Neuropathy and myopathy in two patients with anorexia and bulimia nervosa

Peroneal mononeuropathy and polyneuropathy in adolescents with Anorexia Nervosa: a case report and literature review

Peroneal neuropathy and polyneuropathy are displayed with a variable percentage in subjects affected by eating disorders and in particular by anorexia nervosa. Actually, little is known on features of these complications during the paediatric age. We describe the case of a female adolescent with right peroneal palsy and subclinical polyneuropathy associated with anorexia nervosa (AN). We review previous research about peroneal mononeuropathy and polyneuropathy associated with AN, and we develop a diagnostic and therapeutic protocol to help clinicians recognize and treat these disorders.

Anorexia nervosa and muscle health: A systematic review of our current understanding and future recommendations for study

OBJECTIVE

Conduct a systematic review on muscle size and strength in individuals with anorexia nervosa (AN).

METHOD

In accordance with PRISMA guidelines, we searched Pubmed for articles published between 1995 and 2022 using a combination of search terms related to AN and muscle size, strength, or metabolism. After two authors screened articles and extracted data, 30 articles met inclusion criteria. Data were coded, and a risk bias was conducted for each study.

RESULTS

The majority of studies focused on muscle size/lean mass (60%, n = 18) and energy expenditure (33%, n = 9), with few studies (17%, n = 5) investigating muscle function or possible mechanisms underlying muscle size (20%, n = 6). Studies supported that individuals with AN have smaller muscle size and reduced energy expenditure relative to controls. In some studies (33%, n = 10) recovery from AN was not sufficient to restore muscle mass or function. Mechanisms underlying short and long-term musculoskeletal alterations have not been thoroughly explored.

DISCUSSION

Muscle mass and strength loss may be an unexplored component of physiological deterioration during and after AN. More research is necessary to understand intramuscular alterations during AN and interventions to facilitate muscle mass and functional gain following weight restoration in AN.

PUBLIC SIGNIFICANCE

Muscle health is important for optimal health and is reduced in individuals with AN. However, we do not understand how muscle is altered at the cellular level throughout the course of AN. Here we review what is currently known regarding muscle health during AN and with weight restoration.

Visuo-tactile shape perception in women with Anorexia Nervosa and healthy women with and without body concerns

A key feature of Anorexia Nervosa is body image disturbances, the study of which has focused mainly on visual and attitudinal aspects, did not always contain homogeneous groups of patients, and/or did not evaluate body shape concerns of the control group. In this study, we used psychophysical methods to investigate the visual, tactile and bimodal perception of elliptical shapes in a group of patients with Anorexia Nervosa (AN) restricting type and two groups of healthy participants, which differed from each other by the presence of concerns about their own bodies. We used an experimental paradigm designed to test the hypothesis that the perceptual deficits in AN reflect an impairment in multisensory integration. The results showed that the discrimination thresholds of AN patients are larger than those of the two control groups. While all participants overestimated the width of the ellipses, this distortion was more pronounced in AN patients and, to a lesser extent, healthy women concerned about their bodies. All groups integrated visual and tactile information similarly in the bimodal conditions, which does not support the multi-modal integration impairment hypothesis. We interpret these results within an integrated model of perceptual deficits of Anorexia Nervosa based on a model of somatosensation that posits a link between object tactile perception and Mental Body Representations. Finally, we found that the participants' perceptual abilities were correlated with their clinical scores. This result should encourage further studies that aim at evaluating the potential of perceptual indexes as a tool to support clinical practices.

Impaired Extension of the Digits due to Bilateral Idiopathic Intrinsic Contracture: A Case Report

Idiopathic intrinsic contracture (IIC) with no history of trauma, ischemia, or spasticity is extremely rare. We report herein a case of impaired extension of the digits due to bilateral IICs occurred in a 30-year-old woman with a past medical history of eating disorder and amenorrhea. Although no previous case has been reported in the literature, eight similar cases of IIC have been presented at Japanese domestic conferences. In these eight cases and the present case, resection of the thenar muscle cords and unilateral resection of the lateral band were effective. Since IIC in patients with an eating disorder is a rare condition, it would be treated conservatively at first as tendon sheath inflammation or locking. However, this condition may be resistant to conservative treatment, and surgical treatment should be considered in such cases.

Acute nutritional axonal neuropathy

INTRODUCTION

This study describes clinical, laboratory, and electrodiagnostic features of a severe acute axonal polyneuropathy common to patients with acute nutritional deficiency in the setting of alcoholism, bariatric surgery (BS), or anorexia.

METHODS

Retrospective analysis of clinical, electrodiagnostic, and laboratory data of patients with acute axonal neuropathy.

