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Two Cases of Anorexia Nervosa Associated with Graves' Disease

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Two Cases of Anorexia Nervosa Associated with Graves' Disease Endocrinol. Japon. 1987, 34 (1), 9-12 Two Cases of Anorexia Nervosa Associated with Graves' Disease TOMIFUSAKUBOKI1), HIROYUKISUEMATSU1), ETSURO OGATA2), MICHIKO YAMAMOT02) and KAZUO SHIZUME3) 1)Department of Psychosomatic Medicine, Branch Hospital, University of Tokyo, Japan 2)4th Department of Internal Medicine, Branch Hospital, University of Tokyo, Japan 3)2nd Department of Internal Medicine, Tokyo Women's Medical College, Tokyo, Japan Abstract In this report on two cases of anorexia nervosa associated with Graves' disease, metabolism and the relationship between the two illness are considered. Case1was a25-year-old female. Anorexia was associated with a stressful life situation following marriage. One year after the onset of anorexia, her condition was diagnosed as Graves' disease. In spite of high levels of serum thyroid hormone, she did not show the clinical signs and symptoms of hyperthyroidism. The hypermetabolic state of Graves' disease seems to be suppressed by the hypometabolism of anorexia. Case2was a17-year-old female whose body weight, due to anorexia, at one time had decreased from 55kg to35.2kg. A rebound from anorexia to bulimia increased her body weight to80kg in spite of an association with the hypermetabolic state of Graves' disease. In light of the abovementioned cases, it seems that the clinical picture of Graves' disease is usually hidden by the clinical symptoms of anorexia nervosa. Two cases of anorexia nervosa associated with Graves' disease, none of which were Subjects and Methods reported in the literature, were observed. Generally, metabolism is suppressed by an- Two cases of anorexia nervosa associated orexia nervosa and stimulated by Graves' with Graves' disease, referred to the Department of Psychosomatic Medicine, University of Tokyo, disease. Thus the clinical picture observed from another medical institute for several years, in these cases is quite interesting. In both were studied. cases, anorexia nervosa and Graves' disease occurred concurrently. We therefore asked, "Which disease is more dominant in the Results clinical picture ?" Case 1. Female was25years old at the time of her first visit. Chief com- Received April10, 1986 Supported in part by a Research Grant for plaints: Loss of weight and amenorrhea. Intractable Diseases from the Ministry of Health The patient started to lose weight due and Welfare of Japan. to emotional stresses imposed upon her by Endocrinol. Japon. 10 KUBOKI et al. February1987 Fig.1.•@ This figure shows the intrinsic heart rate in case1 (M. K). It increased to108/minute from the previous level of70/minute, after the blocking of the auto- matic nervous system with propranolol and atropine. an induced abortion in March and marriage sweating, trembling and tachycardia were in May of1980. In July her weight de- observed. There were symptoms of anorexia clined from53kg to50kg. She continued nervosa such as low body temperature, to have no appetite and by January, 1981, sensitivity to cold, a tendency toward brady- her weight had fallen to44kg and men- cardia, hypotension and constipation. Al- struation ceased. By July, her weight had though she was emaciated, she was tireless decreased to40kg. At this time goiter and active. Her heart rate increased to was observed, but no signs of hyperthyroi- 108/minute (intrinsic heart rate) from the dism, such as sweating and trembling fingers, previous level of70/minute, after the block- were seen. Thyroid function tests conducted ing of the autonomic nervous system with in October revealed obvious hyperthyroidism: propranolol (0.2mg/kg) and atropine (0.04 T3.5ng/ml and Triosorb40.4%. However, mg/kg). This indicates that she was in a she felt no palpitation and tachycardia was parasympathetic predominant state (Figure absent. In January1982, she weighed30 1). kg (height: 159cm) and was admitted to The symptoms of both anorexia nervosa the Fourth Department of Internal Medicine, and Graves' disease were mitigated with the University of Tokyo. prescription of antithyroid agents and psy- Although the symptoms of loss of weight, chotherapy for anorexia nervosa. amenorrhea, and nervousness are common to Graves' disease, and despite a high blood Case2. Female was17years old at thyroxine concentration, goiter was the only the time of her first visit. Chief com- clinical sign of Graves' disease and no signs plaints: Anorexia, emaciation, amenorrhea and symptoms of hypermetabolism such as and irritability. Vol.34, No.1 ANOREXIA NERVOSA AND GRAVES' DISEASE 11 Fig.2.