Desiderosmia: a manifestation of iron deficiency in pregnancy.

A pregnant woman in her 20s presented with an excessive desire to smell a specific household cleaning product. She was found to have severe iron deficiency anaemia and her symptoms resolved following intravenous iron supplementation. She described symptoms of fatigue, shortness of breath and olfactory cravings. The specific scent could not be replicated with other smells and the woman had to significantly modify her lifestyle to accommodate the excessive desire. She had a similar experience during her prior pregnancy which resolved after the correction of severe iron deficiency anaemia. This unique symptom has been described as desiderosmia: iron deficiency manifesting as olfactory cravings. This underappreciated but useful symptom is defined as a separate entity to pica, as there is an absence of desire to ingest the product. Desiderosmia can harm mother and baby through inhalation of potentially harmful fumes; hence, women who describe this symptom should be assessed for iron deficiency anaemia.

Effect of niacin supplementation on nausea-like behaviour in an isoniazid-induced mouse model of pellagra.

Niacin deficiency causes pellagra, the symptoms of which include dermatitis, diarrhoea and dementia. Investigating the mechanism underlying these phenotypes has been challenging due to the lack of an appropriate animal model. Here, we report a mouse model of pellagra-related nausea induced by feeding mice a low-niacin diet and administering isoniazid (INH), which is thought to induce pellagra. Mice fed a normal or low-niacin diet received INH (0·3 or 1·0 mg/mg per animal, twice daily, 5 d), and nausea was evaluated based on pica behaviour, which considered the rodent equivalent of the emetic reflex. Furthermore, the effect of therapeutic niacin administration on nausea was evaluated in this model. Urinary and hepatic metabolite levels were analysed by LC coupled with MS. INH-induced pica was observed in mice fed a low-niacin diet but not in those fed a normal diet. Levels of urinary metabolites, such as 1-methyl-2-pyridone-5-carboxamide, kynurenic acid and xanthurenic acid, were significantly reduced in the mice treated with INH compared with those that did not receive INH. Furthermore, niacin supplementation prevented pica and restored the levels of some metabolites in this mouse model. Our findings suggest that INH-related nausea is pellagra-like. We also believe that our newly established method for quantifying pica is a useful tool for investigating the mechanisms of pellagra-related nausea.

A coin crisis: a case report of pica with minireview.

BACKGROUND: Pica is defined as a feeding and eating disorder where there is consumption of nonnutritive substances not consistent with cultural practices or social norms. Its aetiology is still unknown, as its prevalence and optimal treatment, which seem to vary with patients' characteristics and the specific behaviours involved. OBJECTIVES: The authors present a case report of pica treated with copper supplementation, with further diagnostic and treatment considerations. METHODS: Clinical records and interviews were used. A review was conducted using PubMed database. RESULTS: A 59-year-old patient, diagnosed with paranoid schizophrenia, presented with sideroblastic anaemia secondary to zinc-induced copper deficiency in the context of pica. These behaviours ceased with copper supplementation. After 2-year remission, the patient was discontinued on oral copper. One week after, pica behaviours reoccurred, with further remission with renewed copper treatment. Based on temporal relationship, we propose that there might be an association between copper supplementation and pica, not related to its plasma levels. CONCLUSIONS: As far as we know, this is the first case report in the literature with such a long-term follow-up of pica treatment. Our findings challenge the cause-effect relation between micronutrient deficiency and pica and prompts further research in the non-adaptive theories of this poorly understood clinical entity.

High umbilical cord blood lead levels and "calabar chalk" consumption amongst pregnant women in two hospitals in Cameroon.

