{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T14:59:52Z","timestamp":1753887592493,"version":"3.41.2"},"reference-count":41,"publisher":"American Academy of Pediatrics (AAP)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,9,1]]},"abstract":"<jats:p>A 20-year-old female with depression presented to the emergency department with chronic weight loss, weakness, fatigue, hair loss, rash, palpitations, and 2 weeks of cough. Initial history revealed that she had disordered eating habits with dietary restriction, experienced a 50-pound unintentional weight loss over 2 years despite reported adherence to nutritional supplementation, and had a normal gastrointestinal workup. On examination, she was markedly cachectic with a BMI of 10.3kg\/m2 and hypotensive (84\/69 mmHg). Her cardiovascular examination revealed a regular rate and rhythm without a murmur. Her breath sounds were diminished in the upper lobes bilaterally. A skin examination showed diffuse hair loss, skin breakdown, and peeling with a tender, erythematous, papular rash over the bilateral ankles, and nonpitting edema. A chest radiograph showed a right upper lobe opacity and lucent lesions in the left proximal humerus. A focused assessment with sonography for trauma examination showed a large pericardial effusion. Chest computed tomography revealed a right upper lobe opacity with an associated cavitation. Though she began improving with rifampin, isoniazid, pyrazinamide, ethambutol, levofloxacin, azithromycin, and nutritional rehabilitation, her clinical course was complicated by an acute worsening nearly 1 month into her hospitalization with persistent high fevers, worsening cough, development of a murmur, and worsening consolidation on chest computed tomography. Adolescent Medicine, Infectious Diseases, Gastroenterology, and Allergy and Immunology were consulted to guide the diagnostic evaluation and management of this patient\u2019s complex clinical course.<\/jats:p>","DOI":"10.1542\/peds.2022-060983","type":"journal-article","created":{"date-parts":[[2023,8,1]],"date-time":"2023-08-01T08:30:36Z","timestamp":1690878636000},"source":"Crossref","is-referenced-by-count":0,"title":["What Came First: Malnutrition or Severe Disease?"],"prefix":"10.1542","volume":"152","author":[{"given":"Megan N.","family":"Carey","sequence":"first","affiliation":[{"name":"aDepartment of Pediatrics"},{"name":"bDepartment of Pediatrics, Texas Children\u2019s Hospital, Houston, Texas"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lindsay H.","family":"Cameron","sequence":"additional","affiliation":[{"name":"aDepartment of Pediatrics"},{"name":"bDepartment of Pediatrics, Texas Children\u2019s Hospital, Houston, Texas"},{"name":"cInfectious Diseases"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicholas L.","family":"Rider","sequence":"additional","affiliation":[{"name":"dDivision of Clinical Informatics, Liberty University College of Osteopathic Medicine, Lynchburg, Virginia"},{"name":"eDivision of Pediatric Allergy and Immunology, Liberty Mountain Medical Group, Lynchburg, Virginia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Albert","family":"Hergenroeder","sequence":"additional","affiliation":[{"name":"aDepartment of Pediatrics"},{"name":"bDepartment of Pediatrics, Texas Children\u2019s Hospital, Houston, Texas"},{"name":"fSections on Adolescent Medicine"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Adam","family":"Cohen","sequence":"additional","affiliation":[{"name":"aDepartment of Pediatrics"},{"name":"bDepartment of Pediatrics, Texas Children\u2019s Hospital, Houston, Texas"},{"name":"gSection on Pediatric Hospital Medicine, Baylor College of Medicine, Houston, Texas"},{"name":"hPediatric Hospital Medicine"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"417","published-online":{"date-parts":[[2023,8,1]]},"reference":[{"issue":"1","key":"2023111414365579400_B1","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1007\/s11606-015-3438-8","article-title":"Factors influencing hospital admission of non-critically ill patients presenting to the emergency department: a cross-sectional study","volume":"31","author":"Lewis Hunter","year":"2016","journal-title":"J Gen Intern Med"},{"key":"2023111414365579400_B2","first-page":"2082S","article-title":"Child anthropometry and mortality in Malawi: testing for effect modification by age and length of follow-up and confounding by socioeconomic factors","volume":"124","author":"Pelletier","year":"1994","journal-title":"J Nutr"},{"issue":"8","key":"2023111414365579400_B3","doi-asserted-by":"crossref","first-page":"810","DOI":"10.1038\/nm0895-810","article-title":"The limit of human adaptation to starvation","volume":"1","author":"Collins","year":"1995","journal-title":"Nat Med"},{"issue":"5","key":"2023111414365579400_B4","doi-asserted-by":"crossref","first-page":"648","DOI":"10.1016\/j.jadohealth.2022.08.006","article-title":"Medical management of restrictive eating disorders in adolescents and young adults","volume":"71","author":"Society for Adolescent Health and Medicine","year":"2022","journal-title":"J Adolesc Health"},{"issue":"2","key":"2023111414365579400_B5","doi-asserted-by":"crossref","first-page":"178","DOI":"10.1002\/ncp.10474","article-title":"ASPEN consensus recommendations for refeeding syndrome","volume":"35","author":"da Silva","year":"2020","journal-title":"Nutr Clin Pract"},{"issue":"10","key":"2023111414365579400_B6","doi-asserted-by":"crossref","first-page":"1043","DOI":"10.1001\/archsurg.1996.01430220037007","article-title":"Refeeding hypophosphataemia in an intensive care unit: a prospective study","volume":"131","author":"Marik","year":"1996","journal-title":"Arch Surg"},{"key":"2023111414365579400_B7","article-title":"Nutrition and hydration requirements in children and adults","volume-title":"StatPearls","author":"Faizan","year":"2023"},{"issue":"7","key":"2023111414365579400_B8","doi-asserted-by":"crossref","first-page":"e25","DOI":"10.1093\/cid\/cir531","article-title":"The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America","volume":"53","author":"Bradley","year":"2011","journal-title":"Clin Infect Dis"},{"key":"2023111414365579400_B9","unstructured":"Centers for Disease Control and Prevention\n          . 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