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Clinical Medical & Case Reports

Open Journal of

ISSN2379-1039

Volume3(2017)Issue14

YigitbasBA

OpenJClinMedCaseRep:Volume3(2017)

AnorexianervosaaccompaniedbybilateralpneumothoracesAybukeKekecoglu,MD;BurcuArpinarYigitbas,MD*;FadimeKelesoglu,MD;BarisSeker,MD;AyseF

Kosar,MD

*BurcuArpinarYigitbas,MD

I�ntensiveCareUnit,YedikuleChestDiseaseandSurgeryTrainingandResearchHospital,Istanbul,

Turkey.Phone:00904090202;Email:[email protected]

Abstract

Anorexianervosaisaneatingdisorderthatcanbeaccompaniedbyvariouscomplications.An18-year-

oldfemalepatient,whowastreatedfor2yearsduetoanorexianervosa,wasadmittedtoourhospital

because of bilateral pneumothoraces. A bilateral tube thoracostomy was performed, and she was

diagnosedwithidiopathicspontaneouspneumothoraxanddischarged.Thepatientwasadmittedtothe

hospital 9 months later due to respiratory complications. No increase was found in the patient's

pneumothorax, but hypercarbic respiratory failure was discovered. During her treartment in our

intensivecareunitnoneofhercultureswerepositive.Thepatientwasundernon-invasivemechanical

ventilationandmonitored.Shewasintubatedfollowinganincreaseinparenchymalin�iltratesandinthe

severityofherconcurrent respiratory failure.Thepatientdieddue toARDSon the17thdayofher

hospitalization.

Keywords

acuterespiratorydistresssyndrome;anorexianervosa;bilateralpneumothoraces

Introduction

Eatingdisordersarebecomingincreasinglyprevalentinoutpatientclinics.Thesedisordersmay

affecteveryorganandsysteminthebody;however,thelungsaretheless-commonlyaffectedorgans.In

thesecases,spontaneouspneumothorax,pneumomediastinumandemphysemaarereportedtodevelop

frequently[1].Inthisparticularcasestudy,thepatienttobediscussedwastreatedfor2yearsforthe

diagnosis of anorexia nervosa, a tube thoracostomy was performed following the development of

bilateral pneumothoraces, but the patient was transferred to the intensive care unit due to the

deteriorationofhergeneralmedicalcondition.

CasePresentation

The18-year-oldfemalepatientwasadmittedtoemergencyroomcomplainingofshortnessof

breath,respiratorydisorder,andcoughaccompaniedbyexpectoration.Apostero-anteriorchestX-ray

showedbilateralpneumothoracesaccompaniedbyin�iltrationsconcordanttopneumonia. Thepatient

washospitalizedinthechestdiseasesclinic,butthenreferredtotheintensivecareunitwhenhergeneral

medicalconditiondeterioratedandherhypoxemicrespiratoryfailureworsenedinarterialbloodgas.

Accordingtothepatient'shistory,shehadbeentreatedfor2years bythepsychiatrydepartment dueto

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herdiagnosisofanorexianervosa.Shewasanonsmoker.

The patient �irst admitted to emergency room approximately 9months ago, complaining of

shortnessofbreathandcough.Shewashospitalizedduetopneumothoraxobservedinbothofherlungs

during examinations. The case was discussed with the chest surgery department and a tube

thoracostomywasperformed(Fig1).Drainagewasterminatedwhennoincreasewasobservedinthe

currentpneumothorax inboth lungsof thepatient (Fig 2).Thoracic computed tomographyshowed

bilateralpneumothoraces,whichstartedattheupperlobeapicalsegmentlevelinbothhemithoraxesand

continuedtothesuperiorlingulasegmentlevelontheleft,andwhichscatteredtothediaphragmatic

region in the rightmiddle lobe. (Fig 3,4), In the transbronchial biopsy obtained through �iberoptic

bronchoscopy (FOB), minimal �ibrotic thickening, edema and bronchial mucosa fragments were

observed in the normal alveolar septa. Eating disorder-related pneumothorax was considered; the

patientwasdischargedandreceivedoutpatienttreatment.Duringfollow-uptreatments,noprogression

wasobservedinthepneumothorax,whichwasobservedintheupperzonesofbothlungs.

