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Illustrative Case
Chest Pain Among Adolescents With Anorexia Nervosa
Sreekanthan Sundararaghavan, MD,* Tanya Y. Pitts, MD,y
William A. Suarez, MD,* and Christine Johnstone, MDz
Abstract: Chest pain is common among adolescents. However,
chest pain among adolescents with eating disorders is unique. We
report a case of an anorexic adolescent presenting to the emergency
room with acute onset of chest pain due to spontaneous pneumomediastinum. The pathophysiology, etiology, and risk factors of
chest pain among adolescents with anorexia nervosa are reviewed.
Key Words: pneumomediastinum, anorexia, chest pain, adolescents
E
ating disorders are extremely prevalent in Western
societies, with as many as 5% to 10% of the female
population from ages 12 to 30 being affected.1 However, the
incidence among males is significantly lower and these
disorders cross all racial and socioeconomic borders.1,2
Chest pain is a frequent symptom among adolescents,
accounting for about 650,000 primary care visits annually
and approximately 6 out of 1000 emergency department visit
in the pediatric population.3,4 It occurs equally in males and
females. The most common causes of chest pain in an
adolescent include musculoskeletal, psychogenic, gastrointestinal, pulmonary, cardiac, or idiopathic. However, the
most anxiety-provoking etiology for the patient as well as
their family members is the fear of heart disease. In fact,
chest pain is the second most common reason resulting in a
referral to a pediatric cardiologist.5
CASE
A 16-year-old Caucasian female presented to the Emergency
Department with acute onset of chest pain, while at work, the night
before admission. Pain was located in the midsternal region,
radiated to the back and occasionally into her neck. The pain was
throbbing, exacerbated with deep inspiration, and relieved with
lying supine. She complained of sore throat and shortness of breath.
The patient also had a 25-pound weight loss over the last 3 to 4
months. History was negative for cough, wheezing, palpitations,
nausea, vomiting, hemoptysis, sweating, or fever. The past history
was significant for anorexia nervosa, asthma without exacerbations,
appendectomy, and ovarian cyst removal in the past few years.
Her medications included Celexa 20 mg twice daily and
Proventil metered-dose inhaler as needed. Family history was
*Division of Pediatric Cardiology, Department of Pediatrics; yPediatric
Residency Training Program and zDivision of Family Practice, Medical
College of Ohio and Mercy Children’s Hospital, Toledo, OH.
Address correspondence and reprint requests to Sreekanthan Sundararaghavan, MD, FACC, No: 10, First Cross, Fourth Main, NTI Layout, RMV
Second Stage, Bangalore, India 560094. E-mail: sreekanth_raghavan@
yahoo.com.
Copyright n 2005 by Lippincott Williams & Wilkins
ISSN: 0749-5161/05/2109-0603
significant for mitral valve prolapse in the mother and maternal
grandfather with premature coronary artery disease at 55 years. She
denied tobacco, alcohol, or drug use. The physical examination is
significant for an emaciated female with weight of 39.4 kg and
in no acute distress. Vital signs revealed a temperature of 368C
(hypothermic), a heart rate of 47 (bradycardia) beats per minute,
unlabored respirations at 20 breaths per minute, a blood pressure of
87/60 mm Hg (hypotension) with normal oxygen saturation.
HEENT examination was unremarkable. However, neck evaluation
was positive for crepitus bilaterally. Chest examination was
remarkable for reproducible chest pain in the midsternal region.
Cardiovascular examination revealed the patient to be bradycardic
with a normal S1 and S2, and no evidence of murmur, rub, click,
gallop, or thrill. Lungs were clear with decreased breath sounds.
Abdominal examination revealed no organomegaly.
The chest x-ray (Figs. 1 and 2) demonstrated pneumomediastinum with subcutaneous emphysema around the right lateral
chest wall with extension into the neck bilaterally. She had a tubular
chest and narrow cardiac silhouette. The ECG showed sinus
bradycardia with low voltage. No evidence of prolongation of the
QT interval was noted. The basic metabolic profile showed a serum sodium of 139 mEq/dL, potassium level of 4.4 mEq/dL, chloride of 99 mEq/dL, bicarbonate of 27 mEq/dL, BUN 19 mg/dL,
creatinine 1.1 mg/dL, magnesium 2.2 mEq/dL, and phosphorus
4.2 mEq/dL. Albumin and total protein levels were 5.0 and 7.7 g/dL,
respectively.
The patient was admitted with the diagnosis of spontaneous
pneumomediastinum and anorexia nervosa. Upon admission she
was placed on cardiac monitor, as well as strict calorie counting,
along with psychiatric and cardiology consults. The patient’s
respiratory status remained stable throughout the course of her stay.
The patient received supportive care and pain control. She was then
discharged home 2 days later with close follow up by her primary
care physician and psychiatry.
