Ampulla cardiomyopathy after hypoglycemia in three young female patients with anorexia nervosa

Evaluation of Mean Plasma Glucose Levels Using HbA1C in Patients With Severe Eating Disorders

OBJECTIVE

Hypoglycemia causes significant morbidity and mortality in patients with severe eating disorders. We measured average glycemic levels using hemoglobin A1C (HbA1C) in patients hospitalized for extreme anorexia nervosa (AN) and avoidant restrictive food intake disorder (ARFID).

METHODS

This was a prospective, single-center cohort study conducted in an inpatient medical stabilization unit. Clinical outcomes were compared using paired t-tests. Additional analysis comparing clinical variables between undetectable and detectable HbA1c used two-sample t-tests.

RESULTS

The study cohort consisted of 148 individuals, 90% female, average age of 31 years, average admit body mass index of 12.5 kg/m2, and mean percentage ideal body weight of 60.1%. Diagnoses included AN-restricting (54%), AN-binge purge (39%), and ARFID (7%). HbA1C and fructosamine levels decreased from admission to discharge. Serum glucose levels increased significantly from admission to discharge. Mean HbA1C was 4.7% on admission and 4.3% on discharge.

DISCUSSION

This study evaluated mean blood glucose levels using HbA1C in patients with extreme forms of AN and ARFID. Given the concern for morbidity and mortality from hypoglycemia in this population, which can be overlooked on a single point-of-care glucose measurement, HbA1C is a valuable laboratory measure of glycemic status in patients with extreme forms of eating disorders.

Pediatric takotsubo cardiomyopathy: A review and insights from a National Multicentric Registry

Takotsubo syndrome (TTS) in the pediatric population is an infrequent but relevant cause of morbidity and mortality, with limited studies addressing its clinical course and prognosis. We aimed to analyze the clinical features and prognosis of pediatric TTS in a nation-wide multicenter registry and considering the published literature. We included a total of 54 patients from 4 different hospitals in Spain, as well as pediatric TTS patients from the published literature. Comparisons between groups were performed in order to assess for statistically and clinically relevant prognostic differences between pediatric and adult population features. Patients with pediatric TTS are more commonly male and exhibit a higher prevalence of physical triggers. The left ventricular ejection fraction (LVEF) was significantly lower in the pediatric population (30.5 + 10.4 vs 36.9 + 16.9, p < 0.05), resulting in more than fivefold rates of cardiogenic shock on admission compared to the general adult TTS population (Killip IV 74.1% vs 10.5%, p < 0.001) with similar rates of death and recurrence between groups. TTS in the pediatric population presents a distinctive clinical profile, with higher prevalence of atypical symptoms and physical triggers, as well as higher rates of cardiogenic shock on admission and similar mortality and recurrence rates than those of the adult population. This study provides valuable insights into understanding pediatric TTS and underscores the necessity for further research in this age group.

Severe hypoglycemia with reduced liver volume as an indicator of end-stage malnutrition in patients with anorexia nervosa: a retrospective observational study

BACKGROUND

Hypophosphatemia due to excessive carbohydrate administration is considered the primary pathogenesis of refeeding syndrome. However, its association with liver injury and hypoglycemia, often seen in severe malnutrition before re-nutrition, remains unclear. Autophagy reportedly occurs in the liver of patients with severe malnutrition. This study aimed to clarify the pathophysiology of liver injury and hypoglycemia by focusing on liver volume.

METHODS

Forty-eight patients with anorexia nervosa with a body mass index (BMI) of < 13 kg/m2 were included (median BMI: 10.51 kg/m2 on admission). Liver volume was measured in 36 patients who underwent abdominal computed tomography (CT), and the "estimated liver weight/ideal body weight" was used as the liver volume index. Seventeen blood test items were analyzed during the first 60 days.

RESULTS

Liver volume significantly decreased when abdominal CTs were conducted shortly before or after hypoglycemia compared to when the scans were performed during periods without hypoglycemia. Five patients with severe hypoglycemia on days 13-18 after admission had a very low nutritional intake; of them, four showed a marked decrease in liver volume. Severe hypoglycemia was accompanied by low serum triglycerides and liver dysfunction. Patients experiencing hypoglycemia of blood glucose levels < 55 mg/dL (< 3.05 mmol/L) (32 patients; median lowest BMI: 9.45 kg/m2) exhibited significantly poorer blood findings for most of the 17 items, except serum phosphorus and potassium, than did those not experiencing hypoglycemia (16 patients; median lowest BMI: 11.2 kg/m2). All patients with a poor prognosis belonged to the hypoglycemia group. Empirically, initiating re-nutrition at 500 kcal/day (20-25 kcal/kg/day), increasing to 700-800 kcal/day after a week, and then gradually escalating can reduce serious complications following severe hypoglycemia.

CONCLUSIONS

Liver volume reduction accompanied by hypoglycemia, low serum triglyceride levels, and liver dysfunction occurs when the body's stored energy sources are depleted and external nutritional intake is inadequate, suggesting that the liver was consumed as a last resort to obtain energy essential for daily survival. This pathophysiology, distinct from refeeding syndrome, indicates the terminal stage of malnutrition and is a risk factor for complications and poor prognosis. In treatment, extremely low nutrient levels should be avoided.

