Chronic Electrolyte Imbalances Following History of Eating Disorder

Case at a Glance

A 29-year-old female with a 10-year history of severe bulimia nervosa presents with persistent hyponatremia and hypokalemia despite apparent adequate dietary intake, accompanied by peripheral neuropathy symptoms and muscle cramping.

Patient's Story

The patient is a 29-year-old female, 5'6" and 117 lbs, who presents with chronic electrolyte imbalances. She has a significant history of severe bulimia nervosa from ages 14-24. Currently, she experiences frequent loss of sensation in her hands and feet, severe temporomandibular joint dysfunction, and persistent muscle cramping. Despite consuming what she describes as a typical American diet including processed foods, bananas, vegetables, and adding salt to foods, her sodium and potassium levels remain chronically low. She reports that symptoms worsen significantly during illness - during a recent COVID infection, she experienced severe muscle cramping requiring ten times her normal potassium supplementation. The patient also reports recent alcohol use involving binge drinking episodes, which appeared to exacerbate her symptoms, particularly causing immediate muscle cramping when stretching.

Initial Assessment

Physical examination reveals a thin female with BMI of 18.9. Patient demonstrates normal gastrointestinal function despite eating disorder history. Laboratory findings show persistent hyponatremia and hypokalemia. Patient reports temporary symptom relief with potassium supplementation but symptoms return when discontinued. Notable symptoms include peripheral paresthesias, muscle cramping (particularly in calves), fatigue, and intense salt cravings.

The Diagnostic Journey

Initial workup focused on ruling out ongoing purging behaviors, renal losses, and endocrine disorders. Patient's primary care physician initially attributed symptoms to inadequate salt intake, despite patient's report of high sodium food consumption. Further investigation needed to determine if chronic electrolyte losses are related to residual effects of eating disorder, underlying renal dysfunction, or hormonal imbalances affecting electrolyte regulation.

Final Diagnosis

Chronic hyponatremia and hypokalemia, likely secondary to long-term complications of bulimia nervosa with possible underlying renal tubular dysfunction or hormonal dysregulation affecting electrolyte homeostasis.

Treatment Plan

Ongoing potassium supplementation as needed for symptom control. Recommendation for comprehensive metabolic workup including renal function assessment, hormonal evaluation (aldosterone, cortisol, ADH), and possible nephrology consultation. Nutritional counseling to ensure adequate electrolyte intake through balanced diet. Alcohol cessation counseling given exacerbation of symptoms with alcohol use.

Outcome and Follow-up

Patient continues to require potassium supplementation for symptom management. Symptoms persist despite dietary modifications and salt supplementation. Close monitoring needed during acute illnesses when electrolyte requirements appear to increase dramatically. Further specialist evaluation recommended to determine underlying etiology and optimize long-term management strategy.