the start of treatment. Diagnoses were completed through the semi-structured Kiddie-Schedule for Affective Disorders and Schizophrenia interview.

RESULTS

At baseline, the mean age was 15.11 (SD = 1.36). The mean ED duration was 10 months (SD = 5.75). The mean body mass index was 16.1 (SD = 1.8). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis at baseline for restrictive anorexia nervosa was 69.6%, 17.4% for purgative anorexia nervosa, and 24.3% for other specified feeding disorder. At 12 months, 19.4% were in partial remission, whereas at 24 months, 13.8% had fully recovered and 29.2% had partially recovered.

CONCLUSIONS

There was an acceptable physical and psychopathological improvement during the first year of treatment, with recovery being more evident during the first 6 months.

Increased use of antimicrobial medication in bulimia nervosa and binge-eating disorder prior to the eating disorder treatment

OBJECTIVE

We examined the use of antimicrobial medication as a proxy for infections in large patient cohort treated for binge-eating disorder (BED), bulimia nervosa (BN), and anorexia nervosa (AN) over the five-year period preceding eating disorder treatment.

METHOD

Patients (N = 1592) at the Eating Disorder Unit of Helsinki University Central Hospital between 2000 and 2010 were compared with matched general population controls (N = 6368). The study population was linked to the prescription data of antibacterial, antifungal and antiviral medication from the Register on Reimbursed Prescription Medicine. Data were analyzed using regression models.

RESULTS

Individuals with BN and BED had received more often antimicrobial medication prescriptions compared to their controls (OR: 1.7, 95% CI: 1.3-2.1; OR: 2.6, 95% CI: 1.4-4.6, respectively), while no significant difference emerged in AN (OR: 0.9, 95% CI: 0.7-1.0, p = 0.10). Of the main drug categories, the respective pattern was seen in antibacterial and antifungal medication, while increased use for antivirals appeared only in BN (OR: 1.6, 95% CI: 1.1-2.3). Measured with the mean number of prescriptions or mean Defined Daily Doses per individual, patients with BN, BED and males with AN had also higher total antimicrobial medication use.

DISCUSSION

Indicating increased infections, we found elevated use of antimicrobial medication in BN, BED and in males with AN. Infections may be consequence of hyperglycemia, weight gain, or dysregulation of intestinal microbiota associated with core eating disorder behaviors. Or the other way round; changes in intestinal microbiota due to infections, inflammation, or antibacterial medications might contribute to eating disorders in multiple ways. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:542-552).

Management and treatment of eating disorders with severe medical complications on a psychiatric ward: a study of 9 inpatients in Japan

OBJECTIVE

To describe eating disorders inpatients with severe medical complications and elucidate the problems in managing them on a psychiatric ward.

METHOD

Of the 111 eating disorders patients hospitalized on our psychiatric ward from January 2005 to December 2012, 9 had eating disorders with severe medical complications. Through chart review and computerized data collection, we retrospectively evaluated patient clinical data.

RESULT

All 9 patients were women, with a mean age of 22.4±5.7 years, mean body weight of 26.2±3.0 kg, and mean body mass index of 10.5±1.5 on admission. Severe medical complications commonly seen were severe hypoglycemia, refeeding syndrome, coagulation abnormality, and severe liver dysfunction. Three patients died during hospitalization. All patients were managed mainly on the psychiatric ward despite their abnormally low body weight and severe medical complications.

CONCLUSIONS

Patients with eating disorders, although physically serious, often need to be managed on a psychiatric ward, even at the risk of providing less than ideal care for their physical complications. It is important to assess patient status both physically and psychologically and to select an appropriate therapeutic environment for safe and effective treatment.

[Hematological changes in adolescent anorexia nervosa]

OBJECTIVE

Hematological changes often occur in patients with acute anorexia nervosa (AN). However, the relationship between these disturbances and other clinical parameters remains unclear.

METHOD

Leucocyte, erythrocyte, and thrombocyte counts as well as hematocrit, hemoglobin, and differential blood counts were collected at admission and after weight restoration in 88 female adolescent patients with the diagnosis of AN according to DSM-IV. These were then compared to clinical parameters.

RESULTS

At admission, there were mild changes in the blood count, most of which, however, were reversible after weight gain. Patients with a greater weight loss, a lower age-adjusted BMI, and a history of taking psychotropic drugs were more likely to develop hematological abnormalities.

