A 15-year-old girl was brought to the surgery by her father towards the end of the afternoon. She had not attended for about a year, but had previously seen a colleague several times with anorexia nervosa and subsequently been under the care of local paediatricians and child and adolescent mental health services.
She was complaining of fatigue, not unusual in a 15-year-old, but said she was maintaining her target weight of 54kg, was happy that she was managing the anorexia and there were no problems at school.
She then volunteered that she had felt breathless going upstairs for about a month, she looked a little pale, and rather than simply arrange some bloods and review with the results, I decided I should examine her.
A systolic murmur
I was alarmed to hear a loud systolic murmur in the aortic area, radiating to both carotid arteries. Her temperature, pulse and BP were all normal, with no peripheral stigmata of endocarditis. She seemed clinically quite well.
Fortunately, the senior cardiac technician was available to discuss her murmur and he agreed to an urgent echocardiogram the next day, with bloods and cultures at the paediatric day unit.
The echo showed that the murmur did seem to originate at the aortic root, but with no obvious structural abnormality. The blood tests later revealed Hb of 3.9 with a very microcytic film. A transfusion of two units and subsequent high-dose oral iron therapy followed.
A dietary cause
The girl's mother wondered if her diet had been to blame and informed the paediatricians that she had consumed large quantities of milk and high-fibre foods to maintain her target weight. It was thought that the large quantities of milk had inhibited iron absorption over a long period of time, resulting in the severe anaemia.
Six weeks later, the Hb was a healthy 12.6 and the murmur had vanished. The patient felt remarkably better and was working with the paediatric dietitian on a suitable eating plan that would not risk a relapse of her eating disorder.
A review of the case notes revealed that at presentation, the patient had not had bloods taken, nor when seen by paediatricians.
This was subsequently discussed as a significant event to ensure all professionals looking after children with eating disorders check that bloods are taken and screen for anaemia and ferritin deficiency, as well as electrolyte disturbances that are more commonly seen in bulimia.
- Dr Edrich is a GP in north Somerset
- NICE CG9 Eating disorders: full guideline gives a summary of recommended physical assessments in appendix 7: http://guidance.nice.org.uk/CG9/Guidance.