2 At the current admission, blood work was notable for a normocytic anemia (Hgb: 12.0 g/dl, MCV: 94.8 fL), as well as a mildly increased white blood cell count (11.9 × 109/L) with profound lymphopenia (0.0 × 109/L) and 45% band neutrophils. Platelets were 160 × 109/L. Reticulocyte index was 0.36 and iron studies were consistent with ane- mia of chronic disease (iron: 71 ug/dl, ferritin: 676 ng/mL, TIBC: 151 ug/dl, transferrin saturation: 47%). The patient was hypovolemic (BUN/Cr: 72.0) and hyponatremic (Na: 122 mEq/L) with low serum protein (5.4 g/dl), albumin (2.6 g/dl), and prealbumin (7.8 mg/dl). TSH was normal, aminotransferases were mildly elevated, and HIV and viral hepatitis serologies were negative. Psychiatric evaluation, which had not been previously done, revealed a cognitively-intact man with poor insight and judgment regarding his condition. Depressive symptoms were noted, but he denied any history of suicidal ideation or self-injurious behaviors. No signs of psychosis were found. Ritualistic food preparation and restricting dietary habits were noted, although he did not endorse typical anorexia nervosa obsessions about body image or weight, nor did these appear to be consistent with obsessive- compulsive disorder. He expressed feelings of guilt and confusion with regards to sexual orientation and religious beliefs. Following extensive negative testing for other etiologies of cachexia, the patient was diagnosed with an eating disorder, not otherwise speciﬁed (ED-NOS) and a mood disorder, NOS. He was placed in a skilled nursing facility for physical rehabilitation, pending placement in a day hospital program for eating disorder-related psychotherapy. 3. Discussion Despite a ﬁve year history of weight loss and extensive medical evaluations, our patient had no prior psychiatric evaluation. The nonspeciﬁc and diverse clinical histories, physical exam ﬁndings, and laboratory workup of eating disorders are often inappropriately attributed to other, more common causes of malnourishment and wasting. Eating disorder diagnoses in males may be particularly challenging due to the low prevalence of the disorders in this population. While men may account for up to 25% of binge eating disorder diagnoses, they only account for approximately 10% of AN or bulimia nervosa diagnoses [3]. Our patient’s age also placed him in a low prevalence group. Though few epidemiological studies exist, data suggests that the mean age of onset of eating disorders in males is similar to that in females [4], most commonly between adolescence and the mid 20 s [5–8]. One study found that only 5% of males (2/42) and 2% of females (12/557) had onset of AN after the age of 30 [9]. In light of these data, our patient’s presentation is remarkable for his respective age and sex demographics, clearly placing him in a minority among other patients with similar diagnoses. Delayed diagnosis and treatment may be more common in males with non-AN eating disorders compared to those with AN. One study of 135 men with eating disorders found Case Reports in Medicine that men with AN exhibited a mean delay in treatment of only two years, while men with non-AN eating disorders had a mean delay of approximately eight years [6]. Our patient’s diagnosis of an ED-NOS and his delay in diagnosis and treatment of over ﬁve years are consistent with these data. Hematologic abnormalities may be an important clue to an underlying eating disorder, although anemia, leukopenia, severe lymphopenia, and bone marrow dysfunction occur in other cachectic states as well [5, 7, 8, 10]. A recent review of patients with anorexia nervosa (AN) documented approximately one third who were anemic, most commonly with a normocytic anemia. Leukopenias were present in 29– 36% of patients across ﬁve studies, and lymphopenias in a further three studies [7]. Our patient’s severe lymphopenia (absolute lymphocyte count: 0.0 × 109/L) is remarkable, even in the context of eating disorders: of these three studies that documented lymphopenias in AN patients, only one documented lymphopenias that were statistically signiﬁcant when compared to controls groups, and none of the studies showed mean absolute lymphocyte counts less than 1.3 × 109/L [10–12]. Bone marrow atrophy and subsequent dysfunction are the likely etiology of these hematologic ﬁndings. Gelatinous marrow transformation (GMT), commonly found in mal- nourished states such as AIDS, alcoholism, malabsorptive diseases, and malignancies [13], has also been documented in patients with eating disorders. In a study of AN patients’ bone marrow, GMT was documented in 50% (22/44) of the patients. The pattern of bone marrow degeneration correlated with the degree of weight loss, and higher rates of peripheral cytopenias occurred in patients with gelatinous transformation [5]. Given these ﬁndings, the extreme ane- mia, leukopenia, and lymphopenia seen in this patient are likely secondary to the long-standing hypoplastic gelatinous transformation of his marrow. The patient’s low reticulocyte index (0.36) further supports this theory. 4. Conclusions In severe malnutrition, nondiagnostic hematologic abnor- malities are often present. We have reported a case in which, secondary to an eating disorder, a middle-aged male demonstrates many of these ﬁndings. This case demonstrates that the diagnoses of eating disorders can be challenging, especially in low-prevalence populations such as our patient, a middle-aged male. Marked weight loss in conjunction with cytopenias or marrow atrophy should suggest the possibility of an eating disorder in select undiagnosed patients. Acknowledgments The authors would like to thank the patient and his family, and the Alpert School of Medicine at Brown University for supporting this work. The authors have no disclosures to make.