RESULTS

Thirteen patients were identified with a severe, painful, sensory or sensorimotor axonal polyneuropathy that developed over 2-12 weeks with sensory ataxia, areflexia, variable muscle weakness, poor nutritional status, and weight loss, often with prolonged vomiting and normal cerebrospinal fluid protein. Vitamin B6 was low in half and thiamine was low in all patients when obtained before supplementation. Patients improved with weight gain and vitamin supplementation, with motor greater than sensory recovery.

DISCUSSION

We suggest that acute or subacute axonal neuropathy in patients with weight loss or vomiting associated with alcohol abuse, BS, or dietary deficiency is one syndrome, caused by micronutrient deficiencies. Muscle Nerve 57: 33-39, 2018.

The effects of body weight status on orthostatic intolerance and predisposition to noncardiac syncope

Orthostatic intolerance (OI) is frequently the mechanism underlying the occurrence of noncardiac syncope (NCS) and is associated with substantial risk for injury. Body weight status appears to be a modifier of orthostatic responses and possibly influences the propensity to NCS. The majority of cross-sectional studies have found that the lower the body mass index (BMI) the greater the predisposition to OI is, accompanied with both down-regulation of sympathetic nervous system activity and up-regulation of parasympathetic nervous system activity. These changes appear to occur across the whole spectrum of BMI values from underweight to obesity, while they may be associated more strongly with central body fat than total body fat. Weight loss following bariatric surgery has been consistently found to increase OI, attributed first to the effects of weight loss per se, second to the specific type of surgical procedure and third to the potential postoperative autonomic neuropathy due to vitamin deficiency. The increased OI following bariatric surgery renders this intervention not easily tolerable for the affected individuals, mandating increased fluid and salt intake, pharmacological measures or surgical adjustments to attenuate OI. All future studies investigating orthostatic responses and NCS should implement a matching of the population arms for BMI and ideally for body fat.

Functional recovery of a patient with anorexia nervosa: physical therapist management in the acute care hospital setting

BACKGROUND AND PURPOSE

People with severe, long-standing anorexia nervosa (AN) often develop physical manifestations of medical starvation. Functional deficits are not well described, and little information is available to guide physical intervention. This case report describes the physical therapy clinical decision-making process and intervention provided to a patient with severe AN.

CASE DESCRIPTION

The patient was a 48-year-old woman admitted to an acute care hospital with medical complications associated with AN and requiring medical stabilization. On admission, she was unable to complete basic functional activities (eg, bed mobility, transfers, ambulation). She was considered at risk for falls, with a score of 17 on the Performance-Oriented Motor Assessment (POMA) and a score of 19.27 seconds on the Timed "Up & Go" Test (TUG). Physical therapist examination and intervention focused on functional testing and training, strengthening, and postural stability training for return to independence.

OUTCOMES

In 9 weeks, the patient returned to independence in basic activities of daily living, as measured by 3 items from the motor domain (bed mobility, transfers, and ambulation) of the Functional Independence Measure, with improvements from 1 ("total assistance") to 6 ("modified independence") on each item. Postural stability improved to "low risk" for falls (POMA score of 24). Her TUG score improved to 11.00 seconds. Walking speed improved from 0.35 to 0.81 m/s. Once she attained medical stability, she was discharged home with her parents with outpatient services.

DISCUSSION

Physical therapist management of this severely deconditioned patient hospitalized with severe AN focused on the restoration of functional activities, with intervention intensity being guided by physiologic responses. Traditional aerobic and endurance training were de-emphasized to minimize kilocalorie expenditure and tendencies toward exercise compulsion in this patient population.

Vegetarianism and eating disorders: association between eating attitudes and other psychological factors among Turkish adolescents

