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<p class="ltrs-br-ltr-br-title">Psychiatric Presentation of a Child With Crohn’s Disease</p>
<p class="ltrs-br-ltr-br-body-text"><span class="bold">To the Editor:</span> Several cases of pediatric onset of Crohn’s disease have presented with psychiatric symptoms, such as depression, anxiety, and abnormal eating behaviors.<span class="htm-cite"><a href="#ref1">1</a>,<a href="#ref2">2</a></span> These patients usually experience delay in diagnosis of the inflammatory bowel disease.<span class="htm-cite"><a href="#ref3">3</a></span> We describe a patient with weight loss and restrictive eating patterns who was admitted to the psychiatric ward and ultimately found to have Crohn’s disease.</p>
<p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
<p class="ltrs-br-ltr-br-body-text"><span class="bold-italic">Case report.</span> An 11-year-old boy presented to the emergency department in February 2009 for evaluation of a 6-month history of weight loss of 20 lb (25% of the patient’s body weight). The patient reported diffuse abdominal pain associated with meals, early satiety, restrictive eating patterns, fatigue, and anxiety. On initial examination, the patient’s weight was below the 10th percentile and his height was in the 25th percentile for age. Abdominal examination revealed no distention, tenderness, or guarding. He displayed anxiety at mealtimes, psychomotor agitation, and dysphoric mood without irritability and without suicidal ideation. He was admitted to the child psychiatric ward for further evaluation and management of presumed diagnosis of anorexia nervosa, restrictive type (based on <span class="italic">DSM-IV-TR</span> criteria).</p>
<p class="ltrs-br-ltr-br-body-text">The patient was previously diagnosed with <span class="italic">DSM-IV-TR</span> generalized anxiety disorder and had been under psychiatric care for several years. He was managed with psychotherapy and had been managed with several pharmacologic agents, including olanzapine and bupropion. He had developed a mild microcytic anemia over the months prior to presentation but had no other chronic medical disorders.</p>
<p class="ltrs-br-ltr-br-body-text">Sertraline 12.5 mg daily and clonazepam 0.25 mg at bedtime were initiated to manage the anxiety, and supervised mealtimes were implemented to observe and encourage caloric intake. The patient displayed less dysphoria and anxiety over several days, but reported persistent abdominal pain and anxiety at mealtime and continued losing weight despite taking in 3 meals daily (under staff supervision).</p>
<p class="ltrs-br-ltr-br-body-text">Laboratory evaluation revealed a microcytic anemia and an elevated erythrocyte sedimentation rate of 48 mm/h. The gastroenterology service was consulted, and colonoscopy demonstrated external skin tags, an anal fissure, exudates, and erythema at the terminal ileum. Colon and small bowel biopsy findings were consistent with Crohn’s disease. Treatment with ciprofloxacin 500 mg and lansoprazole 30 mg was initiated. The patient was discharged to follow-up with his outpatient psychiatrist and with a comprehensive care plan for management of new-onset inflammatory bowel disease.</p>
<p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
<p class="ltrs-br-ltr-br-body-text">Inflammatory bowel diseases commonly cause postprandial abdominal pain. This recurrent pain may lead to fear of eating, food avoidance (restrictive eating patterns), and consequent weight loss. Restrictive eating patterns are also characteristic of anorexia nervosa. Physicians observing restrictive eating patterns in patients may not always look for the other characteristics of anorexia nervosa (such as fear of weight gain and body image disturbance) before making a presumptive diagnosis of anorexia nervosa.<span class="htm-cite"><a href="#ref4">4</a></span> This patient’s prior diagnosis of generalized anxiety disorder (based on <span class="italic">DSM-IV-TR</span> criteria) most likely led the team to initially suspect a second psychiatric disorder as an explanation for the weight loss.<span class="htm-cite"><a href="#ref3">3</a></span> This reasoning delayed further diagnostic evaluation, resulting in delayed treatment of Crohn’s disease.</p>
<p class="ltrs-br-ltr-br-references-head">References</p>
<p class="references-references-text-1-9"><a name="ref1"></a>1. Engstrom I. Inflammatory bowel disease in children and adolescents: mental health and family functioning. <span class="italic">J Pediatr Gastroenterol Nutr</span>. 1999;28(4):S28–S33. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10204521&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1097/00005176-199904001-00004">doi:10.1097/00005176-199904001-00004</a></span></p>
<p class="references-references-text-1-9"><a name="ref2"></a>2. Engström I, Lindquist BL. Inflammatory bowel disease in children and adolescents: a somatic and psychiatric investigation. <span class="italic">Acta Paediatr Scand</span>. 1991;80(6–7):640–647. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1867081&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1111/j.1651-2227.1991.tb11923.x">doi:10.1111/j.1651-2227.1991.tb11923.x</a></span></p>
<p class="references-references-text-1-9"><a name="ref3"></a>3. Rickards H, Prendergast M, Booth IW. Psychiatric presentation of Crohn’s disease: diagnostic delay and increased morbidity. <span class="italic">Br J Psychiatry</span>. 1994;164(2):256–261. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8173832&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1192/bjp.164.2.256">doi:10.1192/bjp.164.2.256</a></span></p>
<p class="references-references-text-1-9"><a name="ref4"></a>4. Mallett P, Murch S. Anorexia nervosa complicating inflammatory bowel disease. <span class="italic">Arch Dis Child</span>. 1990;65(3):298–300. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2334208&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1136/adc.65.3.298">doi:10.1136/adc.65.3.298</a></span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Mariana Markella, MD</span></p>
<p class="ltrs-br-ltr-br-author"><a href="mailto:mariana.markella@mssm.edu" target="_blank">mariana.markella@mssm.edu</a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Joseph M. Cerimele, MD</span></p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="bold-italic">Author affiliations:</span> Department of Psychiatry, Mount Sinai School of Medicine, New York, New York.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="bold-italic">Potential conflicts of interest: </span>None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="bold-italic">Funding/support: </span>None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="bold-italic">Published online:</span> September 30, 2010 (<span class="doi">doi:10.4088/PCC.10l00955blu</span>).</p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">Prim Care Companion J Clin Psychiatry 2010;12(5):e1</span></p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">© Copyright 2010 Physicians Postgraduate Press, Inc.</span></p>
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