Stress Cardiomyopathy Induced by Refractory Hypoglycemia Due to Acute Sulfonylurea Intoxication

Takotsubo cardiomyopathy (TCM) is a reversible syndrome that resembles a myocardial infarction but without typical coronary stenosis and with an apical "ballooning" image present on an echocardiogram. Multiple triggers have been linked to TCM but rarely, acute severe hypoglycemia. This is a case of a 39-year-old woman who was brought to the emergency department after being found unresponsive at home. She was severely hypoglycemic with a glucose of 18 mg/dL and suspected to have sulfonylurea intoxication. The patient was intubated and transferred to our ICU from an outside facility for a higher level of care. The patient was noted to have an elevated troponin and the initial echocardiogram demonstrated TCM. The patient remained persistently hypoglycemic, despite continuous dextrose infusion and glucagon treatment. Stress dose steroids were added with the eventual resolution of hypoglycemia. A repeat echocardiogram demonstrated the resolution of TCM.

Recurrent Hypoglycemia Secondary to Insulinoma in an Adult With Beckwith-Wiedemann Syndrome

Beckwith-Wiedemann syndrome (BWS) is a rare genetic disorder characterized by genetic and epigenetic changes on the chromosome 11p15.5 region, which includes genes that are important for fetal and postnatal growth. Children with BWS have a higher chance of having hypoglycemia, hyperinsulinemia, and malignancies early in life, although hypoglycemia caused by an insulinoma that develops later in life has not been reported. We describe the diagnosis of insulinoma in a 53-year-old man with BWS in this case report. This is the first case report of insulinoma in an adult with this syndrome.

Continuous glucose monitoring assessment in patients suffering from anorexia nervosa reveals chronic prolonged mild hypoglycemia all over the nycthemeron

OBJECTIVE

Anorexia nervosa (AN) is an eating disorder characterised by voluntary dietary restriction leading to severe undernutrition. Hypoglycaemia is mostly described through severe case reports and is always evaluated by fasting or post-meal blood glucose, showing nothing about hypoglycaemia's length or duration. The interest of continuous interstitial glucose monitoring (CGM), largely used in diabetes mellitus, has never been evaluated in AN patients.

METHOD

Glycaemia cycles in AN patients were assessed using CGM over 5 days and then analysed according to food intake.

RESULTS

Mean glycaemia was within normal range. 91% of the patients presented with at least one episode with glycaemia under 70 mg/dl. Within the 24 h, the percentage of time spent with a glycaemia under 70 mg/dl was of 20.82 ± 3.90% with a maximum of 52%. We found 2.52 ± 0.33 hypoglycaemia events per 24 h, including 21.11 ± 3.76% at night. CGM parameters correlated with cortisol and IGF1 plasma levels. Comparison with estimated carbohydrate intakes discriminated concordant and non-concordant estimations depending on patient.

CONCLUSIONS

AN patients display chronic prolonged mild hypoglycaemia all over the nycthemeron despite normal fasting glycaemia. Associated adaptive increased counter-regulatory hormones might protect AN patients from deeper hypoglycaemia. CGM allowed testing food intake self-estimation reliability of AN patients and could be a very useful biofeedback tool.

Recurrent Takotsubo Syndrome Due to Hypoglycemic Attacks

Takotsubo syndrome (TTS) is a disorder with transient cardiac dysfunction triggered by stress. Rarely, hypoglycemia can also trigger TTS, but there are no case reports of repeated TTS due to hypoglycemia. We report the case of a 51-year-old Japanese woman who was brought to the emergency department with impaired consciousness and shock vitals. Blood tests revealed severe hypoglycemia. She also had an abnormal electrocardiogram with a QS pattern in the anterior thoracic guidance, which led to the diagnosis of TTS after repeated echocardiographic evaluation by a cardiologist. The diagnosis of hypoglycemic coma was made, and the patient was admitted to the intensive care unit (ICU). The patient had anorexia nervosa and had been suffering from a hypoglycemic coma due to anorexia for some time. The patient had a history of hypoglycemic coma about one year before and had been hospitalized in the ICU with TTS at that time. We report the world's first case of repeated TTS due to hypoglycemia. Since hypoglycemia is hemodynamically associated with increased heart rate and systolic blood pressure, TTS should be included in the differential diagnosis when shock vitals are repeated in patients with frequent hypoglycemia.