•@ This figure shows the clinical course of a patient with dys- orexia nervosa and Graves' disease (K.N.). In1979, the patient's weight started to roidism, which had developed again. She fall from55kg to45kg (165cm tall) and kept eating all day long and reached80kg she became amenorrheal as she was tired in July, 1981 (Figure2). from adjusting herself to a new class for her third year of high school. By August, her weight dropped to40kg and she was Discussion referred to the Department of Psychosomatic Medicine, University of Tokyo as a case of Both anorexia nervosa and Graves' anorexia nervosa. disease occurred concurrently in the two At the first visit, the pulse was 132/ cases studied. Generally, while metabolism minute and goiter was noted. A thyroid is suppressed by anorexia nervosa, it is function test revealed T4 20.6ƒÊg/dl, T3 4.1 stimulated by Graves' disease. In case1, ng/ml and a basal metabolic rate of+29.5 hypermetabolism caused by Graves' disease %,and she was diagnosed as having an- was masked by hypometabolism due to orexia nervosa complicated by Graves' anorexia nervosa, and the patients showed disease. a pathology approaching a clinical picture In December, the thyroid function test of anorexia nervosa. Case2was an example returned to normal following treatment with of a patient who became obese because of antithyroid agents, but soon she became bulimia induced by dysorexia nervosa no hyperthyroid. Even though the daily doses matter how much the thyroid hyperfunction- of the antithyroid agents were increased, ed. This case also demonstrated that a her condition did not improve. Upon ques- clinical picture of dysorexia nervosa, or tioning it became evident that she was not obesity resulting from bulimia, predominates taking the medications. After she began over the classical picture of Graves' disease taking medications as prescribed in July, or emaciation, when anorexia nervosa is 1981, she became hypothyroid and the doses complicated by Graves' disease. were reduced accordingly, and she then Chemical hyperthyroidism without typical became euthyroid. Her body weight drop- signs and symptoms of thyrotoxicosis is ped to a nadir of35.2kg in December, 1979, called apathetic hyperthyroidism (Peake, when anorexia developed into bulimia. She 1981; Thomas, 1970). It is encountered continued to gain weight despite hyperthy- more commonly in elderly patients and is Endocrinol. Japon. 12 KUBOKI et al. February1987 often considered an "extreme degree of of anorexia nervosa associated with Graves' depletion of all body systems by long disease in the literature. Anorexia nervosa continued thyrotoxicosis." Our two cases was usually observed in young females in of anorexia nervosa associated with Graves' common with Graves' disease. Although disease closely resembled the case of a- we ound only two cases of anorexia nervosa pathetic hyperthyroidism. The reason the associated with Graves' disease, it is possible hypermetabolism caused by Graves' disease that there were hidden cases. was masked by the hypometabolism due to When the thyroid function returned to anorexia nervosa is unknown. However, normal after treatment with antithyroid the following reasoning seems plausible: agents, some female patients with Graves' 1. The tendency to low T3syndrome disease had this to say "I began to diet in anorexia nervosa. Namely, when T4is because my Graves' disease was showing converted into T3 or rT3the conversion signs of improvement and I was afraid of rate is inclined towardrT3, having no becoming fat if I were to eat as much as biological activity. before." These words could imply a casual 2. The condition of the autonomic relationship between Graves' disease and nervous system on using autonomic drugs. anorexia nervosa. Of course these patients In Case1, the patient's heart-rate increased had the inherent, essential pathogenesis of to108/minute (intrinsic heart rate) from a anorexia nervosa such as obesity phobia. previous level of70/minute, after the block- It is conceivable that body weight gain ing of the autonomic nervous system with in the treatment of Graves' disease triggered propranolol and atropine. Namely intrinsic the onset of anorexia nervosa. heart rate was108/minute due to hyper- thyroidism, but this rate was clinically diminished to70/minute when the parasym- References pathetic nervous system came into domi- nance (Davis, 1974) due to anorexia nervosa. Davis, Paul J. Hyperthyroidism in patients over In light of the facts in this case, it seems the age of60years. Medicine. Vol.53, No. that the clinical picture of Graves' disease 3, 161-181, 1974. is usually hidden by the clinical symptoms Namba, T. On a case of Dysorexia which oc- of anorexia nervosa under the control of curred after the treatment of Hyperthyroidism. the parasympathetic nervous system. Jpn. J. of Psychosom. Med. 18, 401-405, 1978. Peake, Robert L. Recurrent Apathetic Hyper- It is usual that with Graves' disease, the thyroidism. Arch. Intern. Med. 141, 258-260, patient's weight decreases due to hyper- 1981. metabolism. But in Case2, bulimia in- Schepank, H. Anorexia nervosa. Zwillingskasuistik creased her weight in spite of the hyper- uber ein seltenes Krankheitsbild. In; Ursprunge metabolic state induced by Graves' disease. seelisch bedingter Krankheiten, Verlag fur In this way, the clinical picture of dysorexia Medizinishe Psychologie imVerlag Vandenhoeck nervosa, such as obesity due to bulimia, &Ruprecht in Gottingen, 1981. Suematsu, H. Psychosomatic medicine of hyper- suppresses the clinical picture of Graves' thyroidism. Naika. 24, 459, 1969. disease, such as weight loss. Thomas, Fred B. Apathetic Thyrotoxicosis. Arch. We were unable to find any case report Intern. Med. 72, 679-685, 1970..
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