CONCLUSIONS

Although most of the hematological changes in adolescent patients with AN were mild, patients with high weight loss and/or low age-adjusted BMI as well as those on psychotropic medication should be monitored carefully in order to avoid severe medical complications. An altered immune function in adult patients with chronic AN might contribute to a higher rate of infections and thus to an increased mortality.

Mycobacterium chimaera causes tuberculosis-like infection in a male patient with anorexia nervosa

Here we present a 27-year-old male patient--with a known prolonged history of anorexia nervosa (AN)--suffering from tuberculosis like infection. At the time he was admitted to clinical treatment, he had developed fever up to 40°C and survived on a body mass index of 11.8. In this case, Mycobacterium chimaera, generally recognized for low pathogenicity, was identified as the causative agent. Remission from lung infection was achieved after antibiotic treatment according to laboratory susceptibility testing while earlier antituberculosis therapies had failed. Because of a large cavity in the upper left lung, surgical excision was necessary to prevent recurrence of lung infection. Moreover, stabilization of the patient general health problem needs to be supported by a lasting psychotherapy.

The fatal outcome of an individual with anorexia nervosa and Sheehan's syndrome as a result of acute enterocolitis: a case report

OBJECTIVES

To illustrate the close association between a disturbed psychosocial up-bringing, frequent physical illness, and medical interventions.

METHOD

We report a case of a 44-year-old woman with anorexia nervosa (AN) and Sheehan's syndrome who died as a result of a toxic cardiac arrest.

RESULTS

The patient presented with a BMI of 13.6 kg/m(2). She refused any intensive-care treatment and died from toxic cardiac arrest. Postmortem examination revealed an acute gastroenterocolitis.

DISCUSSION

The history of this patient illustrates how psychological deprivation led to eating disturbances, early pregnancy, and the life-threatening delivery of twins. This resulted in a diagnosis of Sheehan's syndrome, hepatitis C, and a ventricular ulcer. A psychosocial event triggered a late exacerbation of her AN. A helpful alliance between patient and staff did not occur as she rejected it.

Malnutrition induces dissociated changes in lymphocyte count and subset proportion in patients with anorexia nervosa

OBJECTIVE

The effect of nutritional state on lymphocytes in patients with anorexia nervosa (AN) was studied.

METHOD

We studied total lymphocyte count (TLC), lymphocyte subsets, and nutritional markers [body mass index (BMI), insulin-like growth factor-1 (IGF-I)], and serum zinc concentration) in 33 patients with AN and 10 healthy controls.

RESULTS

TLC positively correlated with BMI (r = .680, p < .001), IGF-I (r = .609 p < .001), and zinc (r = .589, p < .001). The CD4+ T-lymphocyte (CD4) proportion correlated negatively with BMI (r = -.301, p = .05) and IGF-I (r = -.346, p = .023), counteracting the effect of malnutrition on TLC. However, because this increase in CD4 proportion was weak, patients with very severe malnutrition (indicated by serum zinc less than 40 microg/dL) had critically low CD4 counts of less than 200 cells/microL.

CONCLUSION

Our findings suggest that lymphocyte counts and subset proportion change in an opposite manner in patients with AN, and that decrease in serum zinc levels is nutrition-related.

Investigation of regulatory T cells in anorexia nervosa

OBJECTIVE

The aim of our study was to determine, how severe calorie restriction in anorexia nervosa (AN) may influence regulatory T (Treg) cells and their cellular networks, that is, their main inducers (dendritic cells (DC) and monocytes) and their target cells, CD4+ lymphocytes.

DESIGN

We measured the prevalence of Tregs, myeloid and plasmocytoid DC. The prevalence of tumor necrosis factor-alpha (TNF-alpha) and interleukin (IL)-12-positive monocytes, IL-2, IL-4 and interferon (IFN)-gamma positive CD4+ cells was determined by intracellular staining after activation.

SETTING AND SUBJECTS

In total, 21 AN patients and 19 healthy age-matched controls (body mass index values, median (range): 14.9 (11.1-17.4) vs 23.2 (19.5-27.4) kg/m(2)) have been recruited.

RESULTS

Prevalence of Tregs, DCs, TNF-alpha and IL-12-positive monocytes, IL-4 and IFN-gamma-producing CD4+ cells were similar in AN and controls. The prevalence of IL-2-positive CD4+ cells was somewhat lower in AN (% value, median (range): 12.05 (7.50-16.70) vs 14.40 (12.00-22.00), P<0.05). None of these parameters correlated with the patients' clinical characteristics.

