Q. One of my patients with AN has developed other puzzling symptoms, including what she describes as her “joints popping out of place,” followed by severe pain. She has dislocated a hip and several fingers, and has had several surgeries to ease gastrointestinal problems. Can you help? (GV, Des Moines, IA).
A. What you are describing suggests a case of the Ehlers-Danlos syndrome (EDS), which features joint hypermobility, loose and stretchy skin, and a generalized connective tissue fragility. Michelle Lee, MD, and Mattias Strand MD recently published a very pertinent report of a case of comorbid anorexia nervosa (AN) and EDS in a 23-year-old woman from Southeast Asia (Int J Eat Disord. 2017; December, online version published before print).
They describe a patient with a 12-year history of restrictive-type AN, who had been treated for her disorder for the last 8 years, most recently at a specialist hospital. She had done well, improved her BMI to 19.7, and had entered an intense day treatment program. The authors noticed that the woman had a phobia about gaining weight, and a strong aversion to fat-containing foods. She was also plagued by a number of gastrointestinal complaints, including a number of food allergies, diffuse pain, bloating, and nausea. She had these symptoms off and on for the past 10 years.
To assess EDS, the patient underwent the Beighton Hypermobility Test, a diagnostic rating scale that measures joint hypermobility; her score was 6 (scores of 5 and higher out of 9 are considered potentially pathological). Clinicians typically think of joint laxity and ophthalmologic issues in EDS, but a wide variety of symptoms can occur (and in fact there are numerous recognized subtypes of EDS). Of particular relevance, gastrointestinal symptoms are common.
The overlap of symptoms in AN and EDS makes correctly identifying EDS a challenge The most common type of EDS, which is a genetic disorder that targets the production of collagen, is estimated to affect 1 in 5,000 to 20,000 persons worldwide and the classic type is far more rare, affecting 1 in 20,000 to 40,000 persons worldwide. There is currently no cure.
Drs. Lee and Strand recommend that whenever you encounter a patient with AN and this degree of hypermobility, the Beighton Hypermobility Test is a useful screening tool, and a good place to start, followed by referral to a rheumatologist.