9monthslaterwhenshereadmittedtoouremergencyroomandacceptedtoourrespiratory

intensivecareunit,hergeneralmedicalconditionwaspoorandshewasconfused,dyspneic,tachypneic

andtachycardic.Herappearancewasquitecachecticandbodymassindexwas13kg/m2.Duringthe

physicalexamination,itwasobservedthatrespiratorysoundswerereducedintheupperareasofboth

lungs, and her expiration was longer. Bilateral and common coarse crackles were present during

inspiration. From the cardiovascular system examination S1(+), S2(+), the following results were

obtained:pulse:142/min,arterialbloodpressure:100/60mmHg,arterialoxygensaturationinroomair:

87%,arterialbloodgasvaluesinroomair:Ph:7.29,PCO2:86mmHg,PO2:60mmHg,HCO3:37mmol/L,

PaO2/FiO2:285.Thepatientwasgivennon-invasivemechanicalventilationunderBIPAPvision.IPAP26

cmH2O,EPAP6cmH2OandFiO2werestartedwith35%.Biochemistryanalyseswereasfollows:Glucose

68mg/dl;Urea22mg/dl;Creatinine0.3mg/dl;Uricacid1.6mg/dl;Totalprotein6.6g/dl,2.8g/dl;

Calcium9.2mg/dl;Sodium134mmol/L;Potassium4.5mmol/L;Chlorine98mmol/L;Totalbilirubin0.7

mg/dl;AST16U/L;ALT11U/L;GGT56U/L;LDH190U/L;ALP141U/L;totalcholesterol71mg/dl;

triglyceride78mg/dl;HDL16mg/dl;LDL39mg/dl;VLDL16mg/dl;Iron4mmg/dl;UIBC156mmg/dl;

CRP:33mg/L;WBC:14.9103/mm3;neutrophile10.5103/mm3;haemoglobin13.7g/dl;haematocrit

41.3%.Inthepostero-anteriorchestX-ray,itwasobservedthatthepneumothoraxlinewhichwaslimited

to the bilateral apical region had extended, and that common in�iltrations and consolidation had

developed in the lower right zonewhen compared to theX-ray from9months ago (Fig 5). Thorax

computedtomographyshowedpneumothoraxandcommonperibronchial in�iltrationswithbilateral

ground-glassdensitywerepresent inboth lungs,andnon-homogeneousconsolidation includingair

bronchogramswerepresentinthelaterobasalandporterobasalsegmentsoftherightlung'slowerlobe

(Fig6,7).Thepatient'sclinicalconditiondeterioratedandconfusionincreased,andthefollowingresults

wereobtainedfromarterialbloodanalysis:Ph:7.02,PCO2:129mmHg,PO2:84mmHg,HCO3:33.5

mmol/L,satO2:87.5%FiO2:100%,PaO2/FiO2:84.Shewasthenintubatedbasedontheseresults.Inthe

pressurecontrolmode,shewassupportedwithPEEP:8cmH2O,AbovePEEP:24cmH2OFiO2:40%,

respiratoryrate14.Inherechocardiography,apericardialeffusionof9.5mmwasdetectedintheleft

ventricleposterior,whichsurroundedtheheartentirely.Herejectionfractionwasmeasuredas60–62%.

Intheetiologicalanalyses,immuneglobulinlevelswerenormal,P-ANCAandC-ANCAwerenegative,and

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negative, and rheumatoid level was normal. Blood, urine or deep tracheal aspirates cultures were

negative.Sputumandlavagewerenegativeintermsofacidfastbacilli.Thepatient'sclinicalcondition

deteriorated rapidly, bilateral in�iltrations increased (I�mage 8), ARDS and shock developed and

respiratoryfailureworsened;asaresult,multi-organfailuredeveloped.Thepatientdidn'trespondto

interventionsanddiedonthe17thdayofherhospitalization.

Discussion

Anorexianervosaisaneatingdisorderthatcanbeaccompaniedbyvariouscomplications.Ithas

beenreportedtoaffectgastrointestinal,cardiovascular,hematologic,endocrine,renal,neurologicaland

dermatologicalsystems[1].Therespiratorysystemmaybeaffectedaswell,butitspathophysiologyisnot

yetde�inite.Inanimals,ithasbeendeterminedthatlong-termfastingleadstoadecreaseintotallung

protein,connectivetissue,hydroxyprolineandelastinlevels[2].Emphysemaisalsobelieveddevelopin

thismanner,butthisdamageisde�inedasemphysema-likeratherthanemphysema.

