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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 Pediatric Emergency Care Volume 21, Number 9, September 2005 Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 603 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. n 2005 Lippincott Williams & Wilkins Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Pediatric Emergency Care Volume 21, Number 9, September 2005 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. REFERENCES 1. National Eating Disorders Association. Statistics: Eating Disorders and Their Precursors; 2002. 2. Nielsen S. Epidemiology and mortality of eating disorders. Psychiatr Clin North Am. 2001;24(2):201– 213. 3. Coleman WL. Recurrent chest pain in children. Pediatr Clin North Am. 1984;31:1007–1026. 4. Selbst SM. Chest pain in children. Pediatr Rev. 1997;18(5):169–173. 5. Katsui Anzai A, Merkin TE. Adolescent chest pain. Am Fam Phys. 1996;53(5):1682 –1688. 6. Sharp CW, Freeman CPL. The medical complications of anorexia nervosa. Br J Psychiatry. 1993;162:452 –462. 7. Palla B, Litt IF. Medical complications of eating disorders in adolescents. Pediatrics. 1988;81:613–623. 8. Cuellar RE, Van Thiel DH. Gastrointestinal consequences of the eating disorders: anorexia nervosa and bulimia. Am J Gastroenterol. 1986;81:1113–1124. 9. Overby KJ, Litt IF. Mediastinal emphysema in an adolescent with anorexia nervosa and self-induced emesis. Pediatrics. 1988;81:134– 136. 10. Bratton S, O’Rourke P. Spontaneous pneumomediastinum. J Emerg Med. 1993;11:525–529. 11. Fergusson RJ, Shaw TRD, Turnbull CM. Spontaneous pneumomediastinum: a complication of anorexia Nervosa? Postgrad Med J. 1985; 61:815–817. 12. Schechter JO, Altemus M, Greennfeld DG. Food bingeing and esophageal perforation in anorexia nervosa. Hosp Community Psychiatry. 1986;37:507 –508. 13. Pieters T, Boland B, Beguin C, et al. Lung function study and diffusion capacity in anorexia nervosa. J Intern Med. 2000;248:137 –142. n 2005 Lippincott Williams & Wilkins Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 605