Suspect 'Manorexia' in Males with Multiple Hormonal Problems
By Miriam E. Tucker
Originally published by Medscape Medical News, June 3, 2014
LAS VEGAS — When a young male presents with multiple hormonal issues, physicians should consider the possibility of anorexia nervosa.
That was the message from new research presented here at the American Association of Clinical Endocrinologists (AACE) 23rd Annual Scientific and Clinical Congress by Aren Skolnick, MD, an endocrinology fellow at Hofstra University School of Medicine, Hempstead, New York.
Dr. Skolnick reported on a series of 4 patients, all men in their early 20s who had presented to the emergency room with bradycardia but also had cachexia, hypothermia, and hypotension. They were first seen by cardiology, but endocrinology was consulted because of the patients' numerous hormonal dysfunctions, including 3 each with hypogonadism, hypothyroidism, and cortisol resistance. Two had hypoglycemia, and 1 had high bone turnover. Only 1 had a prior diagnosis of anorexia.
"When you think of anorexia, you think of young women. No one really thinks about the guy with anorexia. Based on the literature, women are typically more affected, but there is a small population of men, and it's probably underestimated," Dr. Skolnick said during a press briefing in which the phenomenon was dubbed "manorexia."
"It's a very important topic and a very interesting point that [Dr. Skolnick] raises, because we're so conditioned to thinking of anorexia as a female disease that when this happens to men, it's easy to not suspect it and for them to get into trouble, which is well evidenced" by this presentation, Joshua D. Safer, MD, associate professor of medicine and molecular medicine at Boston University, Massachusetts, commented to Medscape Medical News.
Indeed, Dr. Skolnick said, 2 of the 4 patients had been referred to surgery for implantation of cardiac pacemakers due to the bradycardia and a third, who had severe gastroparesis, had been about to have a gastric pacemaker implanted.
But when interviewed, the men reported recent weight loss — 2 had each lost over 100 pounds in the past 6 months to 1 year — and they acknowledged not eating and feeling depressed.
"These patients were going to go for invasive procedures that they didn't need. So, it really needs to be on the differential diagnosis for patients who come in with any of these endocrinopathies who you may suspect have had weight loss or be malnourished. They need nutritional support and mental–health services," Dr. Skolnick emphasized.
Regarding the referrals for surgery, Dr. Safer said: "That is kind of striking. It's hard for me to imagine that people didn't recognize it, but it's obviously true."
Anorexia is a severe psychiatric disorder characterized in the Diagnostic and Statistical Manual 4 (DSM 4) by failure to maintain weight above 85% of ideal, distorted body image or denial of the seriousness of the weight loss, fear of gaining weight, and amenorrhea [in women].
"One of the DSM 4 criteria is amenorrhea, but there's no criterion for hypogonadism for men. So, there's a bias in the diagnostic criteria," Dr. Skolnick pointed out.
The literature suggests that the prevalence of anorexia is 0.3% to 3% of women and 0.1% of men, with the latter constituting 5% to 10% of all cases. But, "we think it could be up to 25%," Dr. Skolnick said.
Whereas women with anorexia tend to strive for thinness, men typically aim for a more muscular appearance. Women are more likely to use laxatives or purging, whereas men are more often excessive exercisers. And women tend to benefit more from treatment, possibly because the illness is detected sooner and they receive more social support.
"People know how to treat females with anorexia, but people aren't picking up on the males. So they're coming to physicians later, when they're more severe."
"Manorexia" Affects All Major Organ Systems
The malnutrition resulting from anorexia affects multiple organ systems: cardiac (bradycardia, prolonged QT interval); gastrointestinal (constipation, delayed gastric emptying); hematologic (anemia, leukopenia); renal (hypokalemia, hyponatremia); and neurologic (cortical atrophy, seizures).
And all of the hypothalamic–pituitary axes are involved, so affected men typically have hypogonadal symptoms, including low testosterone, decreased libido, and depression.
They can also present with hypothyroidism, but labs may be misleading. Typically, patients will present with a "sick euthyroid syndrome" or "low–T3 syndrome,— in which T3 levels are low, with low to normal T4 and low to normal TSH, along with classic symptoms such as constipation, delayed reflexes, and cold intolerance, Dr. Skolnick explained.
And the effect on the hypothalamic–growth hormone–insulinlike growth factor–1 (IGF-1) axis leads to growth hormone resistance, which can impair linear growth in pubertal and prepubertal males. At the hypothalamic-adrenal axis, the effect is to lower bone–mineral density, and the resulting osteoporotic effect can be dramatic, with up to a 2–fold increase in fracture risk years after diagnosis, he noted.
"If you're malnourished, the body just wants to conserve energy....These same effects that occur in women also occur in men, but it hasn't been clearly documented in the literature, and no one has ever really reviewed this before."
Although these patients have multiple hormonal abnormalities, correcting these is not the treatment. Food is. "Giving thyroid hormone is a mistake a lot of people make," Dr. Skolnick noted.
Other hormonal therapies have been tried, including recombinant growth hormone, recombinant IGF–1, and estrogen in women with osteoporosis and anorexia, "but the best treatment we know of is [good] nutrition and getting these people fed," he added.
Tube feeding is typically required as a temporizing measure. After that, patients either start eating with the help of mental'health professionals, or if not, total parenteral nutrition (TPN) is necessary.
Of the 4 patients Dr. Skolnick described, 1 began eating full meals again after he had been scheduled to receive electroconvulsive therapy for severe depression. His bradycardia and hypothermia resolved. The patient with gastroparesis also began eating again, his endocrinopathies resolved, and he was discharged to an eating–disorders day program.
The other 2 required TPN and enteral feeds. One was eventually weaned off the former and discharged from hospital after 26 days, on an oral diet with supplemental feeds via gastrostomy tube. His bradycardia and hypogonadism improved.
The other TPN patient — who was the patient with the prior anorexia diagnosis — experienced respiratory failure requiring mechanical ventilation, aspiration pneumonia, and severe anemia and thrombocytopenia requiring blood and platelet transfusions. After 7 months in the hospital, he was discharged to a rehabilitation facility with tracheostomy and percutaneous gastrostomy tubes in place.
The outcome for these 4 men is similar to the literature based primarily on women: About 20% recover fully, another 30% to 40% improve but still struggle, and another 30% do badly. Mortality is high, Dr. Skolnick cautioned.
Dr. Safer said the one clinical take–away from Dr. Skolnick's presentation is that the key to diagnosing "manorexia" is "suspecting it.&uot;
Dr. Skolnick nor Dr. Safer have reported no relevant financial relationships.
American Association of Clinical Endocrinologists (AACE) 23rd Annual Scientific and Clinical Congress. Abstract 822.
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