After administering tube thoracostomy to the patient who developed bilateral spontaneous

pneumothorax,clinicalrecoverywasachievedbuttotalexpansionwasn'tobtainedradiologically.The

patientwasconsultedbythechestsurgeryteam,tubethoracostomywasendedandthepatientreceived

outpatient follow-up treatment. Following discharge, the patient was admitted for two follow-ups

treatments at one-month intervals. It was observed that she had no complaints and that the

pneumothorax line hadn't extended. The patient didn't attend the subsequent follow-ups, but was

admittedtotheintensivecareunitinthe9thmonthduetodeteriorationinhergeneralmedicalcondition

anddevelopmentofrespiratoryfailureeventhoughthepneumothorax linehadn'textended.Thorax

computed tomography showed no increase in bilateral pneumothorax, whereas bronchiectasis and

�ibrosishaddevelopedaswellasconsolidation.Nopathologywasobservedinthepatientthatwouldlead

toapicalbullaorpneumothorax.Thepatient'sconditionwasconsideredassecondarytomalnutrition,

andassociatedwithherrecovery'sdelayandprevention.Eventhoughanutritionprogram(intravenous

liquid,bloodproducts,parenteralandenteralnutrition)wasinitiatedforthepatient,noimprovement

wasobservedinthegeneralconditionandoxygenationparameters.Bif�letal.statedthattreatmentwith

VATS was successful following the long-term leak in the patient with anorexia nervosa and

pneumothorax;asmentioned,structuralchangesoccurinthelungofpatientswithanorexianervosaand

thusleadtoadecreaseinsurfactantgrowthandalimitedrecoveryofthelungs[1].Corlessetal.stated

that bilateral tube thoracostomy was performed in patients with anorexia nervosa and bilateral

spontaneouspneumothorax,andthatabilateralthoracoscopicpleurectomywasperformedtoprevent

recurrence. In patients with anorexia nervosa, alveolar ruptures are thought to emerge from any

condition (such as coughing, vomiting) in which the alveolar structure weakens and intrathoracic

pressure increases [2]. In a case of anorexia nervosa reported byDanzer et al., and also Lee et al.,

pneumomediastinum, pneumothorax and subcutaneous emphysema were observed.

Pneumomediastinum, pneumothorax and subcutaneous emphysema are rarely seen together. It is

thoughtthatthepatient'svomitinganamnesiscausedtheintraabdominalandintrathoracicpressuresto

increaseandtheconditiontooccurevenifthepatientisnotvomitting[3,4].Hochlehnertetal.reporteda

patient with anorexia nervosa who developed spontaneous pneumothorax, and highlighted that

anorexia nervosa caused pneumomediastinummore commonly than pneumothorax. This is a rare

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condition that is generally self limited; its treatment lies in providing analgesia in addition to

conservative treatment [5]. Malnutrition is reported to be associated with emphysema, bulla and

bronchiectasisdevelopment,andthereisacorrelationbetweenBMIandtomographymeasurementof

emphysema[6].Inpatientswithanorexianervosa,itisbelievedthatperipheralintrapulmonaryairleaks

progressinaretrogradefashion:theairisdissectedintheinterstitialareaalongthebronchialtree,and

eventually leads to wide mediastinal, retroperitoneal and subcutaneous emphysema even without

smoking,becauseofthisdif�isioncapacityforoxygendecreases[7].Generally,supplementaltreatment

andweightgainareexpectedtoleadtospontaneousrecoveryinmostcases.

Limitedandlittlerecoveryofourpatientledtodeteriorationofhergeneralmedicalcondition,and

deteriorationofhergeneralmedicalconditionledtodecreasedrecovery.Thepatient,whosepulmonary

functions decreased over time and whose respiratory muscles appeared to have weakened, was

intubated.InthecontrolchestX-ray,consolidationfromhilustoperipherywasdetectedinbothlungs,

anditwasbelievedthatsurfactantde�iciency-relatedARDShaddevelopedinthepatient.Thepatient

didn'trespondtotreatmentanddied.

Conclusion

Anorexianervosacanaffectallsystemsinthebody,includingtherespiratorysystemandlungs.