A Review of Nuclear Imaging in Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy or Takotsubo Syndrome (TTS) is a reversible left ventricular dysfunction syndrome that is increasingly being recognized. Recent advances in nuclear imaging have allowed us to study TTS in greater detail. We searched the PubMed and Medline databases and identified 53 publications with 221 patients reporting nuclear imaging findings in TTS. The age of the patients ranged from 17 to 87 years and were predominantly women (88.2%). The TTS variant was apical (typical) in 170 (76.9%), mid-ventricular in 23 (10.4%), and basal (reverse TTS) in 2 (0.9%). Cardiac perfusion was assessed using ^99mTc sestamibi (MIBI) SPECT, ^99mTc tetrofosmin SPECT, ²⁰¹Tl SPECT, ⁸²Rb PET, ²⁰¹Tl SPECT, and ¹³N ammonia PET. Additional studies used were ¹²³I MIBG SPECT, ¹²³I BMIPP SPECT, ¹⁸F FDG PET, ⁶⁷Ga citrate, and ¹¹C hydroxy-ephedrine. A perfusion defect was seen in 69 (31.2%), and an inverse perfusion–metabolism mismatch (normal or near-normal perfusion with absent myocardial metabolic activity) was seen in 183 (82.8%) patients. Nuclear imaging has a significant role in evaluating, diagnosing, and prognosticating patients with TTS. As nuclear imaging technology evolves, we will surely gain more insights into this fascinating disorder.

Takotsubo cardiomyopathy associated with pneumatosis cystoides intestinalis and postprandial hypoglycemia of anorexia nervosa

Hypoglycemia is not rare in anorexia nervosa (AN). Takotsubo cardiomyopathy (TCM) is characterized by extensive akinesis of the apical region with hypercontraction of the basal segment of the ventricle in the absence of coronary artery disease. Its mechanism is not fully understood, but hypoglycemia is considered one of the physical factors. Pneumatosis cystoides intestinalis (PCI) is a rare disease characterized by multiple gaseous cysts in the intestinal wall. PCI sometimes causes an absorption defect. The case of a 48-year-old woman with AN with PCI and TCM that developed after a postprandial hypoglycemic coma is reported. When the patient was admitted to our hospital, her abdominal X-ray showed a confluent image of grapes, and computed tomography showed gaseous cysts in the intestinal wall from the ascending colon to the transverse colon. PCI was then diagnosed. About 7 days after admission, she developed hypoglycemic coma. However, she recovered from the coma and on the next day she became suddenly hypotensive, with the electrocardiogram showing T-wave inversion. Echocardiography then showed akinesis around the apex and hypercontraction of the basal segments, and TCM was diagnosed. Severe AN with PCI may cause more severe hypoglycemia, resulting in TCM.

Sequelae of Eating Disorders at Imaging

Although eating disorders are common, they tend to be underdiagnosed and undertreated because social stigma tends to make patients less likely to seek medical attention and less compliant with medical treatment. Diagnosis is crucial because these disorders can affect any organ system and are associated with the highest mortality rate of any psychiatric disorder. Because of this, imaging findings, when recognized, can be vital to the diagnosis and management of eating disorders and their related complications. The authors familiarize the radiologist with the pathophysiology and sequelae of eating disorders and provide an overview of the related imaging findings. Some imaging findings associated with eating disorders are nonspecific, and others are subtle. The presence of these findings should alert the radiologist to correlate them with the patient's medical history and laboratory results and the clinical team's findings at the physical examination. The combination of these findings may suggest a diagnosis that might otherwise be missed. Topics addressed include (a) the pathophysiology of eating disorders, (b) the clinical presentation of patients with eating disorders and their medical complications and sequelae, (c) the imaging features associated with common and uncommon sequelae of eating disorders, (d) an overview of management and treatment of eating disorders, and (e) conditions that can mimic eating disorders (eg, substance abuse, medically induced eating disorders, and malnourishment in patients with cancer). Online supplemental material is available for this article. ^©RSNA, 2022.

A Fatal Case of Takotsubo Cardiomyopathy Secondary to Refractory Hypoglycemia in Severe Starvation: An Autopsy Case Report

A 56-year-old, severely malnourished man presented with loss of consciousness due to hypoglycemia. Echocardiography revealed left ventricular apical ballooning, indicating takotsubo cardiomyopathy. Although his caloric intake was gradually increased to avoid refeeding syndrome, hypoglycemia was refractory, and repetitive glucose administration was required. On day 4 of admission, he developed severe refractory hypoglycemia with a progressive decrease in blood pressure. Consequently, pulseless ventricular tachycardia followed by pulseless electrical activity developed. Although venoarterial extracorporeal membrane oxygenation was introduced, the patient did not respond to the treatment and died. Autopsy revealed myocardial degeneration and contraction-band necrosis, indicative of takotsubo cardiomyopathy. No coronary stenosis was observed. The liver showed moderate hepatocyte atrophy and autophagosomes, consistent with starvation and not with refeeding syndrome. We speculated that refractory hypoglycemia induced extreme catecholamine secretion, which led to severe complications of takotsubo cardiomyopathy, such as fatal arrhythmia and extremely low cardiac output. Early recognition of these critically ill patients and timely therapeutic interventions, including strict glycemic control and adequate caloric intake, may improve patient outcomes.

