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Spontaneous Pneumothorax in Anorexia Nervosa

Received July 12, 1996; revised July 23, 1996; accepted September 20, 1996. From the the Department of Psychiatry, University of Minnesota Medical School, and the Department of Neurosciences, University of North Dakota Medical School. Address reprint requests to Dr. Adson, Department of Psychiatry, University of Minnesota, 420 Delaware Street, Box 393 UMHC, Minneapolis, MN 55455.

Key Words: Anorexia Nervosa • Eating Disorders • Pneumothorax

Spontaneous pneumomediastinum is an uncommon problem, accounting for 1 in 7,000 to 12,000 hospital admissions.¹ Similarly, pneumothorax is relatively rare, having an incidence of 5 to 10 per 100,000.² Because of several reports of pneumomediastinum occurring in association with eating disorders, it has been suggested that eating disorders constitute a risk factor for developing this condition.³ While the occurrence of pneumomediastinum in eating disorders is recognized but uncommon, pneumothorax to our knowledge has not previously been reported.

We here report a case of a woman with anorexia nervosa who developed a pneumothorax. The possible etiologies of mediastinal and thoracic complications in the eating disorders are discussed.

Case Report

A 28-year-old Caucasian woman was admitted to the hospital for treatment of anorexia nervosa. On the day of admission to an outside hospital, she became involved in an argument with her husband, then had a dizzy spell and vomited. After this she "passed out" and was taken to the hospital with hypokalemia and dehydration. She weighed 70 pounds at 4 feet 9 inches on admission to the other facility and following hydration was admitted to our hospital at a weight of 83 lbs. She also had suffered some mid-chest pain, along with shortness of breath and some wheezing after the episode of emesis and syncope that precipitated her original hospitalization. She is also a 1-pack-per-day smoker over the past 10 years. She did undergo some sort of nebulizer treatments while at the other hospital, but a chest X ray was not performed.

Associated with some "stresses in her marriage" and pain from a car accident (which caused her to vomit quite often), she had gone from a weight of 95–100 pounds 9 months before admission (the time of the accident) down to a low weight of 57 pounds. With some chiropractic treatments several months following the car accident, she was able to attain a weight of about 80 pounds 4 months before admission. However, she felt too fat, was fearful of gaining weight, and would exercise 1 to 2 hours per day while restricting caloric intake, except for occasional consumption of a half gallon of ice cream at a time "as a reward for myself."

Hospital course: Soon after admission to our hospital, as part of a workup for an abnormal electrocardiogram, a chest X ray was done that showed a significant left-sided pneumothorax. The pulmonary service was consulted; after the pneumothorax had persisted for 1 week, a pigtail chest tube was placed, and the pneumothorax resolved. She was transferred back to the eating-disorder unit, completing her hospital stay without incident (and gaining weight to her goal range). She was discharged home with follow-up in the psychiatry and pulmonary clinics.

Discussion

The development of pneumomediastinum is generally associated with the acute production of high intrathoracic pressures, such as in exacerbations of asthma, coughing, childbirth, the valsalva maneuver, vomiting, or inhalational drug abuse.^3,4 Excessive intraalveolar pressures lead to the rupture of perivascular alveoli with escape of air into perivascular connective tissues and subsequent dissection into the mediastinum.¹ Less commonly, pneumomediastinum is seen in healthy young adults without a definite precipitating cause or in Boerhaave's syndrome (rupture of the esophagus associated with vomiting).

Of the seven reported cases of pneumomediastinum associated with eating disorders (all consistent with a diagnosis of anorexia nervosa), vomiting was a factor in only three. Of the remaining cases, there was no mention of vomiting in one, and in the other three the presence of vomiting was explicitly excluded.^5,6 It is conceivable that vomiting was present but not reported by these other patients.

In contrast to pneumomediastinum, in which nonpulmonary precipitating factors are usually involved, pneumothorax is generally associated with intrinsic lung pathology. Most commonly implicated in the etiology are the development of subpleural blebs (seen with increased prevalence in smokers such as our patient), those with a lean-body habitus, and males. Diffuse interstitial lung disease is also, albeit less often, associated with this phenomenon. Thus, elevated rates of pneumothorax are seen in pneumocystis, eosinophilic granuloma, cystic fibrosis, and asthma with mucous plugging.²

Sahebjami et al.,⁷ in their studies regarding the effects of starvation (average weight loss to 57% of starting weight) on the lungs in rats, found a significant deterioration in the lung interstitium. If these findings are extrapolated to humans, these observations suggest that, because of the deterioration of the lung parenchyma as part of the starvation process in anorexia nervosa, the complication of pneumothorax might be more common than pneumomediastinum; yet the converse appears to be true. A literature search over the preceding 15-year period failed to find any other reports of pneumothorax explicitly associated with eating disorders. It is possible that the combination of the thin-body habitus, lower metabolic rate, and associated lower oxygen demand makes asymptomatic pneumothorax more common. However, significant weight loss in the obese population also does not appear to be a risk factor for developing pneumothorax: a MEDLINE search going back 15 years also failed to reveal an association between "weight loss" or "diet, reducing" and either pneumothorax or pneumomediastinum. Also, Sandoz Nutrition, in postmarketing surveillance of Optifast^TM (used for very low-calorie diets), does not have any records of pneumothorax occurring in conjunction with subjects undergoing very significant weight loss (personal communication, 1996).

Although the co-occurrence of eating disorders and thoracic complications does not appear to be particularly common, theoretical considerations and a sparse literature do point to a possible association. The clinician caring for those with eating disorders should be aware of these conditions because of the possibility of increased rates of these conditions in this population. Pneumothorax generally presents with chest pain and progressive dyspnea; a chest X ray will serve to make the diagnosis. If the problem does not resolve with a period of serial observations, a chest tube will be needed. The presenting symptoms of pneumomediastinum are acute pleuritic chest pain, dyspnea, and neck pain. Physical findings include subcutaneous emphysema and mediastinal crepitation (Hamman's sign).¹ The vast majority of cases will resolve spontaneously, although it is imperative that a contrast esophagram be performed to rule out a perforated esophagus (Boerhaave's syndrome).

REFERENCES

1. Smith BA, Ferguson DA: Disposition of spontaneous pneumomediastinum. Am J Emerg Med 1991; 9:256–259[Medline]
2. Paape K, Fry WA: Spontaneous pneumothorax. Chest Surg Clin N Am 1994; 4:517–528[Medline]
3. deZwaan M, Mitchell JE: Medical complications of anorexia nervosa and bulimia nervosa, in Medical Issues and the Eating Disorders: The Interface, edited by Kaplan A, Garfinkel P. New York, Brunner/Mazel, 1994, pp. 72–73
4. Bullimore DW, Cooke D: Cyclical vomiting with pneumomediastinum. Acta Paediatrica Scand 1982; 71:675–676[Medline]
5. Ferguson RJ, Shaw TRD, Turnbull CM: Spontaneous pneumomediastinum: a complication of anorexia nervosa? Postgrad Med J 1985; 61:815–817[Abstract/Free Full Text]
6. Overby KJ, Litt IF: Mediastinal emphysema in an adolescent with anorexia nervosa and self-induced emesis. Pediatrics 1988; 81:134–136[Abstract/Free Full Text]
7. Sahebjami H, Vassallo CL, Wirman JA: Lung mechanics and ultrastructure in prolonged starvation. American Review of Respiratory Diseases 1978; 117:77–83

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