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Eating Disorder in a Young Active Duty Male
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Eating disorders can have atypical presentations, be challenging to diagnose, and often result in treatment delay, as illustrated here. Bulimia nervosa is characterized by binge eating and inappropriate compensatory behaviors, and is ten times more common in females. Studies show increased prevalence over the past decade, with similar prevalence in young military members and civilians. Risk factors include dieting, gender preference, life-altering events, and history of a psychiatric condition. Relatively little research has focused on eating disorders among military males, but factors unique to this group include rigid weight standards, mandatory semiannual personal fitness assessments, and extended deployments. Bulimia and other eating disorders can have subtle or atypical presentations and are often overlooked in males. Other diagnostic obstacles include career concerns and stigma avoidance, along with provider time constraints, inexperience, or discomfort with the issue. Serious medical complications of bulimia are uncommon, but delayed diagnosis can lead to hospitalization and significant morbidity. This case emphasizes the importance of a thorough history and wide differential when faced with an unusual presentation. Recognizing risk factors and incorporating simple screening tools can aid the timely identification and treatment of service members with disordered eating before unit and mission effectiveness are compromised.
Eating disorders and disordered eating behaviors have been the subject of much research, particularly in the last three decades. Military personnel are presumed to be at higher risk for eating disorders because of required weight and body standards, but few studies have examined this disorder in male military members. Eating disorders can be challenging to diagnose for the primary care provider, as those with bulimia often present with other, seemingly unrelated complaints and concerns. This case illustrates the delayed diagnosis of bulimia in a young active duty male, and the following discussion examines the prevalence and risk factors associated with males and military members, as well as diagnostic challenges and accompanying medical complications.
A 21-year-old Caucasian active duty male, serving with his squadron detachment away from home base, presented to the local Emergency Room with painless bilateral parotid gland enlargement and fatigue. Initial basic lab studies were unre- markable except for an elevated amylase level. His flight surgeon placed him in 9-day quarantine for suspected mumps, titers were drawn, and he received the Measles, Mumps, Rubella vaccine. His symptoms resolved after about 2 weeks, and mumps IgM and IgG antibodies were negative. After return to his home base 3 weeks later, his parotid swell- ing returned, and he also experienced a 10-pound weight loss, neck and inguinal lymphadenopathy, fatigue, and dizziness. Following an episode of syncope, he was admitted to the hospital for further evaluation. Laboratory evaluation showed a hypokalemic, hypochloremic metabolic alkalosis. He was hypotensive with bradycardia and had significant nontender, bilateral parotid gland enlargement. He also had subtle dental erosions. During hospitalization, his electrolytes were corrected, and he underwent an extensive workup. Imaging of his head, chest, abdomen, and pelvis were all normal. An upper endos- copy series with small bowel follow through showed only mild reflux. A trans-thoracic echocardiogram with bubble study was normal. During hospitalization, the patient’s mother was contacted, and she revealed he had a diagnosis of dys- thymia and Asperger’s syndrome in early adolescence, and an obsession with weight and body image later in adoles- cence. Upon questioning, the patient did admit recent pre- occupation with weight and performance after the previous cycle’s Physical Fitness Assessment (PFA), and acknowl- edged frequent purging. Further psychological evaluation from mental health yielded a diagnosis of bulimia nervosa, purging type, and he continued psychiatric care as an out- patient. His parotid swelling diminished, and his electrolyte abnormalities normalized several weeks after reduction of his purging behaviors. He was started on a Selective Serotonin Reuptake Inhibitor (SSRI), and 6 months later was cleared for shipboard deployment with his squadron. Initially, he did well onboard, continuing both medication and cognitive behavioral therapy with a psychologist. However, 5 months into deployment he developed mood changes, and suffered a relapse of binging and purging behavior. After he expressed passive suicidal ideations, he was returned home early from deployment. Although control of his bulimia improved with cognitive behavioral therapy, he was medically discharged for the disorder.
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