Takotsubo cardiomyopathy in a 12-year-old boy caused by acute brainstem bleeding-a case report

Takotsubo cardiomyopathy is characterized by acute and reversible severe left ventricular dysfunction due to intensive emotional or physical stress followed by catecholamine excess. Traditionally it is most common in postmenopausal women, whereas only few cases have been described in childhood. In our case a previously well 12-year-old boy presented with severe cardiogenic shock due to dramatically impaired left ventricular function requiring significant inotropic support and invasive mechanical ventilation. Interestingly, cardiac catheterization, myocardial tissue histology and biochemical laboratory tests did not yield a definitive diagnosis. As his cardiac function improved gradually within several days and deep sedation could be weaned, he was then found to suffer from hemiparesis and absence of protective airway reflexes on neurological examination during the weaning process. Subsequent brain imaging studies revealed a brainstem bleeding due to a fistulous arteriovenous malformation (AVM) appearing to be only a few days old. After endovascular coiling and subsequent microsurgical resection of the malformation, he recovered completely. Our present case demonstrated, that brainstem bleeding could precipitate Takotsubo cardiomyopathy manifesting hemodynamic collapse. Severe ventricular impairment has been described in many adults with subarachnoid hemorrhage; however, this condition is extremely rare among children. When severe cardiogenic shock is diagnosed, precipitating factors such as intracranial processes should be ruled out on a regular basis.

Risk factors for Takotsubo syndrome following cardiac surgery: A case-control study

OBJECTIVE

Takotsubo syndrome following cardiac surgery is a rare occurrence. However, early diagnosis is essential to prevent treatment which could increase the left ventricular outflow tract pressure gradient in patients with Takotsubo syndrome, and lead to cardiogenic shock. Therefore, our study aimed to identify the incidence of Takotsubo syndrome after cardiopulmonary bypass and the associated risk factors and prognosis.

METHODS

We retrospectively studied 5773 patients who underwent cardiopulmonary bypass between February 2007 and July 2017. Among these, Takotsubo syndrome was diagnosed in 52 (0.9%). To evaluate the risk factors for Takotsubo syndrome, 104 of the remaining 5721 patient were randomly selected as the control group (1:2 ratio). Univariate and multivariate logistic regression analyses were used for risk factor analysis.

RESULTS

Majority of patients (69.2%) in the Takotsubo syndrome group underwent mitral valve surgery, compared with 32.7% in the control group. The following risk factors of Takotsubo syndrome were identified: atrio-ventricular valve surgery (odds ratio (OR) 10.5; 95% confidence interval (CI), 2.6-42.5; p = 0.001); and the immediate postoperative use of epinephrine (OR, 3.3; 95% CI, 1.0-10.7; p = 0.05) and dobutamine (OR, 4.8; 95% CI, 1.72-13.3; p = 0.003). Hypertension was a significant protective factor against Takotsubo syndrome following cardiac surgery (OR, 0.22; 95% CI, 0.06-0.73; p = 0.01).

CONCLUSION

Takotsubo syndrome following cardiac surgery is rare. Immediate postoperative use of epinephrine and doputamine, as well as atrio-ventricular valve surgery were factors associated with the development of Takotsubo syndrome.

Fatal bleeding after transfemoral coronary angiography in anorexia nervosa

In 2015, 911,841 left heart catheterizations and 365,038 percutaneous coronary interventions were carried out in Germany. Complication rates for elective cardiac catheterization are low; however, the risk of complications increases with patient age and comorbidity. We present the case of a 49-year-old woman with long-term anorexia nervosa who underwent a diagnostic left heart catheterization on suspicion of takotsubo cardiomyopathy (TTC). She was found with extended hemorrhage from the puncture site approximately 3.5 h after the procedure. Autopsy identified fatal bleeding as the cause of death. Clinical examinations, autopsy findings, and forensic follow-up examinations revealed no pre-existing conditions that could have contributed to fatal bleeding. Anorexia nervosa is an eating disorder with a high mortality rate. Suicide is one of the most frequent causes of death among anorexia nervosa patients. Considering the patient's history of psychiatric problems and previous suicidal utterances, we assume that she manipulated her pressure bandage with suicidal intent.

Pathogenesis of Ventricular Arrhythmias and Its Effect on Long-Term Prognosis in Patients With Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TTC), also known as broken heart syndrome, stress cardiomyopathy (SCM), or apical ballooning syndrome, is a non-ischemic cardiac disease with an initial clinical presentation that is very similar to acute coronary syndrome (ACS). Ventricular arrhythmias (VAs) contribute significantly to an increase in the rates of death in patients with TTC, especially during the acute phase, in which patients with TTC are more susceptible to develop life-threatening arrhythmias (LTA) such as ventricular tachycardia (VT), ventricular fibrillation (VF), torsades de pointes (TdP), and sudden cardiac death (SCD). However, the pathophysiology of TTC and how VA occurs are still a mystery. We aim to review previous literature and discuss the possible mechanisms of VA in TTC patients.

VA usually complicates the acute phase of the disease and worsens the long-term prognosis. Alterations of repolarization (negative T wave, prolonged QTc) indicate a high risk of arrhythmic events (TdP, VT, VF, and SCD). Catecholamine effect on myocardial cells and myocardial edema can create a substrate for the development of VA. Some of the most commonly proposed mechanisms for the development of VA in patients with TTC are coronary vasospasm, myocardial stunning due to catecholamines, re-entry, and triggered activity. Further prospective studies, including a more significant number of patients, are required to understand the disease's pathophysiology better and improve LTA management in patients with TTC.

