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remarkable, with no cholecystectomy, gastrointestinal surgery, or other events known to influence gut microbial composition. Importantly, she did not adhere to a specific diet, smoke, or drink alcohol (confirmed through dietary lists). FMT was successfully performed according to protocol (online suppl. material; for all online suppl. material, see www.karger.com/ doi/10.1159/000495044) with feces from an unrelated healthy female donor with a BMI of 25. Dietary intake was reported through online application 7 days prior to each visit. Changes in metabolic parameters (resting metabolism and bodyweight) and body composition (body fat and lean mass) were assessed at three time points (baseline, 6, 12, and 36 weeks; Fig. 1a). Over this period, the patient gained 6.3 kg in bodyweight (from 45.8 to 52.1 kg), mostly due to a 55% increase in body fat and despite a reported stable caloric intake. Interestingly, resting energy expenditure was decreased on all post-measurements compared to baseline. Gut microbial composition showed an increase in weighted phylogenetic diversity at 6 and 12 weeks with an especially marked increase in the number of Verrucomicrobia (Fig. 1b). As expected from previous FMT studies, the gut microbiota composition slowly changed back towards the patients’ initial personal core microbial composition [5]. No side effects from FMT were reported or observed during the entire study period. In this patient, FMT resulted in a 13.8% weight gain over a 36week period, which could have various explanations. One often proposed hypothesis is the varying degree to which certain microbes can extract calories from food, for example through the production of short-chain fatty acids (SCFAs) from indigestible carbohydrates (see below), resulting in an increased extraction of energy despite stable dietary intake [6]. Furthermore, studies have assigned a role for gut microbes in host metabolic rates, the latter of which was found altered in AN patients [3]. In this case, the resting energy metabolism decreased after FMT, possibly contributing to the gain in bodyweight. The phyla Firmicutes, Bacteroidetes, and, to a lesser extent, Verrucomicrobia and Euryarchaeota were the dominant phyla in both patient and donor. However, the patient and donor showed profound differences with respect to the relative abundance of these bacterial phyla. In line with previous studies, the relative abundance of Bacteroidetes in the patient was significantly lower and Firmicutes levels higher at baseline compared to the healthy donor [7]. Furthermore, there were significant differences in gut microbial composition after FMT, with the introduction of the Akkermansia muciniphila species (Verrucomicrobia in Fig. 1b). As a mucin degrader, higher levels of A. muciniphila have repeatedly been associated with improved metabolic health, and regression towards an optimum bodyweight for both obese as well as underweight individuals [6]. The effect is thought to be mediated through the production of SCFAs as well as cross-feeding other beneficial microbes with mucin-degradation products like oligosaccharides. Anorexia nervosa (AN) is a life-threatening eating disorder characterized by a distorted body image and excessive dieting, leading to severe underweight and concomitant mental and somatic comorbidities. Weight restoration is an important treatment target since it prevents deterioration and improves patients’ overall prognosis, but effective strategies to achieve this goal are lacking. Especially in the restricting type, underweight can be resistant despite hypercaloric diets [1]. The gut microbiome has recently been identified as one of the regulators of human bodyweight. Fecal microbiota transplantation (FMT) from obese to nonobese subjects has led to weight gain despite unchanged dietary intake in animals as well as humans [2]. It has been repeatedly shown that shortand long-term dietary patterns including undernutrition and dieting in patients with AN can change the microbiota composition [3]. The notion that the gut microbiome can also affect nervous system functions through the gut-brain axis makes its involvement in eating behavior and psychiatric disorders plausible [4]. Accordingly, we present a case in which FMT led to weight gain in a 26-year-old female after unsuccessful attempts to maintain a healthy bodyweight following clinical recovery from AN (restricting type), confirmed by a clinical psychiatrist at an eating disorder center (PsyQ in Groningen). The disease had presented 2 years earlier, and the body mass index (BMI) increased from 14 to 19 with cognitive-behavioral therapy, transient psychotropic medication, and short-term force feeding. Despite the maintenance of a hypercaloric diet of 2,500 kcal/day and a desire to maintain a healthy weight, her BMI dropped and stabilized at 15 after discharge. Except for a stable regime of prednisolone and methotrexate for preexisting autoimmune dermatomyositis, she had not used any medication or supplements since discharge (a year before presentation to our clinic). Her medical history was otherwise unReceived: March 23, 2018 Accepted after revision: October 22, 2018 Published online: January 9, 2019

Weight Gain after Fecal Microbiota Transplantation in a Patient with Recurrent Underweight following Clinical Recovery from Anorexia Nervosa