LAS VEGAS – Anorexia nervosa in men may present in unusual ways, confounding the diagnosis and leading to inappropriate treatment, suggests a case series reported at the annual meeting of the American Association of Clinical Endocrinologists.
The four men, who ranged in age from 21 to 24 years, were seen in the emergency department with abnormal thyroid function test results, hypogonadism, and hypercortisolemia, according to data reported in a poster. Their symptoms included bradycardia (with heart rates in the 20s and 30s), gastroparesis, hypothermia, acute systolic heart failure, and erectile dysfunction.
"Only one of the cases had a prior diagnosis of anorexia, so it was kind of a mystery to everyone when they came in," first author Dr. Aren H. Skolnick said in a press briefing.
Some of the men were transferred to the cardiac care unit. Two were scheduled for cardiac pacemaker implantation, and one was scheduled for gastric pacemaker implantation before endocrinologists delved further into their history and made the correct diagnosis of anorexia.
"When we think of anorexia, we think of young women with eating disorders. No one really thinks about the guy with anorexia," said Dr. Skolnick, an endocrinology fellow at Hofstra North Shore-LIJ School of Medicine, Long Island (New York) Jewish Medical Center. "These patients were going to go for invasive procedures that they didn’t need, so [anorexia] really needs to be on the differential diagnosis, at least for anyone coming in with any of these endocrinopathies who you suspect may have had weight loss or are malnourished."
Most of the patients’ symptoms resolved with improved caloric intake and nutrition, although it hasn’t been smooth sailing in all cases, Dr. Skolnick said. "The best treatment we know of is nutrition – getting these people fed," he maintained. Although studies have looked at treatment with recombinant growth hormone, recombinant insulinlike growth factor-1 (IGF-1), estrogen for women, and thyroid hormone, "hormone therapy isn’t appropriate most of the time."
Some data suggest that men account for only about 10% of patients with anorexia, but they probably make up more like 25% because of underreporting and misdiagnosis, In fact, one of the diagnostic criteria in the DSM-IV is amenorrhea, "but there are no criteria for hypogonadal symptoms for men, so there is a bias even with the diagnostic criteria."
Male anorexia – sometimes termed "manorexia" – and female anorexia share similar risk factors, but their features differ somewhat. "Women tend to strive for thinness; men strive for a more muscular appearance. Women tend to have a little more of the laxative use or purging type; men are the more excessive exercise type," he explained.
There is also a sex disparity in treatment benefit. "Women tend to benefit more from treatment, possibly because they are picked up earlier," Dr. Skolnick elaborated. "There is more social support for them; people know how to treat female anorexia. And people aren’t picking up on the male anorexia, so they are coming to physicians later and their cases are may be more severe, or people don’t feel comfortable dealing with it."
Patients can develop a variety of endocrinopathies that may trigger endocrinology consults. Anorexia can affect the hypothalamic-pituitary axis, including the gonadal axis, leading to hypogonadal symptoms; the pituitary-thyroid axis; growth hormone or IGF-1, leading to impaired growth in children and adolescents; and the adrenal axis.
Dr. Skolnick and his colleagues were asked to consult on the patients because their laboratory findings were inconsistent. "Some of them had a sick euthyroid type of hypothyroidism, where their TSH may be borderline low-normal, with a low T3 or T4, which is why they called us, because they weren’t sure what was going on. In addition, they had symptoms of hypogonadism, low testosterone on labs, and cortisol resistance or increased cortisol because of the stress," he explained.
The endocrinologists’ differential diagnosis consisted of anorexia, depression, and malingering. Detailed histories revealed that the patients had a weight loss of up to 113 pounds over the past few months; therefore, they had severe protein and caloric malnourishment. They also reported depression, not eating, and exercising a lot; one said he had been using a fat-reducing agent.
Dr. Skolnick disclosed no relevant conflicts of interest.