A 17-year-old girl is brought to the office by her mother, who is concerned about her daughter's weight loss and mood changes. The girl has lost 4.5 kg (10 lb) in the last 2 months and has been uncharacteristically irritable. The mother says that she has suddenly become a "picky eater" and that she now often refuses to eat, insisting that she is "just not hungry." She also worries that her daughter is not sleeping enough. When questioned about these concerns, the patient denies having any problems and says that she feels "fine" and just has lots of energy. She adds, "Isn't it healthy to be thin and fit? I don't understand what my mother is worried about." The patient's height is 157.5 cm (5 ft 2 in) and weight is 47.6 kg (105 lb). Physical examination shows a thin body habitus, erythema of the nasal mucosa, and mild facial acne. Which of the following is the most likely diagnosis?

Question

A 17-year-old girl is brought to the office by her mother, who is concerned about her daughter's weight loss and mood changes.  The girl has lost 4.5 kg (10 lb) in the last 2 months and has been uncharacteristically irritable.  The mother says that she has suddenly become a "picky eater" and that she now often refuses to eat, insisting that she is "just not hungry."  She also worries that her daughter is not sleeping enough.  When questioned about these concerns, the patient denies having any problems and says that she feels "fine" and just has lots of energy.  She adds, "Isn't it healthy to be thin and fit?  I don't understand what my mother is worried about."  The patient's height is 157.5 cm (5 ft 2 in) and weight is 47.6 kg (105 lb).  Physical examination shows a thin body habitus, erythema of the nasal mucosa, and mild facial acne.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Cocaine is a stimulant that produces increased energy, decreased appetite, and reduced need for sleep. Individuals who abuse cocaine often have mood changes (eg, euphoria, irritability) and weight loss secondary to decreased appetite. The diagnostic hallmark in this scenario is erythema of the nasal mucosa, which is a common finding in individuals who snort cocaine. In severe cases, perforation of the nasal septum can occur. In addition to mood disturbance, other psychiatric complications of cocaine use include anxiety, panic attacks, grandiosity, and psychosis (ie, delusions and hallucinations). (Choices A, B, and C) The physical finding of erythema of the nasal mucosa, normal weight (BMI of 19.2 kg/m²), and lack of other characteristic features of eating disorders (eg, discrepancy between desired and perceived body image) make these diagnoses less likely. Anorexia nervosa is associated with intense fear of gaining weight and distorted body image despite a significantly low weight (BMI <18.5 kg/m²). Avoidant/restrictive food intake disorder involves lack of interest and avoidance of eating based on the sensory characteristics of food, with typical onset in infancy or early childhood. Diagnosis of bulimia nervosa requires evidence of binge eating and compensatory behaviors. (Choice E) This patient's mood changes are better explained by cocaine use. Cyclothymic disorder presents with ≥2 years of subclinical hypomanic and depressive symptoms that do not meet full criteria for hypomania or major depressive episodes. (Choice F) Opioid use is associated with euphoric and sedating effects and would not explain this patient's increased energy and decreased need for sleep. (Choice G) Synthetic cannabinoid use may produce a variety of effects depending on the exact chemical constituents of the synthetic; however, at low doses these agents typically mimic the effects of cannabis (eg, euphoria, paranoia). Synthetic cannabinoid agents are most commonly smoked and are not associated with erythema of the nasal mucosa or weight loss. Educational objective: Cocaine abuse should be suspected in an individual with weight loss, behavioral changes, and erythema of the nasal mucosa. References: Cocaine's appetite for fat and the consequences on body weight. (http://www.ncbi.nlm.nih.gov/pubmed/25321424) Diagnosis and consequences of cocaine addiction. (http://www.ncbi.nlm.nih.gov/pubmed/22856661)

A 17-Year-Old Girl Is Brought to the Office by Her