Fatal Refeeding Syndrome Despite Cautious Inpatient Refeeding in Severe Anorexia Nervosa: A Case Report

Technical Summary: Fatal Refeeding Syndrome Despite Cautious Inpatient Refeeding in Severe Anorexia Nervosa

Problem Statement
Refeeding syndrome (RFS) is a potentially fatal metabolic complication arising from the nutritional rehabilitation of severely malnourished patients, particularly those with anorexia nervosa (AN). While established protocols emphasize slow caloric escalation and electrolyte correction, the literature indicates that sudden decompensation can still occur in patients with extreme baseline risk, even within inpatient settings. This case report addresses the gap in understanding how "cautious" refeeding can fail in severe, chronic AN, specifically highlighting the limitations of current monitoring capabilities in resource-constrained environments and the critical window of vulnerability during the initial days of nutritional rehabilitation.

Methodology
This study is a single-patient case report detailing the clinical course of an 18-year-old female with a four-year history of restrictive eating and severe malnutrition (BMI 15.1 kg/m²). The patient was admitted to a multidisciplinary inpatient unit at the National Institute of Mental Health and Neurosciences (NIMHANS) and Government Medical College, Seoni.

The management protocol included:

• Multidisciplinary Care: A team comprising psychiatry, clinical psychology, endocrinology, internal medicine, and clinical nutrition.
• Interventions: Initiation of a cautious refeeding protocol, electrolyte correction, continuous cardiac monitoring, motivational interviewing, supportive psychotherapy, and family-based interventions.
• Data Collection: Comprehensive baseline investigations were performed prior to refeeding, including a 12-lead electrocardiogram (ECG), complete blood count, and serum electrolytes (specifically phosphate, potassium, sodium, and calcium). The timeline of clinical events, laboratory values, and interventions was documented contemporaneously from admission through the patient's death.
• Ethical Considerations: The report was conducted under a waiver from the Institutional Ethics Committee, adhering to the Declaration of Helsinki. Written informed consent for publication was obtained from the patient's legal next of kin.

Key Results
The patient presented with profound emaciation, amenorrhea, and refusal to eat. Baseline investigations revealed severe microcytic anemia (Hemoglobin 7.2 g/dL), hypokalemia (2.6 mmol/L), hyponatremia (131 mmol/L), and hypophosphatemia (0.73 mmol/L; reference 0.81–1.45 mmol/L). The ECG demonstrated sinus bradycardia with a prolonged QTc interval (>500 ms), indicating high arrhythmic risk.

Despite the initiation of a cautious refeeding protocol and partial cooperation with oral intake, the patient experienced rapid clinical deterioration on Day 5 of hospitalization. Symptoms included acute hypotension, confusion, and generalized edema, accompanied by significant electrolyte instability. These features were clinically consistent with refeeding syndrome. The patient was transferred emergently to the intensive care unit (ICU) and died within 48 hours of the transfer. The terminal cardiac rhythm was not documented, and no autopsy was performed.

Key Contributions
The primary contribution of this report is the documentation of a fatal outcome despite adherence to a multidisciplinary, "cautious" inpatient refeeding protocol. The case highlights several critical factors:

1. Baseline Risk Stratification: The presence of baseline hypophosphatemia, hypokalemia, and QTc prolongation created a biologically plausible substrate for acute collapse upon refeeding, suggesting that "cautious" caloric initiation alone is insufficient without aggressive phosphate-forward prevention.
2. Diagnostic Delays: The patient's history illustrates a common pathway in Indian and Southeast Asian contexts where eating pathology is misidentified as physical illness or "fussiness," leading to delayed psychiatric referral until the patient is medically fragile.
3. Monitoring Limitations: The report notes that while baseline biochemistry was available, serial post-refeeding measurements of phosphate, magnesium, and potassium were not obtained with the frequency recommended by current guidance, preventing a full reconstruction of the biochemical trajectory.
4. Ethical and Legal Context: The case underscores the difficulty in managing patients with severe AN who lack insight and refuse life-saving interventions, particularly within the uncertain legal frameworks for compulsory treatment in India.

Significance and Claims
The authors claim that this case underscores the necessity of moving beyond simple caloric restriction in refeeding protocols. They argue that even with inpatient multidisciplinary management, refeeding syndrome can be rapidly fatal when baseline medical risk is extreme.

The paper asserts that prevention requires:

• Structured, Protocolized Monitoring: Specifically, phosphate- and magnesium-focused surveillance, thiamine prophylaxis, and tightly controlled fluid management.
• Early Referral: Strengthening consultation–liaison psychiatry to detect eating disorders in general medical settings earlier.
• Specialized Pathways: The development of standardized national or institutional refeeding bundles and specialized eating-disorder care pathways that integrate medical stabilization with psychological care.
• Family Education: Explicit counseling for families regarding the lethal risks of the early refeeding window and the consequences of body-related comments on adolescents.

The authors maintain a modest tone regarding causality, acknowledging that as a single uncontrolled observation, the report cannot establish generalizable causal attribution but serves to generate hypotheses regarding risk stratification and the intensity of monitoring required for severe AN.