INTRODUCTION: "Calabar chalk" is a lead-laden pica mostly consumed by pregnant women worldwide as a remedy for morning sickness. This clay material has been shown to have lead levels of up to 40mg per kilogram. Meanwhile blood lead levels, even at doses less than 10µg/dl will be toxic to humans and even worse-off to the fetus as it crosses the placenta. We, therefore, sort to determine the prevalence of "Calabar chalk" consumption amongst pregnant women and if it translates to higher umbilical cord blood lead levels. METHODS: We carried out a cross-sectional study by prospectively and consecutively enrolling 300 pregnant women from December 2014 through February 2015. A questionnaire was administered to ascertain "Calabar chalk" consumption. The levels of lead in the umbilical cord blood of 51 participants of each group of those who consumed and didn't consume "Calabar chalk" were measured by spectrometry and compared using the T-test (p<0.05). RESULTS: The prevalence of "Calabar chalk" consumption was 43.33%. This was mostly consumed during pregnancy only (46.34%), with higher rates observed amongst primigravidas. The mean umbilical blood lead levels amongst those who consumed and those who did not consume "Calabar chalk" was 39.19µg/dl and 25.33µg/dl respectively (P=0.111). CONCLUSION: The prevalence of "Calabar chalk" consumption was high in the pregnant women population. The overall umbilical cord blood lead levels were extremely high in both consumers and non-consumers. We recommend health education and chelation therapy to be considered.

Rapunzel syndrome: an infrequent cause of severe iron deficiency anemia and abdominal pain presenting to the pediatric emergency department.

BACKGROUND: Iron deficiency anemia (IDA) and abdominal pain are commonly seen in a pediatric emergency department (8 and 18% incidence respectively in our center). They are manifestations of a wide variety of diseases ranging from benign to immediately life-threatening. Trichobezoar is an under-diagnosed entity that has to be considered in children and adolescents, expecially female, suffering from trichotillomania (compulsion to pull hair) and trichophagy (compulsion to swallow hair). When undiagnosed, gastric bezoars may cause gastric ulceration, perforation, haemorrhage and obstruction. CASE PRESENTATION: To underline the importance of including this pathology in the differential diagnosis of IDA and abdominal pain, we present the case of a 14 year-old girl with a huge trichobezoar which completely filled the stomach and extended into the small bowel. Since trichobezoar has an extension to the small bowel, it is classified as Rapunzel syndrome. As the bezoar couldn't be removed by endoscopy, the girl underwent surgical intervention. The patient passed through a gradual re-feeding, with iron and vitamins supplementation, and through a psychiatric counselling. CONCLUSION: The Rapunzel syndrome is a rare entity that may be complicated by life-threatening events. A prompt diagnosis and an appropriate therapy can reduce comorbidities. Gradual re-feeding with supplementation of micronutrients allows adequate catch-up weight with normalization of haematochemical nutritional parameters. Since many of these patients suffer from psychiatric pathology such as PICA with emotional problems and mental retardation, psychological/psychiatric counselling plays an important role in order to prevent bezoar recurrence.

Lead in a case of encephalopathy.

A 2-year-old boy with a history of pica was admitted with vomiting and treated overnight for viral tonsillitis. A week later, he presented with a prolonged afebrile seizure and required intubation and ventilation. Antibiotics and acyclovir were started. Despite extensive investigations including MRI head, no cause was identified. Four days later, he deteriorated with signs of raised intracranial pressure. On day 5, blood lead concentration in the sample collected at admission was reported as grossly elevated, consistent with a diagnosis of severe lead poisoning from ingesting lead-containing paint at the family home. Chelation therapy was started but, unfortunately, he did not make a neurological recovery, and care was withdrawn. A serious case review identified a lack of awareness of lead poisoning and its relation to pica as a root cause. We report this case to share our experience and the importance of considering lead poisoning in children with pica.

The Association Between Postpartum Depression and Pica During Pregnancy.

INTRODUCTION & OBJECTIVES: Postpartum depression (PPD) is a common disorder and social debilitating that has adverse effects on the mother, child and family. Pica is an eating disorder characterized by persistent ingestion of substances that the consumer does not define as food. The aim of this study was to investigate the association of postpartum depression with pica during pregnancy. METHOD: This is case-control study was carried out in health centers in west Tehran. 152 depressed women (case group) and 148 non-depressed women (control group) were selected randomly from these health care centers. In addition to collecting demographic and pica data, the Edinburgh Depression Scale was used. The data was analyzed by both descriptive and analytic analyses such as chi-squared and logistic regression in SPSS version 16. RESULT: In this study, there wasn't a significant association between PPD and pica during pregnancy (P=0.153, OR=2.043, CI=0.767, 5.438), but, postpartum depression has a significant association with type (clay) (P= 0.024) and duration (more than 2 months) (P= 0.023) of pica practice. CONCLUSIONS: In the present study, pregnancy pica was not important risk factor for PPD but there were similar risk factors such as iron supplementation during and postpartum pregnancy with pica and PPD.

