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									                                                                                                                                                                                            Case Report




BUJim且a                                                    nerVOSa                                                    preSenting                                            aS               aCUte
Car寸iOgeniC ShOCk
Elaine M C C h a u 周 慕 慈 ^                                 Wing-Hing                    Chow周榮興




Summary                                                                                                                 nephropathy, tetany and rhabdomyolysis.                              T h e electrolyte
                                                                                                                        abnormalities              can further predispose                    the patients to
          Many         young            people,             especially                females,                 have
                                                                                                                        adverse         side-effects of drugs.                         We have       recently
distorted            image        about         their body            and become                        obsessed
                                                                                                                        encountered a case of bulimia nervosa with an unusual
with       dieting.            As dieting               escalates,               this      may lead              to
                                                                                                                        presentation of acute cardiogenic shock.
psychological                   disorders            such        as bulimic              practices             and
abuse           of laxatives,                emetics          and appetite                           suppressant
drugs.          We present                  a case       of bulimia            nervosa                 presenting
with       cardiogenic                      shock         and        discuss             the                possible    Case

contributing                causes           of the acute              heart       failure,             including              A previously healthy 24-year-old female patient
electrolyte            abnormalities                  and drug                 effects.
                                                                                                                        presented to the Accident and Emergency                                    Department
                                                                                                                        after collapsing at work.                       She claimed to have             general
                                                                                                                        malaise for 3 to 4 days and h a d taken some over-the-
                                                                                                                        counter           medications,                 including            trimethoprim-
摘要                                                                                                                      sulphamethoxazole and antacids.                              Furthermore, she had
           許多年輕人,尤其是女性,因對體形有著不正確                                                                                        been taking an appetite suppressant, sibutramine, for
的認識而強迫性節食。節食行為的不斷加重,可導致                                                                                                 about 1 week prior to admission.                             She developed       sudden

^kS理障礙的出現,如暴食和濫用瀉藥、催吐劑和抑制                                                                                               onset of flushing a n d dyspnoea prior to collapsing.                                 On

食欲的藥物。本文報告了一例神經性暴食症(bulimia                                                                                             arrival in hospital, she w a s found to have                                     severe
                                                                                                                        hypotension and acute pulmonary oedema on Chest X-ray.
nervosa)伴^^源性休克的病例,並討論了可能導致急
                                                                                                                        She required resuscitation with mechanical                                  ventilation
性^L3力衰竭的原因,包括電解質紊亂和藥物作用。
                                                                                                                        and intravenous inotropic agents (dobutamine, dopamine
                                                                                                                        and      adrenaline).                 Echocardiogram                  showed        poor

HK Pract          2005;27:475-477                                                                                       c o n t r a c t i o n o f t h e left v e n t r i c l e .    A n intra-aortic balloon
                                                                                                                        p u m p w a s inserted prior to transferring to our hospital for
                                                                                                                        further m a n a g e m e n t of suspected fulminant myocarditis.


Introduction                                                                                                                    O n arrival at o u r hospital, the patient w a s ventilated
                                                                                                                        and had cold peripheries.                       S h e w a s in sinus        tachycardia
          Electrolyte abnormalities are c o m m o n in patients
                                                                                                                        (160/min) and her blood pressure was 70/50 despite
with eating disorders such as anorexia nervosa or bulimia
                                                                                                                        three intravenous inotropic agents a n d the intra-aortic
nervosa and can lead to serious complications, such as
                                                                                                                        balloon pump.                Cardiac monitor showed frequent n o n -
muscle               weakness, arrhythmias, cardiomyopathy,
                                                                                                                        sustained ventricular tachycardia.                                  Echocardiogram
                                                                                                                        showed          a non-dilated                left     ventricle      with     globally
E l a i n e M C C h a u , MBBS (Lond), FRCP (Edin), F H K A M (Medicine)                                                impaired systolic function (ejection fraction 15%) and
Senior     Medical         Officer,
                                                                                                                        normal          heart       valves.           Arterial        blood       gas showed
W i n g - H i n g C h o w , MBBS (HK), FRCP (Edin), FHKAM (Medicine)
                                                                                                                        metabolic acidosis.                     There w a s elevation of cardiac
Chief     of    Service,