DISCUSSION
Eating disorders are highly prevalent among teenagers
due to societal pressures. Chest pain among most teenagers
is benign, however, they provoke a lot of anxiety among
patients and family members. Although there are no studies
that describe the incidence or prevalence of chest pain in this
subset of adolescent population, deeper understanding of the
different etiologies helps in their emergency care. Review of
the literature was performed using Medline search from 1960
to 2003 and the results were reviewed. Our search resulted in
7 case reports. Of significance is the absence of reviews
pertaining to the risk factors and pathophysiology of chest
pain that are unique to patients with anorexia nervosa.
They are predisposed to esophageal rupture, ulcer, tear,
pneumomediastinum, GERD, and arrhythmias. Most deaths
among anorexic patients are attributed to the cardiac system.
In many studies up to 87% of anorexic patients will have
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Sundararaghavan et al
Pediatric Emergency Care Volume 21, Number 9, September 2005
The decompression of air into the neck prevents tamponade
and pneumothorax.10
A gastrograffin swallow may or may not be necessary
to rule out esophageal tear. Patients with esophageal perforation usually have significant epigastric pain, which may
be exacerbated by swallowing or breathing and result in
respiratory distress.12 In one study, all patients with esophageal perforation had a widened mediastinum and left-sided
pleural effusions.12 If these signs are present, gastrograffin
swallow should be performed, but approximately 5% to 27%
will have a negative esophagram.9,12
It is quite possible that the acute 25-pound weight loss
with the underlying reactive airway disease provoked air
leakage, hence, the pneumomediastinum. Sudden weight loss
may result in mobilizing protein stores in the absence of fat
stores among this population, and thus, the lack of support to
the alveoli, which in turn facilitates air leaks and alveolar
rupture. However, this hypothesis is not well supported as
the serum albumin levels and protein stores have been found
to be normal in most anorexics including our patient.13 It is
interesting to note that our patient also had asthma that could
have increased the susceptibility for pulmonary complications, although no specific inciting event could be identified.
Pieters et al13 found that although the diffusion capacity was
FIGURE 1. Chest roentgenogram with pneumo mediastinum. Arrows point to the subcutaneous air in the neck.
some cardiac abnormalities.6 They range from arrhythmias,
hypotension, prolongation of the QT interval to congestive
heart failure.6,7 Of all complications, arrhythmias are the
most important as they could result in fatality.
Gastrointestinal complications represent the largest
category resulting in chest pain in this population. Gastroesophageal reflux, esophagitis, esophageal erosions, and ulcers are frequent as a resultant of purging activity secondary to
repetitive exposure of the esophagus to gastric acid.5,7,8 Repetitive vomiting and retching activity also places these individuals at higher risk for esophageal rupture, esophageal tears,
and Boerhaave syndrome (esophageal rupture that occurs with
vomiting after a meal).6,9 This syndrome is more likely to
present in a bulimic patient, rather than an anorexic patient.6,8
Pulmonary complications are relatively rare, however,
can be serious if not immediately identified. Pneumomediastinum is a rare but known cause of chest pain among all
adolescents.5 This is usually a self-limited disease.5,9,10 The
incidence may be increased in patients with anorexia and
bulimia.5,11 The pathophysiology of pneumomediastinum is
related to an increase in the pressure gradient between the
alveolar and interstitial spaces which enhance leakage of air
from the alveolar opening and ruptured alveoli into the
perivascular adventitia, yielding interstitial emphysema.10 If
the pressure rises abruptly, a pneumothorax may occur, as
with forceful retching, seen with self-induced vomiting.11
604
FIGURE 2. Lateral chest roentgenogram showing the anterior pneumo mediastinum.
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intact in patients with anorexia nervosa, the residual volumes
were increased up to 162%. In this study, the FEV1/FVC was
normal among anorexics. However, in patients with asthma
where this ratio is altered, associated increase in residual
volumes may provoke air leaks predisposing the patients to
pneumomediastinum and pneumothorax. Further randomized
studies are necessary to evaluate this hypothesis.
Diagnostic workup should include continuous monitoring of vital signs, 12-lead EKG, chest x-ray, and electrolytes. Our patient did not have an esophagram, as the
abovementioned symptoms were absent. Also, this patient
was anorexic and not bulimic.
Treatment of pneumomediastinum is directed toward
the underlying etiology. Although supportive in most cases,
care should include analgesics, bed rest, and antitussive
agents to prevent coughing. One hundred percent oxygen
will enhance reabsorption of the free air. The chest pain
usually resolves after 1 and 2 days and chest radiograph
usually returns to baseline within a week.10
SUMMARY
Chest pain is a frequent symptom in children and
adolescents prompting emergency room visits. However,
understanding the risk factors of chest pain and the pathophysiology unique to eating disorders such as anorexia nervosa will result in cost-effective management and care. Clues
to the cause of chest pain in most cases can be obtained with
a thorough history and physical examination. Presence of
reactive airway disease in a patient with an eating disorder
Chest Pain Among Adolescents With Anorexia Nervosa
may increase the risk of pneumomediastinum and pneumothorax, and diagnostic evaluations and management should
focus on these diagnoses especially when chest pain is one of
the presenting complaints.
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