1/46. A case of Cotard's syndrome associated with self-starvation. Cotard's syndrome is a psychotic condition often associated with nihilistic delusions. This syndrome can be associated with destructive behaviors directed at the self and/or others. In this report we highlight the psychiatric-legal issues involving a case of Cotard's syndrome associated with self-starvation. ( info) |
2/46. Evidence for an anabolic action of essential amino acid analogues in uremia and starvation. nitrogen-free analogues of essential amino acids, when administered with those essential amino acids for which analogues are ineffective or unavailable, exert three actions that may be beneficial in protein-deficient or protein-intolerant subjects. First, they bring about an increase in the concentrations of essential amino acids in the blood at the expense of the concentrations of certain non-essential amino acids, notably alanine and glutamine. This effect is most readily demonstrated in children with congenital defects of the urea cycle enzymes, but can also be seen during daily therapy of adults with portal-systemic encephalopathy. Second, these compounds promote nitrogen balance through their suppressive effect on urea synthesis (an effect not attributable to re-utilization of ammonia derived from urease action in the gut). This action is demonstrable in obese subjects who are already conserving nitrogen maximally at the end of a prolonged fast and can also be shown in the first week of fasting when the branched-chain keto acids alone are administered. In both situations, improved nitrogen conservation persists long after the analogues are metabolized, suggesting enzyme adaptations. In chronic uremics, nitrogen balance can be maintained in some (but not all) patients on very low nitrogen intakes. Third, these mixtures may delay or reverse the progressive decline in glomerular filtration rate characteristic of chronic renal failure in some cases: thus, for example, 5 of 6 patients taken off chronic dialysis have maintained lower serum urea concentrations without evidence of protein malnutrition for periods of 2-24 months. ( info) |
3/46. A common cause of altered mental status occurring at an uncommon age. Wernicke's encephalopathy is a neurologic disorder due to a nutritional deficiency of thiamine, characterized by ocular palsies, ataxia, and altered mental activity. While Wernicke's encephalopathy is commonly attributed to alcoholism in the adult population, it has been described in children receiving prolonged parenteral nutrition and those with malignancies and AIDS. The disease, however, is rarely diagnosed in the pediatric population during life. We report a case of Wernicke's encephalopathy in a child with prolonged starvation and aim to improve awareness of a potentially fatal but treatable disease. ( info) |
4/46. Gelatinous transformation of bone marrow in prolonged self-induced starvation. In bone marrow from 3 patients with prolonged, severe self-induced starvation, fat atrophy, hypoplasia of haemopoietic cells and characteristic gelatinous transformation of marrow were noted. The gelatinous substance appeared amorphous and stained pink with the Wright-Giemsa stains. Histochemical and ultrasturctural studies indicated that it consisted of acid mucopolysaccharides and was extracellular in nature. Similar marrow abnormalities were produced in rabbits by limitating their food intake for 4 months. These marrow abnormalities in the experimental animals could be reverted to normal by restoring their nutritional status. It is proposed that the gelatinous transformation of marrow is caused by excessive production of mucopolysacchrides of the ground substance to compensate for the mobilization of marrow fat which occurs to meet the energy requirement. It is further postulated that excessive production of acid mucopolysaccharides may provide a microenvironment unsuitable for haemopoietic proliferation. The relevance of these findings to other conditions associated with marrow aplasia, is discussed. ( info) |
| The refeeding syndrome is an underappreciated entity characterized by acute electrolyte derangements--notably hypophosphatemia--that occur during nutritional repletion of patients with significant suboptimal caloric intake. Adverse effects of hypophosphatemia include cardiac failure, muscle weakness, immune dysfunction, and death. hypokalemia and hypomagnesemia commonly complicate refeeding syndrome as well; however, this report briefly reviews the clinical manifestations of refeeding-induced hypophosphatemia. ( info) |
| A 1-year-old boy had severe anoxic brain injury owing to a cardiorespiratory arrest. He had an initial metabolic acidosis, but this largely resolved by hospital day 2. He then had a persistent, profound metabolic acidosis. Evaluation on hospital day 6 found that the patient had ketonemia, ketonuria, and a normal serum glucose level; he had received no intravenous dextrose during his hospitalization. The dextrose-free fluids were given initially to protect his brain from the deleterious effects of hyperglycemia after brain injury. Continuation beyond 24 hours was inadvertent. The initiation of dextrose-containing intravenous fluids produced a rapid resolution of his metabolic acidosis. starvation usually produces a mild metabolic acidosis, but when combined with physiologic stress, starvation may cause a severe metabolic acidosis. Among the few reports of severe starvation ketoacidosis, our case is unique because the patient was monitored closely in an intensive care unit, allowing us to describe the time course of the acidosis in detail. ( info) |
| homicide by starvation is a very rare occurrence, especially when the victim is ambulant. This paper presents a case where the death of the individual went undiscovered for more than 3 weeks. A successful conviction for murder ensued. The paper also discusses social and pathological problems associated with this crime. ( info) |
8/46. Does the expert witness fit the crime? Injury to a child by starvation--a dietitian's testimony. After the death of their four-month-old infant, the parents were charged with injury to a child by starvation. The medical examiner documented blunt force trauma and severe malnutrition at autopsy, but the cause of death was undetermined. The legal team hired a neonatal dietitian who was able to determine that impaired growth only occurred when the infant was in the care of his parents. This information, along with other testimony, established that the lack of nutrition compromised this infant's ability to grow and develop normally, and thus contributed to the infant's death. A jury found the father guilty of injury to a child with intent, and was sentenced to 50 years in prison. The mother agreed to a plea bargain serving 25 years. The purpose of this report is to offer insight, information, and facts from this case for the benefit of others. ( info) |
9/46. Extreme gestational starvation ketoacidosis: case report and review of pathophysiology. A case of severe starvation ketoacidosis developing during pregnancy is presented. The insulinopenic/insulin-resistant state found during fasting in late gestation predisposes to ketosis. Superimposition of stress hormones, which further augment lipolysis, exacerbates the degree of ketoacidosis. In our patient, gestational diabetes, twin pregnancies, preterm labor, and occult infection were factors that contributed to severe starvation ketoacidosis. diagnosis was delayed because starvation ketosis is not generally considered to be a cause of severe acidosis, and because the anion gap was not elevated. Improved understanding of the complex fuel metabolism during pregnancy should aid in prevention, early recognition, and appropriate therapy of this condition. ( info) |
10/46. Estimation of caloric deficit in a fatal case of starvation resulting from child neglect. We report the case of a 3-year-20-day-old girl who died of starvation as a result of severe neglect. Her body weight had been 12 kg 70 days before her death, but was only 5 kg at the time of autopsy. From information supplied by her parents to police, we calculated her daily caloric intake and estimated the factors for physical activity. The daily recommended dietary allowance for the victim was calculated from 700 kcal/ day x the appropriate factor for physical activity. In the absence of enough food, body fat (7.2 kcal/g body fat) and protein (4 kcal/g protein) would have been used to compensate until death. The calculated body weight at the time of death was around 5 kg. The statements of the parents therefore appear to be true. ( info) |