Heart and anorexia nervosa

Anorexia nervosa, one of the more frequent and severe eating disorders, is a chronic psychiatric disease with potentially serious somatic consequences. This behavioral symptomatology leads to weight loss, undernutrition, and more or less severe-potentially life-threatening-somatic complications including respiratory, hepatic, digestive and cardiac features, electrolyte disturbances, endocrine and bone impairment, immunodepression, and related opportunistic infections. In this review, the authors report an overview of cardiac diseases in this disease.

The role of multimodality imaging in takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is a syndrome of transient left ventricular (LV) dysfunction mimicking acute coronary syndrome. Although the mechanisms underlying the occurrence of TC are unknown, several imaging techniques contribute to its diagnosis. Here we review the current knowledge about TC, in particular, the pathophysiology and the role of imaging including nuclear cardiovascular medicine.

Clinical Overlap Between Myopericarditis and Stress Induced Cardiomyopathy: A Diagnostic and Therapeutic Challenge

Patient: Female, 47

Final Diagnosis: Stress induced cardiomyopathy

Symptoms: Chest pain

Medication: —

Clinical Procedure: Catch • echo

Specialty: Cardiology

Transient Left Ventricular Contractile Dysfunction during the Treatment of Rhabdomyolysis: A Case Report and Literature Review

Transient left ventricular contractile dysfunction (TLVCD) is often observed as a result of stress-related cardiomyopathy; however, recent reports suggest that rhabdomyolysis and eating disorders can also induce the development of TLVCD. We report a 52-year-old malnourished man who developed acute heart failure on day 4 of treatment for rhabdomyolysis. Transthoracic echocardiogram revealed severe hypokinesis at the apical and mid-ventricular segments, except for the basal segments of the left ventricular wall, which recovered within one week. We discuss the pathogenesis of TLVCD with sympathetic nerve activation in association with rhabdomyolysis or refeeding syndrome.

Takotsubo Cardiomyopathy Coexisting with Acute Pericarditis and Myocardial Bridge

Takotsubo cardiomyopathy (TCM) is a stress-induced cardiomyopathy that occurs primarily in postmenopausal women. It mimics clinical picture of acute coronary syndrome with nonobstructive coronary arteries and a characteristic transient left (or bi-) ventricular apical ballooning at angiography. The exact pathogenesis of TCM is not well recognized. Hereby we present an unusual case of TCM that presents with signs and symptoms of acute pericarditis and was also found to have a coexisting coronary muscle bridge on coronary angiography. We discuss the impact of these associations in better understanding of the pathogenesis of TCM.

Cardiovascular Impact of Eating Disorders in Adults: A Single Center Experience and Literature Review

Eating disorders have multiple medical sequelae, including potentially life-threatening cardiovascular complications. This article describes our cardiology practice experience of treating adults with eating disorders in the outpatient setting and documents baseline cardiac findings in this complex patient population. We describe our findings in patients across the spectrum of eating disorders; past studies have generally focused on anorexia only. This article also includes a review of the current literature on cardiovascular complications associated with disordered eating.

Cardiac changes in anorexia nervosa

Introduction Anorexia nervosa is an eating disorder, which is associated with many different medical complications as a result of the weight loss and malnutrition that characterise this illness. It has the highest mortality rate of any psychiatric disorder. A large portion of deaths are attributable to the cardiac abnormalities that ensue as a result of the malnutrition associated with anorexia nervosa. In this review, the cardiac complications of anorexia nervosa will be discussed.

METHODS

A comprehensive literature review on cardiac changes in anorexia nervosa was carried out.

RESULTS

There are structural, functional, and rhythm-type changes that occur in patients with anorexia nervosa. These become progressively significant as ongoing weight loss occurs.

CONCLUSION

Cardiac changes are inherent to anorexia nervosa and they become more life-threatening and serious as the anorexia nervosa becomes increasingly severe. Weight restoration and attention to these cardiac changes are crucial for a successful treatment outcome.

Myocardial Injury without Electrocardiographic Changes after a Suicide Attempt by an Overdose of Glimepiride and Zolpidem: A Case Report and Literature Review

A 40-year-old diabetic man was admitted to our hospital for poor glycemic control. During hospitalization, he took 42 mg glimepiride and 50 mg zolpidem as a suicide attempt. The following day, the creatine kinase-MB fraction and troponin I levels were elevated to 112 IU/L and 8.77 ng/mL, respectively, without any electrocardiographic abnormalities. The patient recovered completely without any complications. Four weeks later, coronary computed tomography angiography and myocardial perfusion scintigraphy revealed moderate one-vessel coronary disease without the evidence of myocardial ischemia or old infarction. Cardiac-specific markers must be considered in sulfonylurea-induced hypoglycemic patients, particularly when the patient is unconscious and does not exhibit any clinical manifestations.