Department of Cardiology, Grantham Hospital.
                                                                                                                        enzymes             with        very        high           levels    of    creatinine

Correspondence to:              Dr Elaine M C Chau, Department of Cardiology, Grantham
                                                                                                                        p h o s p h o k i n a s e - M B i s o e n z y m e at 6 2 . 3 n g / m l          (normal
                                H o s p i t a l , 125 W o n g C h u k H a n g R o a d , H o n g K o n g .               < 6 n g / m l ) a n d o f t r o p o n i n - I at 6 . 3 1 ( n o r m a l < 0 . 4 n g / m l ) .


The      Hong     Kong       Practitioner            V O L U M E 27         December           2005                                                                                                            475
Case Report


Most remarkable was the presence of severe electrolyte                                             Discussion
disturbance,              including            hypokalaemia                   (potassium
                                                                                                           W e b e l i e v e t h a t t h i s is t h e f i r s t r e p o r t o f               severe
2.0mmol/l), hypochloraemia (chloride                                        100mmol/l),
                                                                                                   e l e c t r o l y t e d i s t u r b a n c e p r e s e n t i n g a s c a r d i o g e n i c s h o c k in
hypocalcaemia (calcium 1.76mmol/l, corrected                                          calcium
                                                                                                   a patient with bulimia nervosa.                            Frequent vomiting over
2.04mmol/l)                and      hypomagnesaemia                         (magnesium
                                                                                                   a p r o l o n g e d p e r i o d m a y m a n i f e s t as a " p s e u d o - B a r t t e r ' s
0.55mmol/l).              H e r s e r u m a m y l a s e level w a s e l e v a t e d at
                                                                                                   syndrome"              electrolyte             pattern         with           hypokalemic
297U/L (normal range 38-119U/L).                                    History from             the
                                                                                                   alkalosis and hypochloraemia.1                                 In o u r p a t i e n t , r e n a l
p a t i e n t ' s relatives revealed that, over the past year or so,
                                                                                                   t u b u l a r d i s o r d e r is r u l e d o u t b e c a u s e o f n o r m a l           urinary
the patient had regular eating binges with                                   consumption
                                                                                                   electrolyte excretion.                          Severe hypocalcaemia and
of excessively               large       amounts           of food          followed          by
                                                                                                   hypokalemia                 which was refractory                         to      replacement
secretive          self-inflicted              vomiting,            suggestive          of     a
                                                                                                   treatment but responsive to m a g n e s i u m infusion has b e e n
diagnosis of bulimia nervosa.                            Despite having a body
                                                                                                   described            in a c a s e          of anorexia               nervosa.2               Both
m a s s i n d e x of o n l y 17.7 ( h e i g h t 1 5 6 c m , w e i g h t 4 3 k g ) ,
                                                                                                   h y p o k a l e m i a and hypomagnesaemia                          m a y lead to cardiac
she had a misconceived obsession about her b o d y                                     weight
                                                                                                   a r r h y t h m i a s , such as ventricular t a c h y c a r d i a or torsade de
and had b e e n taking sibutramine from a friend for about
                                                                                                   pointes.              Hypomagnesaemia                            itself        may         cause
1 w e e k prior to a d m i s s i o n .
                                                                                                   hypokalemia,                 which may be refractory                          to    potassium
                                                                                                   supplementation                     until           correction          of       magnesium
        After correction                 of electrolyte i m b a l a n c e ,                  her
                                                                                                   deficiency.3 M o r e importantly, m a g n e s i u m deficiency can
haemodynamics                   and corresponding                    left      ventricular
                                                                                                   lead to refractory circulatory shock.4                                It is i m p o r t a n t t o
function          improved             slowly.            On     the      third       day     of
                                                                                                   r e c o g n i z e that the s e r u m m a g n e s i u m level represents < 1 %
admission, she underwent transvenous endomyocardial
                                                                                                   of total b o d y stores and m a y not reflect                                       total-body
biopsy,          during          which         she      developed               sustained
                                                                                                   magnesium               concentration.                  Apart         from         the    severe
ventricular tachycardia and required defibrillation.                                        Four
large       pieces        of m y o c a r d i u m           were       obtained          from       electrolyte disturbance, another laboratory clue                                               that

