The patient, a 33-year-old female Caucasian nurse, was referred to our Centre for Eating Disorders by her GP. She was affected by a severe untreated form of ANp with a duration of illness of 19 years. She smoked 15 cigarettes per day for over 15 years and drank 1 glass of wine at meals.
Four years previously, the patient had been kept under observation by the Psychiatry department for attempted suicide by medicinal overdose. The patient had also been treated with anti-depressives for about 15 years, although this therapy had been suspended about three months before her referral to our Centre.
No significant pathologies emerged in the review of the medical history of the patient's family. During the psychological assessment she reported the separation of her parents when she was a child and her difficulty in maintaining intimate relationships in adulthood. She embarked on her first diet following the death of her maternal grandmother; at this time she considered her weigh excessive (BMI 25). Three years prior to her arrival at the Centre, she had undergone a cone biopsy for adenocarcinoma in situ and had suffered a spontaneous abortion in the 3rd month of pregnancy.
She presented the main core eating disorder symptoms: she denied her underweight condition, she was obsessed with thoughts of food, weight and shape, she thought she couldn't stop bingeing and vomiting. She had decreased energy and difficulties in organizing her daily life. She worked compulsively and reported difficulties to relax. Affective disregulation and problems in her interpersonal relationships emerged in her clinical picture.
Upon her arrival at the Centre, she complained asthenia, lipothymia, ectopic heartbeat and abdominal pain; the intestine was not assessable due chronic laxative abuse. Binging (3-4 times/day) and the following severe purgative practices were disclosed: self-induced vomiting (28 episodes/week), laxative intake (1 cp day of senna) and diuretic use (occasional). Daily physical hyperactivity was also divulged: 2 hours of running or workout.
The diagnostic assessment revealed ANp and the concomitant Axis II Condition: Borderline Personality Disorder (according to the Diagnostic and Statistical Manual of Mental Disorders, Edition IV-TR).
The following data were revealed: weight 49 kg, height 1.67 m, BMI 17.5 kg/m2; blood pressure 125/85 mmHg; heart rate 72/min; respiratory rate 32/min; cutaneous temperature 36,2 C. Almost all of the teeth underwent odontoiatric cures or were substituted. Hair, nails and skin appeared normal.
Laboratory findings: serum total calcium 2.33 mmol/l, sodium 140 mEq/l, plasmatic proteins 7,6 g/dl with albumin 54,9% (4,17 g/dl). Hypokalaemia (3.1 mEq/l) was found and responded only to prolonged endovenous potassium (30 mEq/day of potassium chloride for 3 weeks), despite the patient's claimed cessation of the aforementioned purgative activity. Due to the persistent hypokalaemia, renin and aldosterone levels were evaluated, and the following data emerged: secondary hyperaldosteronism (Aldosterone > 100 ng/dl, active renin 408.9 muU/ml); creatinine in the normal range (0.8 mg/dl) and reduced creatinine clearance (70 ml/min); urinary electrolytes and ammonia were not available because the patient left the hospital against medical advice. Haemogas analysis in ambient air revealed pO2 127.80 mmHg, pCO2 38.8 mmHg, pH 7.39, HCO3- 22.80 mmol/l, and SO2 98.80%.
Oesophagogastroduodenoscopy (OGDS) showed grade "A" reflux oesophagitis (according to Los Angeles Classification); abdominal ultrasound revealed bilateral reduction of the thickness of the renal cortex; renal scintigraphy exposed a bilateral delay in the arrival phase of the trace and no signs of obstructive uropathy were noted.