Objective To illustrate that serious medical complications, such as cerebral venous thrombosis, can result from the combination of psychiatric and medical disorders.
Case A 15-year-old boy presented initially to the ER with a 4-day history of headache, vomiting, and photophobia. Head CT was normal, and the patient was discharged home after PRBC transfusion for hemoglobin of 5. Two days later he presented to the ER with progressive headaches and new-onset tonic-clonic seizures. PMH: Obsessive-compulsive disorder, which included severe obsessions with food textures and appearances with very high milk consumption. He also had idiopathic inflammatory bowel disease with chronic iron deficiency anemia. PE: Malnourished, uncooperative male in moderate distress with a nonfocal neurologic examination. Labs: HGB: 11, MCV: 65, platelets: 737,000, prealbumin 13 (16-40). MRA showed complete superior sagittal sinus thrombosis extending to both transverse and straight sinuses. Hypercoagulable workup was negative, stool hemoccult was positive, and colon biopsies showed inactive chronic colitis. In spite of treatment with heparin and warfarin the patient had progressive blurry vision, bilateral sixth nerve palsy, papilledema, and loss of visual acuity requiring optic nerve sheath fenestration and VP shunt placement.
Discussion This patient's prolonged history of obsessive compulsive disorder and inflammatory bowel disease caused significant malnutrition, iron deficiency anemia, reactive thrombocytosis, and, ultimately, cerebral venous thrombosis. This rare disorder is most frequently reported in the presence of acute dehydration, cyanotic heart disease, malignancy, nephrotic syndrome, or coagulopathies. In the pediatric population, severe iron deficiency anemia is another uncommon cause of cerebral venous thrombosis, although the exact mechanism remains unclear. Treatment of the thrombosis includes aggressive anticoagulation with heparin followed by warfarin. There is no available evidence regarding the efficacy or safety of thrombolytic therapy in these cases. Pediatricians should be alert to the fact that psychiatric disorders with abnormal dietary patterns, especially when combined with underlying medical problems, can lead to serious permanent complications, as in this case.
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