CONCLUSIONS

Our results suggest that the antigen presenting cell - regulatory T cell - CD4+ lymphocyte axis is not affected by calorie and nutritional deficiency.

Anaerobic bacterial empyema accompanying intrathoracic gas formation in anorexia nervosa

OBJECTIVE

Intrathoracic gas formation due to anaerobic pleuropulmonary infection is rare.

METHOD & RESULTS

We experienced a case of empyema with intrathoracic gas formation by an anaerobic bacterium in a young woman with anorexia nervosa (AN).

CONCLUSION

We should therefore be alert to the possibility of serious infection in patients with AN, even when they have few complaints or normal white blood cell counts.

Psychiatric, somatic, and gastrointestinal disorders, and Helicobacter pylori infection in children with recurrent abdominal pain

AIMS

To examine the utility of the Rome II criteria in children with recurrent abdominal pain (RAP) and compare them to those who met Apley's criteria and those who met neither criteria.

METHODS

Prospective study in general paediatric clinics in Komagane, Japan. Children with abdominal pain were classified into those who met Rome II criteria, those who met Apley's criteria, and those who met neither.

RESULTS

A total of 182 children with RAP participated; 45 children met Rome II criteria, 55 met Apley's criteria, and 82 met neither. Children who met Rome II criteria had a significantly higher prevalence of psychiatric and somatic disorders compared to the group met neither (36% v 6%, 22% v 10%, respectively). The overall prevalence of H pylori was 7%; prevalence increased with age from 3% at age < or = 10 to 10% for children >10 years. Children who met Rome II criteria had a significantly higher prevalence of H pylori infection than the reference group (18% v 4%). In a logistic regression model, all the study variables were included in the model specifying first the Rome II criteria group as the independent variable; psychiatric disorders, H pylori infection, and older age group were independent risk factors.

CONCLUSIONS

More than half the children suffering from recurrent abdominal pain met neither Apley's nor Rome II criteria. Children who meet Rome II criteria should be evaluated for psychiatric disorders and should be tested for H pylori infection. Despite the overall trend for a fall in the prevalence of H pylori infection among children in Japan, there are subpopulations of sick children where the prevalence of the infection is relatively high.

Adipose tissue and the immune system

Adipocytes anatomically associated with lymph nodes (and omental milky spots) have many special properties including fatty acid composition and the control of lipolysis that equip them to interact locally with lymphoid cells. Lymph node lymphocytes and tissue dendritic cells acquire their fatty acids from the contiguous adipocytes. Lymph node-derived dendritic cells suppress lipolysis in perinodal adipocytes but those that permeate the adipose tissue stimulate lipolysis, especially after minor, local immune stimulation. Inflammation alters the composition of fatty acids incorporated into dendritic cells, and that of node-containing adipose tissue, counteracting the effects of dietary lipids. Thus these specialised adipocytes partially emancipate the immune system from fluctuations in the abundance and composition of dietary lipids. Prolonged, low-level immune stimulation induces the local formation of more adipocytes, especially adjacent to the inflamed lymph node. This mechanism may contribute to hypertrophy of the mesentery and omentum in chronic inflammatory diseases such as HIV-infection, and in smokers. Paracrine interactions between adipose and lymphoid tissues are enhanced by diets rich in n-6 fatty acids and attentuated by fish oils. The latter improve immune function and body conformation in animals and people. The partitioning of adipose tissue in many depots, some specialised for local, paracrine interactions with other tissues, is a fundamental feature of mammals.

Bacterial infections in anorexia nervosa: delayed recognition increases complications

OBJECTIVE

We compared the natural history of bacterial infection in patients with anorexia nervosa (AN) with controls, and assessed which of a range of patient characteristics were associated with infection, fever response, and the rate of infectious complications in AN patients.

METHOD

The charts of 311 consecutive hospital admissions of AN patients were reviewed. Patients who had a bacterial infection while in the hospital were compared with the AN patients who did not have an infection, with respect to a range of demographic and disease variables. Fever response and infection complication rate also were evaluated in AN patients with a bacterial infection and in nonanorectic control subjects admitted with a bacterial infection.

RESULTS

AN patients with a bacterial infection showed a reduced fever response, were often difficult to diagnose because of fewer signs and symptoms, and infection became more frequent with increasing patient age.

DISCUSSION

A reduction in fever response and the signs and symptoms of infection significantly delayed diagnosis in AN patients and increased the complication rate from bacterial infection. We recommend that an increased index of suspicion and an early complete blood count and bacteriologic cultures be adopted for the investigation of bacterial infection in AN patients.