different         sites in the right v e n t r i c l e                using          6-French      s u g g e s t s t h e d i a g n o s i s o f b u l i m i a n e r v o s a in o u r p a t i e n t

biopsy forceps.                H i s t o l o g y of cardiac b i o p s y s h o w e d                is t h e f i n d i n g o f h y p e r a m y l a s a e m i a , w h i c h is p r e s e n t in

d i f f u s e i n t e r s t i t i a l o e d e m a in all f o u r p i e c e s but              no   m a n y bulimic patients.5                   It is s a i d t h a t t h e r e is a p o s i t i v e

inflammatory             cells, including polymorphs,                         lymphocytes          correlation b e t w e e n the frequency of vomiting and the

or giant cells.              Furthermore, the myocytes were not                                    extent of elevated serum a m y l a s e level.

enlarged or necrotic and did not show any evidence of
damage.             The      patient then developed                           significant                  A n o t h e r contributing factor to the c a r d i o g e n i c                      shock
p e r i c a r d i a l e f f u s i o n o n d a y 10 o f a d m i s s i o n , r e q u i r i n g       in this p a t i e n t m a y be d r u g - r e l a t e d .                 Sibutramine,               a
pericardiocentesis.                  Pericardial fluid was negative                          for   s e r o t o n i n a n d n o r e p i n e p h r i n e t r a n s p o r t e r b l o c k e r , is an
virus       isolation.              Serum          antibody            screening             for   appetite suppressant agent.                           However, adverse cardiac
cardiotropic viruses, mycoplasma, chlamydia and human                                              side-effects              such        as     hypertension,                    arrhythmias,
immunodeficiency virus was also negative.                                            She was       tachycardia and even death from cardiac arrest have been
s u c c e s s f u l l y e x t u b a t e d w h e n h e r left v e n t r i c u l a r   function      reported.6         I n d e e d t h e d r u g is n o t o n l y c o n t r a i n d i c a t e d        in
r e t u r n e d to n o r m a l (EF 6 0 % ) .              She w a s taken off                the   p a t i e n t w i t h c a r d i o v a s c u l a r d i s e a s e s b u t a l s o in t h o s e w i t h
intra-aortic balloon p u m p and inotropic support and was                                         anorexia and bulimia nervosa.                                 Patients with               eating
fit f o r d i s c h a r g e a t t h r e e w e e k s a f t e r a d m i s s i o n .    She was       disorders are also k n o w n to abuse diuretics, laxatives,
referred for psychiatric consultation u p o n discharge.                                           e n e m a s or emetics, the use of which was denied by our
                                                                                                   patient.        Misuse of diuretics, laxatives and enemas can
        At follow-up,                she was           well      with       normal          left   p l a c e t h e b u l i m i c at g r e a t r i s k f o r e l e c t r o l y t e      imbalance.
ventricular function on echocardiogram.                                              Urinary       It h a s b e e n r e p o r t e d t h a t c h r o n i c i p e c a c i n g e s t i o n             for
excretion of potassium,                      which was initially                     elevated      e m e s i s can result in c a r d i o m y o p a t h y , w h i c h m a y or m a y
at    134mmol/day                 (normal range                  15-44mmol/day),                   not be reversible7
returned to n o r m a l on f o l l o w - u p .                   Urinary excretion
o f s o d i u m , m a g n e s i u m a n d c a l c i u m w e r e all                    within              A l t h o u g h c a r d i o g e n i c shock due to acute                     fulminant
the normal range.                 Ultrasound scan of the kidneys was                               m y o c a r d i t i s m a y p r e s e n t in a s i m i l a r w a y , t h e l a c k o f
normal.                                                                                            fever and viral illness s y m p t o m s , a b s e n c e of inflammatory