The purpose of this study was to determine whether differences exist in eating attitudes, self-esteem, social trait anxiety and social physique anxiety of self-reported vegetarian and nonvegetarian Turkish adolescents. The sample for the Turkish University' students is designed to provide the estimates of vegetarian indicators and prevalence. The participants were 608 females and 597 males, in total 1205 adolescents aged between 17 and 21 years. Disturbed eating behaviors (EAT-26> or =20) was found in 45.2% (14 of vegetarian) of the total vegetarian sample; which included two of the male vegetarians and 12 of the female vegetarians. The mean BMI was 19.78+/-1.49 kg/m(2) for female vegetarians and 20.78+/-2.46 kg/m(2) for female nonvegetarians (p<0.05). Male vegetarians had significantly higher score than male nonvegetarians on EAT-26 (17.25+/-11.18 for male vegetarians and 9.38+/-6.60 for male nonvegetarians), dieting (6.50+/-7.65 for male vegetarians and 2.55+/-3.87 for male nonvegetarians) and oral control (6.13+/-4.67 for male vegetarians and 3.20+/-3.19 for male nonvegetarians) scores (p<0.05). Besides, female vegetarians had significantly higher score than female nonvegetarians on EAT-26 (22.04+/-13.62 for female vegetarians and 11.38+/-8.28 for female nonvegetarians), dieting (10.35+/-9.58 for female vegetarians and 4.41+/-5.30 for female nonvegetarians), oral control (7.78+/-5.13 for female vegetarians and 3.33+/-3.51 for female nonvegetarians) and STAI (51.39+/-7.28 for female vegetarians and 47.29+/-5.13 for female nonvegetarians) scores (p<0.05). As a conclusion, the present study indicated abnormal eating attitudes, low self-esteem, high social physique anxiety, and high trait anxiety in Turkish vegetarian adolescents. The vegetarian adolescents may be more likely to display disordered eating attitudes and behaviors than nonvegetarians.

Veränderung der Muskelkraft bei Patientinnen mit Anorexia nervosa während der stationären Behandlung - eine Pilotstudie

Zusammenfassung: Fragestellung: Die Veränderung der Muskelkraft bei Patientinnen mit Anorexia nervosa während der stationären Behandlung sollte durch exakte Messung bestimmt werden. Methode: Unter Verwendung einer etablierten Messvorrichtung inkl. des Softwareprogramms «Quantitative Muscle Assessment» wurden in den Wochen 1, 2, 3, 4, 6, 8 und 10 des stationären Aufenthaltes die Maximalkräfte in vier verschiedenen Übungen für jede Körperseite bei zehn Patientinnen bestimmt. Alle wiesen vor der stationären Aufnahme einen vergleichbaren Krankheitsverlauf mit reiner Nahrungsrestriktion ohne überdurchschnittliche sportliche Betätigung auf. Ergebnisse: Es ergaben sich Hinweise auf einen interindividuell zu beobachtenden mehrphasigen Verlauf der Kraftrestitution. Die aufgrund der einfachen Durchführung andernorts häufig angewandte Übung Handgrip zeigte im Gegensatz zu den anderen untersuchten Muskelgruppen keine einheitliche Entwicklung. Seitendifferenzen waren nicht zu beobachten. Schlussfolgerungen: Patientinnen mit Anorexia nervosa zeigen eine objektivierbare, interindividuell vergleichbare, mehrphasige Zunahme der Maximalkraft der untersuchten Muskelgruppen während der Gewichtsrestitution.

Metabolic abnormalities associated with skeletal myopathy in severe anorexia nervosa

The aim of this study was to characterize the metabolic disturbance associated with the skeletal myopathy resulting from extreme weight loss in anorexia nervosa. Muscle function was examined in eight female patients with severe (40%) weight loss due to anorexia nervosa and histologically confirmed myopathy. A wide range of biochemical and hematologic investigations were carried out, including serum enzymes and the response of plasma lactate to ischemic exercise of forearm muscles. All patients showed proximal muscular weakness. A diminished lactate response to ischemic exercise was a consistent finding, and a reduction of serum carnosinase activity was also found. There were no other consistent biochemical or hematologic abnormalities apart from lymphopenia of no clinical consequence. These findings contribute to our understanding of severe protein-energy malnutrition on the musculoskeletal system. The resulting disorder is a metabolic myopathy from which the patients recover rapidly as their nutrition improves. Although the patients admitted to a variety of abnormal eating behaviors, no correlation was found between a specific type of abnormal eating behavior and subsequent biochemical abnormalities. Reinstating appropriate eating behavior will treat the myopathy.

Eating disorders and reflex sympathetic dystrophy syndrome: is there a common pathway?

The comorbidity of eating disorders and reflex sympathetic dystrophy syndrome in the same patients raises the possibility of a common pathway for both conditions. Reflex sympathetic dystrophy syndrome may be manifesting itself in those individuals who have sympathetic overdrive. Microtrauma, often induced by compulsive exercise, and depression may be contributory factors. It is recommended that: patients with eating disorders who develop pain in an extremity should be investigated for possible reflex sympathetic dystrophy syndrome; patients with reflex sympathetic dystrophy syndrome should be discouraged from dieting, and eating disorders should be suspected if they begin to lose weight or are already malnourished.