Spontaneouspneumothorax isoneof thecomplicationsassociatedwiththisdisease.Long-termand

severemalnutritionmaylimitrecoveryandevenmakeitirreversible.Emphysema-likedestructionand

surfactantde�iciencywerereportedinthesepatients.Asinourcase,thegeneralmedicalconditionmay

deteriorate, the damagemay be irreversible, and the patientmay die. Such complicationsmust be

considered inpatientswith anorexianervosa, and earlynutrition and treatmentprogramsmust be

initiated.

Figures

Figure1:ChestX-rayofthepatienttakenduring�irst

hospitalizationshowingbilateralpneumothoracesand

p e r f o rmed b i l a t e r a l t u b e t h o r a c o s t omy.

Pneumothoracesareshownbyboldarrows.

Figure2:ChestX-rayof thepatientat the timeof

drainremoval,pneumothoracesinbothlungsdidn't

resolve completely but there was no increase in

pneumothoraces. Pneumothoraces are shown by

boldarrows.

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Figure 3,4: Chest computed tomography taken during the patient's �irst hospitalization showing bilateral

pneumothoraces.Pneumothoracesareshownbyarrows.

Figure5:ChestX-rayofthepatienttakenthird

day in the respiratory intensive care unit in

secondhospitalizationafter9monthsshowing

bilateralpneumothoracesprogressionandnew

in�iltrations.

Figure 6,7:Chest computed tomography of the patient 15th day in the

respiratory intensive care showing pneumothorax and in�iltrations with

bilateralground-glassdensitywithnon-homogeneousconsolidationinthe

rightlung'slowerlobe

Figure 8: Chest X-ray of the patient taken 15th day in the respiratory

intensivecareunitshowingbilateralin�iltrationsresultedinARDS2days

beforepatientwasdeceased.

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References

1.Bif�lWL,NarayananV,GaudianiJL,MehlerPS.Themanagementofpneumothoraxinpatientswithanorexia

nervosa:Acasereportandreviewoftheliterature.PatientSafSurg.2010;4(1):1.

2.CorlessJA,DelaneyJC,PageRD.Simultaneousbilateralspontaneouspneumothoracesinayoungwomanwith

anorexianervosa.I�ntJEatDisord.2001;30(1):110–2.

3.DanzerG,MulzerJ,WeberG,LembkeA,KocaleventR,KlappBF.Advancedanorexianervosa,associatedwith

pneumomediastinum,pneumothoraxandsofttissueemphysemawithoutesophageallesion.I�ntJEatDisord2005;

38(3):281–284.

4.LeeKJ,YumHK,ParkIN.SpontaneousPneumomediastinum:AnUnusualPulmonaryComplicationinAnorexia

Nervosa.TubercRespirDis2015;78(4):360–362.

5.HochlehnertA,LoweB,BludauHB,BorstM,ZipfelS,HerzogW.Spontaneouspneumomediastinuminanorexia

nervosa:Acasereportandreviewoftheliteratureonpneumomediastinumandpneumothorax.EurEatDisorders

Rev2010;18:107–115.

6.CoxsonHO,ChanIHT,MayoJR,HlynskyJ,NakanoY,BirminghamCL.Earlyemphysemainpatientswithanorexia

nervosa.AmJRespCritCareMed2004;170:748–752.

7.MehlerPS:BrownC.AnorexiaNervosa–medicalcomplications.JEatDisord2015;3:11.

ManuscriptInformation:Received:March02,2017;Accepted:July04,2017;Published:July10,2017

1 2 2 2AuthorsInformation:AybukeKekecoglu,MD ;BurcuArpinarYigitbas,Md *;FadimeKelesoglu,MD ;BarisSeker,MD ;AyseF2Kosar,MD

1I�ntensiveCareUnit,YedikuleChestDiseaseandSurgeryTrainingandResearchHospital,Istanbul,Turkey2DepartmentofChestDiseases,YedikuleChestDiseaseandSurgeryTrainingandResearchHospital,Istanbul,Turkey

Citation: Kekecoglu A, Yigitbas BA, Kelesoglu F, Seker B, Koasar AF. Anorexia nervosa accompanied by bilateral

pneumothoraces.OpenJClinMedCaseRep.2017;1285

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