We report the case of a 20-year-old anorexic girl (BMI=12.9), who was misdiagnosed the first time and developed severe electrolyte imbalances due to lack of awareness about refeeding syndrome. Few cases of RS have been reported in literature and protocols have been suggested for prevention and management of this syndrome, including the awareness of circumstances in which it is most likely to develop, refeeding slowly and building-up micronutrient content over several days. Improved awareness and understanding of refeeding syndrome along with a well-coordinated plan are vital in delivering safe and effective nutritional rehabilitation. We suggest a slow and gradual increase in nutrition along with nutritional counselling and psychotherapy

Abid, Shahab

Ayub, Adil

Parkash, Om

English

eCommons@AKU

eCommons@AKUDepartment of Medicine Department of MedicineMay 2014Refeeding syndrome in a young girl with anorexianervosa.Om ParkashAga Khan University, om.parkash@aku.eduAdil AyubAga Khan UniversityShahab AbidAga Khan University, shahab.abid@aku.eduFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_med_medPart of the Gastroenterology Commons, Rehabilitation and Therapy Commons, Sports MedicineCommons, and the Sports Sciences CommonsRecommended CitationParkash, O., Ayub, A., Abid, S. (2014). Refeeding syndrome in a young girl with anorexia nervosa.. JCPSP: Journal of the College ofPhysicians and Surgeons--Pakistan, 24(supplement 2), s78-s80.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_med_med/203S78 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (Special Supplement 2): S78-S80INTRODUCTIONRefeeding syndrome (RS) is a potentially lethalcondition, defined as severe electrolyte and fluidimbalance that occurs due to aggressive nutritionalrehabilitation in malnourished patients.1 Patients at riskof developing RS are those with marasmus, proteinenergy malnutrition and massive weight loss (obeseand anorexia nervosa patients).2 The actual incidenceof refeeding syndrome is unknown, but a studydemonstrated a rate of 0.43% in hospitalized patients,with malnutrition being one of the strongest risk factors.3The predominant features of refeeding syndromeinclude severe hypophosphatemia, hypokalemia andhypomagnesia together with other fluid imbalanceabnormalities which may lead to life-threatening cardiac,central nervous system, pulmonary and haematologiccomplications.4 Although refeeding malnourishedpatients may look straight forward, but the syndromemay emerge with oral, enteral and parenteral nutritionand can be fatal if not recognized and treated in a timelyand proper manner. We report the case of a 20-year-old lady, a knowncase of anorexia nervosa, who developed refeedingsyndrome on aggressive nutrition and was managed atour hospital with total parenteral nutrition (TPN). This isin fact the first case of refeeding syndrome reported fromPakistan, where potential cases of refeeding syndromecan occur, due to large proportion of northern populationliving in relief camps with inadequate nutrition.CASE REPORTA 20-year-old girl from Karachi presented to theemergency care in March, 2010 with 2 days history ofsevere abdominal pain, vomiting and generalizedweakness. She had secondary amenorrhea and long-standing/chronic constipation since 3 years and wasdiagnosed to have anorexia nervosa a month ago. Shehad typical psychiatric history for anorexia nervosa andfear of being obese hence, avoiding food. She wasencouraged to eat a large amount of meat a day beforeadmission, after which she developed afore-mentionedsymptoms. Over the previous 12 weeks she had lost16 kg in weight. On examination, she weighed only29 kg and was 150 cm tall (Body Mass Index (BMI) =12.9). She was pale and emaciated with a pulse rate of100 beats/minute and blood pressure of 90/50 mm/Hg.CVS and chest examination was remarkable andabdominal examination revealed sunken abdomenwith mild tenderness in the right iliac fossa and nopalpable viscera. Musculoskeletal examination showedgeneralized muscle wasting. Laboratory examinationshowed low albumin, hypokalemia, hypophosphatemia,hypochloremic metabolic acidosis and deranged liverfunction tests (Table I). Abdominal and chest X-rayswere normal and abdominal ultrasound revealed asingle gallstone. Upper and lower gastrointestinalendoscopy was also done to rule out malabsorptionsyndrome. Computed Tomography (CT) chest andabdomen were completely normal. Electrocardiography(ECG) showed a normal QT interval of 0.36 second.Further