Acute painful diabetic neuropathy following severe weight loss

A 34-year-old man, recently diagnosed as diabetic, presented an acute painful neuropathy. He reported a profound weight loss during the months preceding onset. There were no motor symptoms, and only mild neurological signs were observed on examination. Improvement was related to a good glycemic control and weight gain. Acute painful diabetic neuropathy is a condition that may affect diabetic patients shortly after development of the disease. The pathogenetic roles played by different factors are reviewed.

Neuromyopathic complications in a patient with anorexia nervosa and vitamin C deficiency

A 19-year-old female patient with anorexia nervosa developed profound weight loss over 1 year associated with vegetarianism and excessive exercise. There was severe wasting and proximal muscle weakness in the legs and bilateral weakness of eye closure. A purpuric rash developed due to vitamin C deficiency. This case demonstrates a new neurological sign in anorexia nervosa indicating a weakness of the orbicularis oculi muscles as part of a more general myopathy. The myopathic and scorbutic features may have a common pathogenesis.

Nutritional disorder of anorexia nervosa: a review

In the treatment of anorexia nervosa, the importance of weight restoration has been well documented. Resting energy expenditure, which is initially reduced, often increases markedly in association with refeeding. Previous studies that have examined micronutrient status in anorexia nervosa have reported inconsistent and sometimes contradictory conclusions, due to the heterogeneity of the population, the cross-sectional nature of these investigations, and, at times, the use of inappropriate methods to determine nutrient status. Abnormal nutritional findings in patients with anorexia nervosa are primarily a consequence of semistarvation. Neuroendocrine abnormalities, degree of recovery, and phase of treatment affect interpretation of data. Despite the importance of nutritional rehabilitation, few controlled studies that address the clinical efficacy of various dietary treatment regimens have been conducted.

Neurologic complications of anorexia nervosa

The records of 100 patients with anorexia nervosa were reviewed. Neurologic complications were present in 47 patients. Neuromuscular abnormalities were most common and were present in 45% of patients. Generalized muscle weakness was detected in 43% of patients and peripheral neuropathies in 13%. Less common neurologic complications included headaches (6%), seizures (5%), syncope in the absence of orthostatic hypotension (4%), diplopia (4%), and movement disorders (2%). Neurologic problems due to chronic deficiency diseases were rare; only one patient had symptoms directly attributable to a vitamin B12 deficiency and none had evidence of Wernicke's encephalopathy. In most patients, the neurologic complications were reversed completely after correction of nutritional deficiencies and fluid and electrolyte imbalances.

Muscle complications of malnutrition in children: a clinical and electromyographic study

The authors report the clinical and electromyographic (EMG) findings in a series of 13 children with a pseudomyopathic motor deficit in the context of malnutrition (Body Mass Index < or = 3rd percentile) caused by primary protein-calorie deficiency or secondary to chronic disease. The infants (nine cases) manifested a regression or stagnation of motor abilities, with hypotonia and amyotrophy; older children and adolescents (four cases) presented clear amyotrophy with a deficit in muscle strength consisting primarily of proximal muscular weakness. Detection and stimulation-detection EMG demonstrated myogenic signs in at least two muscles in all patients. Myogenic signs were dominant in all proximal muscles. Latencies were normal in all patients. Motor nerve conduction velocities were slowed in three infants and in one adolescent. A temporal dispersion of motor responses was observed in 11 proximal muscles. The muscle biopsy, performed in five cases, revealed an inequality in the calibre of fibres, with atrophy dominating in type II fibres. The authors emphasize the value of EMG in disclosing the myopathic process, thereby contributing to the etiological diagnosis of motor difficulties in children suffering from malnutrition or a chronic disease.

Case report: reversal of severe leukopenia by granulocyte colony-stimulating factor in anorexia nervosa

Recent attempts to reduce weight by patients with anorexia nervosa have sometimes led to life-threatening hematologic complications. This report describes an instance in which a patient with anorexia nervosa and pancytopenia drastically improved with treatment that included administration of granulocyte colony-stimulating factor. The patient had lost 27 kg of body weight within 8 months. Even after admission, the blood cell count continued to decrease rapidly as follows: platelet, from 244 x 10(3)/microliters to 44 x 10(3)/microliters; erythrocyte, from 4.04 x 10(6)/microliters to 2.58 x 10(6)/microliters; and leukocyte, from 4.8 x 10(3)/microliters to 1.6 x 10(3)/microliters (granulocyte, 0.8 x 10(3)/microliters). Complications included pneumomediastinum, pneumothorax, purpura, petechiae, hepatomegaly, fever, gangrenous stomatitis, and somnolence. Bone marrow aspiration disclosed absence of fat cells, marrow hypoplasia, and infiltration of the mature lymphocytes. Intravenous hyperalimentation, blood transfusion, gamma-globulin, and antibiotics were administered, but leukopenia and fever remained. However, administration of recombinant human granulocyte colony-stimulating factor dramatically reversed the leukopenia and fever. With careful nutrition therapy, the patient's blood cell count and bone marrow normalized by the time of discharge. It was concluded that severe hematologic disorders may occur in patients with anorexia nervosa, and advanced treatment may be required to save the patient's life.