Cardiovascular disorders in anorexia nervosa and potential therapeutic targets

Anorexia nervosa (AN) is an eating disorder in which a distorted self-perception of body image and an excessive fear of gaining weight result in extreme restrictions in eating habits. AN may be divided into two types: a "binge-eating/purging type" during which the individual regularly engages in overeating and then purging behavior, and a "restricting type", in which she does not. AN is a serious medical problem in young people in Western societies. It is widely reported that patients with AN exhibit an enhanced mortality rate as compared with age-matched healthy subjects, which has been mainly ascribed to cardiac complications. At least one-third of all deaths in patients with anorexia nervosa are estimated to be due to cardiac causes, mainly sudden death. Cardiovascular complications of AN can be present in up to 80% of cases, and among them alterations in cardiac electrical activity, structure and hemodynamics have been reported as causes of morbidity and mortality. The objective of this brief review is to summarize current knowledge on the main cardiovascular complications of AN, their underlying mechanisms and the possible therapeutic approaches.

Takotsubo cardiomyopathy: how much do we know of this syndrome in children and young adults?

Since Takotsubo cardiomyopathy was first described by Sato in 1990, multiple cases have been reported, but only few in children, among whom this type of cardiomyopathy is to some extent underappreciated. A series of children with this syndrome were therefore reviewed, drawing comparison with cases reported by others. The review addresses the current challenges in diagnosis, presentation, triggers, clinical course, management, and possible pathogenic mechanisms of the entity.

A 6-year-old girl with undiagnosed hemophagocytic lymphohistiocytosis and takotsubo cardiomyopathy: a case report and review of the literature

Hemophagocytic lymphohistiocytosis (HLH) is a rare disorder of highly stimulated immune responses to antigens that leads to life-threatening inflammation and multiple organ dysfunction. At presentation, HLH may uncommonly mimic septic shock. In this case, we present a 6-year-old girl presenting to the pediatric emergency department with a febrile illness and anemia that subsequently developed decompensated shock, initially thought to be septic. She was ultimately diagnosed with HLH. During initial HLH treatment, this patient also developed takotsubo cardiomyopathy, a unique pattern of reversible left ventricular dysfunction characterized by transient apical ballooning and hypokenesis of the left ventricle that spontaneously resolves. There are very few case reports of HLH-associated takotsubo cardiomyopathy. We believe that this is the first case of takotsubo cardiomyopathy in a child with HLH.

Takotsubo cardiomyopathy and anaesthesia: case report and review of the literature

Takotsubo cardiomyopathy is an acute syndrome characterized by cardiac failure from disturbances in the contractility of the left ventricle. It is presumably caused by sympathetic over stimulation. We describe a case of postoperatively developed Takotsubo cardiomyopathy in a 69-year-old female. The syndrome developed in connection with awareness during complete residual paralysis. The literature on this syndrome is reviewed and implications for anaesthesia described.

Perioperative management of severe anorexia nervosa

As the prevalence of anorexia nervosa (AN) increased, surgery in severe AN patients also increased in the 2000s. We experienced a surgical case of a patient with severe AN, showing an extremely low BMI of 8.6 kg m(-2). We investigated the problems associated with this case and propose criteria to manage severe AN. We endeavour to report on the perioperative management of rare and severe symptoms and surgical indications of severely malnourished patients. All published reports were identified through comprehensive searches using PubMed, BioMedLib, and the Japan Medical Abstracts Society with the following terms and keywords: 'anorexia nervosa', 'eating disorder', 'hypoglycaemia', 'leucocytopaenia', 'gelatinous bone marrow', 'surgery', and 'operation'. In cases of AN with a BMI under 13 kg m(-2), marked hypoglycaemia, leucocytopaenia <3.0×10(9) litre(-1), or both, potentially fatal complications frequently occur. Accordingly, patients need strict nutritional support to avoid re-feeding syndrome until surgery. During the course of anaesthesia, careless loading of glucose or catecholamine may lead to disturbance of electrolytes or fatal arrhythmia. Intensive care and early feeding as soon as possible after surgery are important to prevent surgical site infection. Although not many perioperative cases of AN have been reported, clinicians must be aware of the danger and the causes of mortality in critical cases. Thus, the decision to undertake surgery must be taken carefully and close perioperative coordination among physicians, surgeons, psychiatrists, anaesthesiologists, and intensivists is essential.

Insulinoma presenting with cardiac arrest and cardiomyopathy

A 33-year-old woman presented with ventricular fibrillation cardiac arrest and was found to have a blood glucose of 1.83 mmol/L. Cardiac catheterisation revealed a dilated left ventricle with an ejection fraction (EF) of 26% and angiographically normal coronary arteries. Continuous dextrose infusion was required to treat hypoglycaemia, which prompted consideration of insulinoma as a possible cause for her cardiomyopathy. Whipple's triad was demonstrated; a 72 h fast provided biochemical evidence of insulinoma, and imaging localised a tumour in her pancreas. The tumour was resected and pathology confirmed insulinoma; pancreaticoduodenectomy cured her hypoglycaemia. No alternate cause of cardiomyopathy was found and 4 months after surgery her EF improved to 41%. High insulin levels can close cardiac K(ATP) channels associated with dilated cardiomyopathy; the catecholamine surge from hypoglycaemia may also contribute to ventricular remodelling. Hypoglycaemia can cause QT segment prolongation, and may have precipitated fibrillation in this patient's arrhythmia-prone myocardium.

