title: Cardiogenic shock caused by a left midventricular obstruction during refeeding in a patient with anorexia nervosa.
abstract: OBJECTIVE
  Refeeding syndrome occurs when reinstating nutrition to severely malnourished patients. It can sometimes be fatal, particularly as a result of cardiac involvement such as congestive heart failure and arrhythmias. The aim of this study was to report a case of cardiogenic shock that occurred during refeeding in a patient with anorexia nervosa (AN). The cardiogenic shock was due to a previously unrecognized mechanism, namely a transient left midventricular obstruction that completely disappeared after treatment.
  
  
  METHODS
  A 46-y-old woman with AN who had followed a carbohydrate- and a fat-deficient diet for >10 y was hospitalized for dyspnea on exertion. She had severely impaired cardiac systolic function on admission and was considered high risk for refeeding syndrome. During a stepwise increase of calories, she showed no electrolyte or mineral abnormalities characteristic of refeeding syndrome.
  
  
  RESULTS
  After intravenous administration of a fat emulsion, the patient suffered from cardiogenic shock due to an unexpected mechanism, namely a left midventricular obstruction caused by cardiac hypercontraction, a thickened left ventricular wall, and intravascular volume depletion. With cessation of the fat emulsion and initiation of volume repletion she recovered from shock immediately and her echocardiogram returned to normal by discharge.
  
  
  CONCLUSIONS
  This case illustrated a novel cause of cardiogenic shock during refeeding and the need for caution during the intravenous administration of a fat emulsion in patients with initial left ventricular systolic dysfunction.
authors.affiliation: Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Yoko
authors.initials: Y
authors.lastname: Sakamoto
authors.affiliation: Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan. Electronic address: kioka@cardiology.med.osaka-u.ac.jp.
authors.forename: Hidetaka
authors.initials: H
authors.lastname: Kioka
authors.affiliation: Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan; Molecular Research Center for Children's Mental Development, United Graduate School of Child Development, Osaka University, Suita, Osaka, Japan.
authors.forename: Ryota
authors.initials: R
authors.lastname: Hashimoto
authors.affiliation: Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Saori
authors.initials: S
authors.lastname: Takeda
authors.affiliation: Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan.
authors.forename: Kota
authors.initials: K
authors.lastname: Momose
authors.affiliation: Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Tomohito
authors.initials: T
authors.lastname: Ohtani
authors.affiliation: Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Osamu
authors.initials: O
authors.lastname: Yamaguchi
authors.affiliation: Medical Education Center, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Masafumi
authors.initials: M
authors.lastname: Wasa
authors.affiliation: Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Satoshi
authors.initials: S
authors.lastname: Nakatani
authors.affiliation: Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Yasushi
authors.initials: Y
authors.lastname: Sakata
mesh_terms: D000856:Anorexia Nervosa / Q000150:complications / Q000628:therapy*; D004452:Echocardiography; D004573:Electrolytes; D005217:Fat Emulsions, Intravenous / Q000008:administration & dosage; D005260:Female; D006321:Heart / Q000503:physiopathology; D006760:Hospitalization; D006801:Humans; D008875:Middle Aged; D055677:Refeeding Syndrome / Q000150:complications / Q000628:therapy*; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000209:etiology / Q000628:therapy*; D018487:Ventricular Dysfunction, Left / Q000150:complications* / Q000628:therapy
chemical_list: D004573:Electrolytes; D005217:Fat Emulsions, Intravenous
keywords: Anorexia nervosa; Heart failure; Left ventricular obstruction; Refeeding syndrome; Shock