A 44-year-old woman came to the hospital emergency department complaining of asthenia, anorexia and weight loss of about 20 kg in the last 7 months (usual weight 50-52 kg, current weight 30 kg at admission).
The symptoms began after placement of a dental prosthesis with subsequent chewing problems.
Personal history included: amenorrhea from 35 years of age, smoker, chronic alcoholism and long-term depressive syndrome for whom no treatment was followed.
Physical examination at admission revealed significant cachexia and trunk and lower limb lesions consistent with scratching lesions.
Analytically significant hypoproteinemia and mild hyponatremia.
The chest X-ray showed no pathological findings.
The patient was admitted to the internal medicine service to guide the diagnosis of anorexia nervosa, in the context of major depression, starting anxiolytic and antidepressant treatment after psychiatric evaluation.
To describe upper endoscopy as part of the clinical picture and to detect elevated levels of the antigen car-embryogenic colitis (CEA) several diagnostic tests were carried out which showed: hepatic steatosis and abdominal echography of
Pathologic examination was normal.
Enteral nutrition was initiated with a high protein diet and at 48 hours of evolution there were edemas with fovea in the lower limbs.
Intravenous albumin to treatment, due to the existence of hypoproteinemia and hypoalbuminemia, slightly improved third spaces, but dyspnea, irritative cough and decreased diuresis were added to the clinical picture.
Immediately progressive edema of the lower limbs increased, ascites appeared and was later associated with global respiratory failure, reason why the patient was admitted to the Intensive Care Unit (ICU).
Upon arrival to the ICU, the patient is seriously ill.
Examination revealed extreme cachexia, tachypnea with abdominal breathing, tachycardia of 120 bpm, TA 100/85, jugular engorgement at 45°.
Rhythmic cardiac tones without murmurs and crepitants ̄s on pulmonary auscultation.
Globulous abdomen with intense swelling of the wall and signs of ascites with hepatomegaly.
The lower limbs had significant edemas up to the root of the thigh.
Initial gas, with FiO2 50%, showed Ph 7.26, PO2 62, PCO2 49, HCO3 21 and SO2 91%.
The ECG showed a sinus rhythm with low voltages in all leads and a BIRDHH image.
Radiology showed significant cardiomegaly and a pattern compatible with pulmonary edema.
Right heart catheterization was performed and the following hemodynamic results were obtained: CVP 26, PVD 39/21 (31), PAP 34/22(29), PCP 20, GC 2.3, Ic 1.3 600 shock 39%, IRVO 5200.
Emergency echocardiography was performed to rule out cardiac taping with the objective of significant dilation of the right cavities without dilatation of the left cavities, global hypocontractility of the left ventricle with apical dyskinesia and systolic akinesia of the anterior septum.
Severe tricuspid insufficiency with PSAP of 32 mmHg and dilatation of suprahepatic veins.
Inotropic support was initiated with dopamine and dobutamine and depleting treatment with furosemide with hemodynamic stability and wide diuresis.
Despite this, the patient has progressive blood gas deterioration that requires OTI and MV connection.
The abdominal CAT scan revealed an important arachnoid mass without other findings.
In the ICU controls, severe analytical hypofatemia (0.30 mmol/l), hypomagnesaemia, iron and folic acid deficiency with normal levels of vitamin B12, hypokalaemia and low albumin levels stood out.
amenorrhea antecedent cortisol from 35 years old was determined hormonal levels obtaining a pattern of hypergonadotropic hypogonadism (increase of FSH and LH), hyperthyroidism and normal levels
The electromyography (EMG) showed findings compatible with severe axonal polyneuropathy.
Hyperproteic enteral nutrition was started progressively and supplementation (thiamine, folic acid, magnesium, monosodium phosphate, potassium and trace elements) was given parenterally.
The patient had a favorable left hemodynamic status and could be extubated 48 hours after the withdrawal of vasoactive drugs, with progressive reduction of ventricular edema and signs of failure.
Oral tolerance was initiated and the patient was discharged to the endocrinology unit on the seventh day of evolution.
Control echocardiogram: normal size of cavities with mild hypokinesia of the IV septum and apical segments of the free wall that led to mild depression of ventricular function.
Mild tricuspid regurgitation.
Normal inferior vena cava clamp.
Nutritional treatment started in our service with progressive normalization of nutritional parameters.
At the six-month follow-up visit to the endocrinology outpatient clinic, blood tests were normal with normal FSH, LH and prolactin values, maintaining a pattern of subclinical hypothyroidism.
The patient's weight had risen to 52 kg.
