(109) Is it ARFID? Considering a Broad Differential for Failure to Thrive

Abstract: Background/Significance

Avoidant/Restrictive Food Intake Disorder (ARFID) is a feeding and eating disorder characterized by decreased food intake resulting in impaired functioning, and weight/nutrition outcomes. ARFID is highly comorbid with many psychiatric disorders. Presenting symptoms are broad and non-specific including loss of interest in eating, abdominal discomfort, fear of choking/vomiting, dizziness, metabolic abnormalities, impaired concentration, and weakness. The Pediatric Consultation-Liaison psychiatrist (CLP) may be consulted to assess for ARFID in the setting of feeding/eating difficulties or weight loss; given the heterogeneity of presentations, it is important to maintain a broad differential.



Case

A 13-year-old boy with 22q11 deletion syndrome, developmental delay, and Tetralogy of Fallot status-post surgical repair presented to the hospital with rapid weight loss and fevers after dental procedures. Preliminary work up revealed normocytic anemia, elevated eosinophils, elevated LDH, and negative blood cultures. He met 0 major and 3 minor Duke criteria for endocarditis. Echocardiography reflected the previously completed instrumentation, without vegetations. Imaging of the abdomen was obtained to rule out malignancy and revealed hepatosplenomegaly. CLP was consulted for anxiety and “picky eating” as contributors to weight loss. The patient/mother attributed the patient’s new onset anorexia to his febrile illness and resultant nausea. Interviews with the patient and mother revealed a lifelong pattern of “picky eating” without weight loss, and known anxiety in medical settings. The CLP recommended additional work up for the etiology of weight loss. Infectious disease was consulted yielding additional history, noting the patient lives with pets, including a recently adopted feral cat. The patient was later diagnosed with disseminated Bartonellosis. Psychiatry followed for titration of mirtazapine to assist with anxiety, mood, and appetite.



Discussion

Symptoms of ARFID can be non-specific and include changes in mood and anxiety accompanied by weight loss. These symptoms led to CLP evaluation for feeding/eating disorder as an etiology. The CLP determined low likelihood of ARFID. This feedback allowed the primary team to broaden their differential diagnosis ultimately leading to identification of an infectious etiology. The CLP collaborated with the team to treat anxiety related to adjustment to prolonged hospitalization and the patient and his mother welcomed re-involvement of the CLP upon re-admission for exacerbation of illness.



Conclusions

CLPs are asked to comment on the possibility of a feeding/eating disorder as a part of a differential for failure to thrive. In these situations, the CLP can encourage widening of the differential diagnosis when indicated while supporting the patient and family.

Reference
Antar AAR, Goyal A, Murphy K, Schimmel M, Gilotra NA, Martin I, Crane GM, Sciortino C, Avery RK, Houston BA. Disseminated cat-scratch disease presenting as nausea, diarrhea, and weight loss without fever in a heart transplant recipient. Transpl Infect Dis. 2017 Jun;19(3). doi: 10.1111/tid.12678. Epub 2017 May 26. PMID: 28199763.