Radiology of eating disorders: a pictorial review

Eating disorders are a major challenge for health professionals, with many patients receiving ineffective care due to underdiagnosis or poor compliance with treatment. The incidence of eating disorders is increasing worldwide, producing an increasing burden on healthcare systems, and they most often affect young patients, with significant long-term complications. The effects of long-term malnutrition manifest in almost every organ system, and many can be detected radiologically, even without overt clinical findings. Musculoskeletal complications including osteoporosis result in a high incidence of insufficiency fractures, with long-term implications for bone health and growth, while respiratory complications are often recognized late due to disordered physiologic responses to infection. Gastrointestinal complications are numerous and in extreme cases may result in fatal outcomes after acute gastric dilatation and rupture subsequent to binge eating. In patients with severely disordered eating, in particular anorexia nervosa, marked derangement of electrolyte levels may result in refeeding syndrome, which requires emergent management. Recognition of such complications is critical to effective patient care and requires radiologists to be aware of the spectrum of imaging abnormalities that may be seen. Since many patients are reluctant to disclose their underlying condition, radiologists also play a critical role in identifying previously undiagnosed eating disorders.

Trauma induced left ventricular apical ballooning syndrome in a 15 year old: a rare case of Tako-tsubo cardiomyopathy

We present a case of a 15 year old girl who developed transient left ventricular apical ballooning syndrome, Tako-tsubo cardiomyopathy, after a significant motor vehicle accident. On post-trauma day three she developed heart failure with mid-to-apical left ventricular wall dysfunction with an EF of 10%-15%. The patient eventually regained full cardiac function by post-trauma day seven. Here we present the first case report of trauma induced left ventricular apical ballooning syndrome in pediatrics.

Hypoxic hepatitis

Hypoxic hepatitis (HH), an acute liver injury also known as 'ischaemic hepatitis' or 'shock liver', is frequently observed in intensive care units. HH is heralded by a massive but transient rise in serum aminotransferase activities caused by anoxic necrosis of centrilobular liver cells. Cardiac failure, respiratory failure and toxic-septic shock are the main underlying conditions accounting for more than 90% of cases, but HH may also occur in other circumstances. Until recently, liver ischaemia, i.e. a drop in hepatic blood flow, was considered the leading, and even the sole, hemodynamic mechanism responsible for HH, and it was generally held that a shock state was required. In reality, other hemodynamic mechanisms of hypoxia, such as passive congestion of the liver, arterial hypoxaemia and dysoxia, play an important role while a shock state is observed in only 50% of cases. Accordingly, 'ischaemic hepatitis' and 'shock liver' are misnomers. Therapy of HH depends primarily on the nature of the underlying condition. The prognosis is poor, with more than half of patients dying during the hospital stay.

Sudden death in eating disorders

Eating disorders are usually associated with an increased risk of premature death with a wide range of rates and causes of mortality. “Sudden death” has been defined as the abrupt and unexpected occurrence of fatality for which no satisfactory explanation of the cause can be ascertained. In many cases of sudden death, autopsies do not clarify the main cause. Cardiovascular complications are usually involved in these deaths. The purpose of this review was to report an update of the existing literature data on the main findings with respect to sudden death in eating disorders by means of a search conducted in PubMed. The most relevant conclusion of this review seems to be that the main causes of sudden death in eating disorders are those related to cardiovascular complications. The predictive value of the increased QT interval dispersion as a marker of sudden acute ventricular arrhythmia and death has been demonstrated. Eating disorder patients with severe cardiovascular symptoms should be hospitalized. In general, with respect to sudden death in eating disorders, some findings (eg, long-term eating disorders, chronic hypokalemia, chronically low plasma albumin, and QT intervals >600 milliseconds) must be taken into account, and it must be highlighted that during refeeding, the adverse effects of hypophosphatemia include cardiac failure. Monitoring vital signs and performing electrocardiograms and serial measurements of plasma potassium are relevant during the treatment of eating disorder patients.

Hypoglycemia revisited in the acute care setting

Hypoglycemia is a common finding in both daily clinical practice and acute care settings. The causes of severe hypoglycemia (SH) are multi-factorial and the major etiologies are iatrogenic, infectious diseases with sepsis and tumor or autoimmune diseases. With the advent of aggressive lowering of HbA1c values to achieve optimal glycemic control, patients are at increased risk of hypoglycemic episodes. Iatrogenic hypoglycemia can cause recurrent morbidity, sometime irreversible neurologic complications and even death, and further preclude maintenance of euglycemia over a lifetime of diabetes. Recent studies have shown that hypoglycemia is associated with adverse outcomes in many acute illnesses. In addition, hypoglycemia is associated with increased mortality among elderly and non-diabetic hospitalized patients. Clinicians should have high clinical suspicion of subtle symptoms of hypoglycemia and provide prompt treatment. Clinicians should know that hypoglycemia is associated with considerable adverse outcomes in many acute critical illnesses. In order to reduce hypoglycemia-associated morbidity and mortality, timely health education programs and close monitoring should be applied to those diabetic patients presenting to the Emergency Department with SH. ED disposition strategies should be further validated and justified to achieve balance between the benefits of euglycemia and the risks of SH. We discuss relevant issues regarding hypoglycemia in emergency and critical care settings.