past history revealed that she had consultedmultiple gynaecologists in the last 2 years for hersecondary amenorrhea, who prescribed her somemedicines which regulated her cycles, but her prolactinlevels were increased. She became pre-occupied withthoughts of being overweight (in spite of a weight of 42kg and BMI of 18.6), stopped her medicines and starteddieting and vigorous exercises. Her parents consulted apsychiatrist who diagnosed her with anorexia nervosaand prescribed anti-depressants. There was no familypsychiatric history and no major childhood illness.She was discharged after 4 days on esomeprazole andadvised for nutritional counselling. She again presentedCASE REPORTRefeeding Syndrome in a Young Girl with Anorexia NervosaOm Parkash1, Adil Ayub2 and Shahab Abid1ABSTRACTWe report the case of a 20-year-old anorexic girl (BMI=12.9), who was misdiagnosed the first time and developed severeelectrolyte imbalances due to lack of awareness about refeeding syndrome. Few cases of RS have been reported inliterature and protocols have been suggested for prevention and management of this syndrome, including the awarenessof circumstances in which it is most likely to develop, refeeding slowly and building-up micronutrient content over severaldays. Improved awareness and understanding of refeeding syndrome along with a well-coordinated plan are vital indelivering safe and effective nutritional rehabilitation. We suggest a slow and gradual increase in nutrition along withnutritional counselling and psychotherapy.Key Words: Refeeding syndrome.   Anorexia nervosa.   Nutritional rehabilitation.Department of Medicine1 / Medical Student2, The Aga KhanUniversity Hospital, Karachi.Correspondence: Dr. Om Parkash, F/A-12, Pak Tameer Plaza,Gulshan-e-Iqbal, Block 14, Karachi.E-mail: om.parkash@aku.eduReceived: June 23, 2012;   Accepted: April 06, 2013.3 days later with severe phosphatemia, abdominaldistension and feet swelling. She was diagnosed to haverefeeding syndrome with severe electrolyte imbalance.Nutritional consult was taken and she was started onTPN 1 (for controlled gradual intake), which was laterchanged to TPN 2 as she did not tolerate oral diet. Shewas prescribed 1500 kcal/day diet and antiemetics werestarted before meals to stop initial vomiting. She wasalso engaged into psychotherapy and motivationaltherapy. There was gradual improvement in hercondition and she was slowly switched to total oralintake. In 4 weeks, she gained 5 kg in weight andbecame quite stable. She was discharged on esomep-razole, antidepressants and vitamin supplements.Presently, 2 years after discharge from the hospital, sheis stable and taking proper meals regularly. She feelswell and there have been complaints of occasionalvomiting only.DISCUSSIONAggressive nutrient uptake especially carbohydrate mayevoke insulin release and increase uptake of glucose,phosphate, magnesium etc. and the electrolyteimbalances can result in severe complications andsudden death. The natriuretic effect of insulin alsocauses sodium retention and oedema. Severephosphatemia, the most dominant feature of refeedingsyndrome can result in dyspnea, respiratory failure,hypotension, shock, arrhythmias and cardiac failure.Increased utilization of thiamine in these conditions maycause thiamine deficiency in some patients, which mayresult in Wernicke's encephalopathy.5 Other clinicalsigns and symptoms are shown in Table II.A protocol for prevention and management of refeedingsyndrome indicated the circumstances in which it is mostlikely to develop and stressed on importance ofrefeeding slowly and building up micronutrient contentover several days with frequent monitoring.4 Itemphasized that the treatment should never beexecuted with haste and the targeted weight gain shouldnever exceed 1 kg/week. In adults, reports haverecommended starting at 1000 kcal/day.6 The proteinshould not be restricted during nutritional support, butsodium and fluids should be restricted to prevent fluidoverload (Na 20 mEq/d and fluids < 1000 ml/d).7 Theguidelines for electrolyte and thiamine replacement aregiven in Table III.Refeeding syndrome anorexia nervosaTable I: Biochemical values.Admission values ReferenceHb (g/dl) 11.3 13.7 - 16.3Platelets ( x 109/l 148 150 - 400Albumin (g/dl) 2.3 3.5 - 4.8Phosphate (mmol/l) 1.6 2.2 - 4.8Potassium (mmol/l) 2.6 3.6 - 5Magnesium (mmol/l) 1.8 1.9 - 2.5Calcium (mmol/l) 6.9 8 - 11Chloride (mmol/l) 74 104 - 114Sodium (mmol/l) 120 136 - 138BUN (mg/dl) 12 6 - 16Creatinine (mg/dl) 0.6 0.85 - 1.35Bicarbonate (mEq/l) 33.5 17.5 - 27.5Total bilirubin (mg/dl) 5.3 0.25 - 1SGPT (IU/L) 148 3 - 33SGOT (IU/L) 174 18 - 32Alkaline phosphatase (IU/L) 86 28 - 124Table II: Clinical signs and symptoms of refeeding syndrome.1Hypophosphatemia Hypokalemia Hypomagnesia Thiamine deficiency Na retention HyperglycemiaDyspnea Arrhythmias Arrhythmias Encephalopathy Oedema HypotensionHypotension, thrombocytopenia Paralysis, muscle necrosis Tremors diarrhea Lactic acidosis Fluid overload Respiratory failureRespiratory failure Constipation Seizures - - KetoacidosisShock Rhabdomyolysis Coma - - DehydrationArrhythmias - Diarrhea - -Cardiac failure - - - - -Table III: Guidelines for replacement therapy.1Phosphate Intravenous replacement dose (administer over 6-12 hours)Children: 0.08-0.24 mmol/kg Maximum daily dose: 1.5 mmol/kgAdults: Initially 0.08 mmol/kg for mild and 0.16 mmol/kg for severe hypophosphatemiaMaximum dose: 0.24 mmol/kg per doseMagnesium Intravenous replacement dose (administer over 4 hours)Children: 25 - 50 mg/kg per dose ( 0.2-0.4 mEq/kg per dose)Maximum single dose: 2000 mg (16 mEq)Adults: 1 g every 6 hours for 4 doses for moderate and 8 - 12 g/d in divided doses for severePotassium Intravenous replacement dose (administer over atleast 1 hr)Children: 0.3 - 0.5 mEq/kg per dose Max Dose: 30 mEq per doseAdults: sameThiamine Children: 10 - 25 mg/d administered PO everyday for 2 weeks and then 5-10 mg/d for 1 month.Adults: 5 - 30 mg per dose 3 times per day, administered IV and then 5-30 mg/d administered PO for one monthJournal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (Special Supplement 2): S78-S80 S79Om Parkash, Adil Ayub and Shahab AbidS80 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (Special Supplement 2): S78-S80Although, nutritional rehabilitation is an essential compo-nent of the physical treatment of anorexia nervosa andother malnourished states, but psychological treatmentis also necessary to address the anxiety issues of thepatient. A good therapeutic alliance between the doctor,patient and the family establishes a cooperation thatenables to work on motivational factors. The treatmentat home is discussed in some studies to have morebenefits.1 These include encouraging the patient's senseof responsibility and control over the treatment,eliminating the psychiatric trauma of hospitalization andincreased chances of rehabilitation in patient's ownnatural environment. Still, due to the chances ofinfection, bleeding, air emboli and addiction to TPN, thepracticality of home treatment is being questioned.8 So,improved awareness and understanding of refeedingsyndrome along with a well-coordinated plan are vital indelivering safe and effective nutritional rehabilitation.In summary, rehabilitation of anorexia nervosa or othermalnourished states can result in fatal electrolytedisturbances (refeeding syndrome) and, therefore,proper and timely nutrition is recommended. We suggesta slow and gradual increase in nutrition along withnutritional counselling and psychotherapy, including thepatient's family, to prevent resistance from the patientand to ensure long-term compliance by the patient.REFERENCES1. Fuentebella J, Kerner JA. Refeeding syndrome. Pediatr ClinNorth Am 2009; 56:1201-10.2. Khan LU, Ahmed J, Khan S, Macfie J. Refeeding syndrome: aliterature review. Gastroenterol Res Pract 2011. Epub 2010 Aug 25.3. Mehanna H, Nankivell PC, Moledina J, Travis J. Refeedingsyndrome--awareness, prevention and management. Head NeckOncol 2009; 1:4.4. Stanga Z, Brunner A, Leuenberger M, Grimble RF, Shenkin A,Allison SP, et al. Nutrition in clinical practice-the refeedingsyndrome: illustrative cases and guidelines for prevention andtreatment. Eur J Clin Nutr 2008; 62:687-94.Epub 2007 Aug 15.5. Reuler JB, Girard DE, Cooney TG. Current concepts.Wernicke's encephalopathy. N Engl J Med 1985; 312:1035-9.6. Miller SJ. Death resulting from over zealous total parenteralnutrition: the refeeding syndrome revisited. Nutr Clin Pract2008; 23:166-71.7. Palesty JA, Dudrick SJ. The goldilocks paradigm of starvationand refeeding. Nutr Clin Pract 2006; 21:147-54.8. Latzer Y, Eysen-Eylat D, Tabenkin H. A case report: treatmentof severe anorexia nervosa with home total parenteralhyperalimentation. Int J Eat Disord 2000; 27:115-8.

Refeeding syndrome in a young girl with anorexia nervosa.

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Refeeding syndrome in a young girl with anorexia nervosa.

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