Assessment of somatosensory indicators of polyneuropathy in patients with eating disorders

The somatosensory functions of small-diameter nerve fibres were tested on the lower and upper extremities in nine patients with anorexia nervosa, ten patients with bulimia nervosa and ten control subjects, by analysing warmth, cold, and pain thresholds. To test large-diameter nerve fibres, the vibration threshold was also measured. Both patient groups had markedly elevated pain thresholds compared with the control subjects. In contrast, warmth and cold thresholds were only suggestively elevated while vibration thresholds were not at all increased in the patients. A distal-proximal pattern of somatosensory deficits, suggestive of peripheral polyneuropathy, was not observed. Hence, a peripheral polyneuropathy affecting small or large afferent fibres as a consequence of an eating disorder seems to be a rare event.

Oesophageal and gastric motor activity in patients with bulimia nervosa

Previous studies showed that symptoms of oesophageal motor disorders can be misinterpreted as indicating anorexia nervosa and that in primary anorexia nervosa gastric motility is frequently impaired. We investigated in 32 women with bulimia nervosa whether symptoms of oesophageal motor disorders could be obscured by or be mistaken as forming part of bulimic behaviour, and whether impaired gastric motility was frequent as well. Oesophageal motility was normal in 18 of 26 patients studied, another four had incomplete lower oesophageal sphincter relaxation. Two patients had vigorous achalasia and each one achalasia and diffuse oesophageal spasm, all of whom experienced two types of vomiting: one self-induced and one involuntary, in which the vomit was non-acidic and tasted as the preceding meal. Gastric emptying of a semisolid meal was studied in all patients except of the eight with oesophageal motor abnormalities. Emptying was significantly slower than in healthy controls and grossly delayed in nine of 24 patients. Antral contraction amplitudes were lower and increased less postcibally than in controls. In conclusion (i) bulimic behaviour can obscure symptoms of oesophageal motor disorders and (ii) gastric emptying is frequently delayed in bulimia nervosa.

Physical complications in anorexia nervosa. Haematological and neuromuscular changes in 12 patients

Of twelve patients consecutively admitted to the Maudsley Hospital Eating Disorders Unit, four had neuromuscular abnormality, eight haematological abnormality, and four no abnormality. All those having neuromuscular signs had concomitant haematological dysfunction. Vomiting, and food restriction with vegetarianism, appeared more likely to lead to complications than either food restriction alone or laxative abuse. The physical status of severely underweight patients admitted for refeeding needs to be carefully monitored.

Electrophysiologic follow-up in Whipple's disease

Neurologic and electrophysiologic findings in a 57-year-old man with Whipple's disease are reported. The patient had severe proximal weakness and weight loss of more than 20 kg. Conventional electromyography and nerve conduction studies suggested mild neuropathy in distal segments of lower limbs and myopathy in proximal muscles. Automatic analysis of the electromyogram in proximal muscles was consistent with myopathy. Conduction velocity of muscle fibers in situ showed low propagation velocity of the impulse. Weakness, weight loss, and all the electrophysiologic parameters improved after treatment, including a compression of the peroneal nerve at the knee, perhaps related to weight loss (slimmer's paralysis).

Clinically apparent eating disorders in young diabetic women: associations with painful neuropathy and other complications

Of 208 young women with insulin dependent diabetes, 15 (7%) had a clinically apparent eating disorder (anorexia nervosa or bulimia), a much higher prevalence than reported in non-diabetic women. Most, but not all, of these patients had a long history of poor glycaemic control. In contrast with previous suggestions, control did not deteriorate after the onset of the eating disorder. There was a high incidence and an early onset of diabetic complications. Eleven of the 15 patients had retinopathy, six with proliferative changes; six had nephropathy; and six neuropathy. Most strikingly, four patients with anorexia nervosa developed acute painful polyneuropathy. In each case pain started when the eating disorder developed, almost coinciding with the peak of weight reduction. Remission of pain occurred as weight was regained. The symptoms were accompanied by abnormalities in peripheral nerve electrophysiology and autonomic nerve function, some improvements in which accompanied weight recovery. It is suggested that nutritional factors may contribute to the high rate of early onset diabetic complications, particularly neuropathy.