A case of anorexia nervosa complicated with strongly suspected stress-induced cardiomyopathy and mural thrombus

Stress-induced cardiomyopathy is a unique reversible cardiovascular disease precipitated by acute emotional or physical stress. It is associated with a high prevalence of chronic anxiety disorder that precedes the onset of cardiomyopathy, as well as comorbid cardiovascular risk factors that are similar to the ST segment elevation of myocardial infarction. A thirty-five-year-old woman suffering from anorexia nervosa visited our hospital complaining of severe general weakness. She was diagnosed with stress-induced cardiomyopathy and mural thrombus using a transthoracic echocardiogram. Therefore, she was given anticoagulation therapy and nutrition with immediate psychiatric interventions. After two weeks of treatment, the follow-up echocardiogram indicated a significant improvement of the left ventricular dysfunction and mural thrombus.

A case of transient left ventricular apical ballooning syndrome in a child: clinical features and imaging findings

Transient left ventricular apical ballooning syndrome (TLVABS) is an acute cardiac disease that is characterized by transient left ventricular systolic dysfunction involving the apical region. The symptoms and electrocardiographic changes of TLVABS mimic those observed in acute myocardial infarction while obstructive coronary arterial lesions are not seen in patients with TLVABS. TLVABS usually occurs in elderly women after physical or emotional stress. However, it is very rare in children and so it not well known to pediatricians. Accordingly, TLVABS in children can be misdiagnosed as myocarditis or cardiomyopathy. We report here on a case of child who showed the typical findings of TLVABS in association with pericarditis. He presented with dyspnea and pericardial effusion, which required pericardiocentesis. After pericardiocentesis, he showed the typical echocardiographic and electrocardiographic findings of TLVABS. The MRI findings at 14 days after the initial symptoms showed normal coronary arteries and normal left ventricular function without any wall motion abnormalities. In addition, no delayed hyper enhancement was found on delayed-enhanced (DE)-MRI. We also reviewed the other reported cases of TLVABS in patients who were under the age of 40.

Tako-tsubo cardiomyopathy complicated by recurrent torsade de pointes in a patient with anorexia nervosa

We report the case of a 57-year-old woman with anorexia nervosa showing evidence of "tako-tsubo" cardiomyopathy complicated by several syncopes due to recurrent episodes of torsades de pointes. Prolongation of QT interval and QT dispersion have been reported both in the "tako-tsubo" cardiomyopathy and in anorexia nervosa. The QT prolongation and the QT dispersion has been linked as risk indicators for sudden cardiac death. The combination of "tako-tsubo" cardiomyopathy with a condition associated with the prolongation of QT and/or with an increase of QT dispersion, such as anorexia nervosa, makes the acute and subacute prognosis of this disease much more severe than usual.

Broken heart syndrome in a 17-year-old girl

Broken heart syndrome is characterized by transient left ventricular dysfunction with chest pain, electrocardiographic changes, and release of myocardial enzymes mimicking acute myocardial infarction. Physical and emotional stress usually precede the onset of symptoms. This dysfunction, known as takotsubo cardiomyopathy (TC), has been observed predominantly in women older than 60 years of age but very rarely reported in younger adults or children. Here we describe a 17-year-old girl with TC.

Complete recovery from severe myocardial dysfunction in a patient with anorexia nervosa

This report describes a patient who experienced cardiopulmonary arrest caused by severe hypoglycemia and malnutrition, which was successfully treated with percutaneous cardiopulmonary support (PCPS) and intra-aortic balloon pumping (IABP). A 33-year-old female with anorexia nervosa (AN) was transferred to the emergency center because of a loss of consciousness. On admission, she was extremely emaciated, hypotensive, and hypoglycemic (10 mg/dl). A chest X-ray showed butterfly shadow. Echocardiography showed severe hypokinesis of left ventricular wall motion. On the 3rd hospital day, she experienced cardiac arrest. Myocardial dysfunction caused by malnutrition was suspected, and therefore both PCPS and IABP were administered for circulatory support and myocardial protection. Thereafter, cardiac function gradually recovered and she was later weaned from PCPS and IABP on the 9th and the 10th hospital day, respectively. She was discharged from the intensive care unit on the 43rd hospital day with normal cardiac function. Her neurological outcome after 6 months as evaluated by the Glasgow Outcome Scale was considered to be good recovery. Cardiomyopathy in AN patients is reversible ventricular dysfunction, and circulation assisting devices are considered for the treatment of cardiogenic shock.