476                                                                                                             The Hong       Kong     Practitioner         V O L U M E 27       December 2005
                                                                                                                                                                                                Case Report


                                                                                                   or a b s e n c e of s e l f - i n d u c e d v o m i t i n g or m i s u s e of
   Key       messages                                                                              laxatives, diuretics or emetics.                                                       The major cardiac

   1.     B u l i m i a n e r v o s a is a s e r i o u s a n d p o t e n t i a l l y life-         c o m p l i c a t i o n o f e a t i n g d i s o r d e r s is a r r h y t h m i a s                                         which

          threatening illness affecting mainly young w o m e n .                                   m a y lead to s u d d e n c a r d i a c d e a t h . T h e m a r k e r s for fatal
                                                                                                   a r r h y t h m i a s in t h e s e p a t i e n t s a r e p r o l o n g a t i o n o f Q T
   2.     The binging and purging activity associated with
                                                                                                   interval and Q T dispersion on electrocardiogram8.
          the purging subtype of bulimia nervosa can lead
          to e l e c t r o l y t e   imbalance,          cardiac          arrhythmias,
          heart failure and death a m o n g many other medical
          complications.
                                                                                                   Conclusion

   3.     Abuse of appetite suppressants, laxatives, diuretics                                             In c o n c l u s i o n , acute c a r d i o g e n i c s h o c k s h o u l d be

          a n d e m e t i c s is n o t u n u s u a l in b u l i m i c s a n d s i d e -            added            to       the          list         of       potential                      life-threatening

          effects of the drugs m a y further complicate the                                        complications of eating disorders.                                                        Family               physicians
          clinical picture.                                                                        should have a high index of suspicion for eating disorders
                                                                                                   in p a t i e n t s            with           preoccupation                            with           body              weight.
   4.      U s e o f s i b u t r a m i n e is c o n t r a i n d i c a t e d in p a t i e n t s
                                                                                                   Detailed enquiry of eating habits, abnormal                                                                       behaviour
           with eating disorders.
                                                                                                   such as purging, possible drug abuse, especially e m e t i c s ,
   5.      Apart from the diagnostic criteria, other features                                      laxatives                a n d a p p e t i t e s u p p r e s s a n t s , is i n d i c a t e d .
           in s u p p o r t i n g    a diagnosis            of bulimia            include          U n f o r t u n a t e l y , d u e to denial of s y m p t o m s , the d i a g n o s i s
           abnormal E C G findings, electrolyte disturbances
                                                                                                   is o f t e n d e l a y e d .             In patients d i a g n o s e d with or s u s p e c t e d
           and raised serum amylase level.
                                                                                                   to have eating disorders, m o n i t o r i n g of e l e c t r o c a r d i o g r a m
                                                                                                   for Q T abnor malities                                     or a r r h y t h m i a s ,                  and           periodic
                                                                                                   measurements of electrolyte levels, including potassium,

cells on endomyocardial biopsy and negative                                              viral     calcium and magnesium, are recommended.                                                                       ?

screening m a k e the diagnosis of viral myocarditis unlikely
b u t c a n n o t r u l e it o u t . M y o c a r d i t i s p e r s e c a n n o t a c c o u n t
for the severe electrolyte i m b a l a n c e .                            To postulate             References
concomitant myocarditis and bulimia-induced severe                                                 1.    M a n d e l L . S e r u m e l e c t r o l y t e s in b u l i m i c p a t i e n t s w i t h p a r o t i d s w e l l i n g .   Oral
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described by her relatives.                          A c c o r d i n g to the W o r l d            4.    V i n c e n t J L , B u s e t M , D u f a y e P, et al.                Circulatory shock associated with
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type and the non-purging type depending on the presence




The Hong      Kong    Practitioner        V O L U M E 27       December       2005                                                                                                                                                    477

								
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