Maternal cautopyreiophagia as a rare cause of neonatal hemolysis: a case report.

Hyperbilirubinemia in the first 24 hours of life in a newborn is pathologic, necessitating additional evaluation. We report the first case of hemolysis and subsequent hyperbilirubinemia in an otherwise normal term neonate resulting from oxidative stress in the form of maternal cautopyreiophagia: the ingestion of burnt matchstick heads. During the third trimester of pregnancy, the infant's mother consumed more than 300 burnt matchstick heads weekly for 4 weeks. Matches contain potassium chlorate, a powerful oxidant that when ingested can ultimately lead to the destruction of erythrocytes, disseminated intravascular coagulation, kidney injury, or death. The infant's bilirubin rose as high as 17 mg/dL at 22 hours of life; however, the infant did well with a brief course of phototherapy. This case highlights the importance of prenatal questioning about maternal ingestion of potentially oxidative substances and assessing the possible risk for the infant.

A study on the effects of pica and iron-deficiency anemia on oxidative stress, antioxidant capacity and trace elements.

Pica is defined as developmentally inappropriate consumption of nonnutritive substances for at least 1 month. There are a few studies on serum trace element levels of patients with pica. The literature contains contracting data on the levels of oxidative stress and antioxidant levels in patients with iron-deficiency anemia (IDA). The effect of pica on oxidative stress and antioxidant capacity has not been investigated yet. The present study evaluated the effects of pica and IDA on oxidative stress and antioxidant capacity as well as on the levels of trace elements including serum zinc and selenium in 47 children with IDA plus pica, 22 children with IDA only and 21 nonanemic children as controls. The results demonstrated significantly lower levels of serum selenium and zinc in pica and IDA groups compared to the control group. Total oxidant levels were highest in the pica group and consistently, the lowest total antioxidant capacity was observed again in the pica group. Comparison of pica and IDA groups yielded significantly lower levels of total antioxidant levels and significantly higher oxidative stress index in the pica group. Consequently, it is thought that the detrimental effects of pica within the organism were mediated by adverse impacts on antioxidant capacity and oxidative stress. These effects should be kept in mind while managing patients with pica.

Intestinal obstruction secondary to a colonic lithobezoar.

A bezoar is an accumulation of indigestible exogenous matter in the stomach and intestine. A myriad of ingested substances have been found impacted in the digestive tract. Bezoars are uncommon causes of intestinal obtruction during childhood. Lithobezoar, an accumulation of ingested stones within the alimentary tract, is an extremely rare clinical entity. We report one such case in a 9-year-old boy with a history of pica and long-term constipation resulting in intestinal obstruction secondary to a colonic lithobezoar. Only two such cases have been reported previously.

Ingesta de nutrientes en mujeres con pagofagia y otras formas de pica durante el embarazo / Nutrient intake in women with pagophagia and other forms of pica during the pregnacy

Objetivo: La finalidad de la investigación fue conocer y evaluar las características de la ingesta de nutrientes en gestantes con diagnóstico de pica (consumo de sustancias no nutritivas).Materiales y métodos: Se estudió un grupo de 71 mujeres que presentaron pagofagia (consumo compulsivo de hielo) y otras formas de pica y se comparó con un grupo control sin el trastorno conformado por igual número de mujeres con similares características socioculturales y antropométricas. Ambos grupos se seleccionaron en forma aleatoria entre las puérperas asistidas en el Hospital de la Matanza, Provincia de Buenos Aires, Argentina. Resultados: No se observaron diferencias estadísticamente significativas en los consumos de energía, proteínas totales, hierro y calcio. Sin embargo, las mujeres con pica revelaron ingestas inferiores (p < 0,03) de carbohidratos, proteínas animales, hierro hemínico y zinc. Los valores de mediana para las mujeres con y sin el trastorno fueron respectivamente: carbohidratos (g): 379/426, proteínas animales (g): 35/39, hierro hemínico(mg): 1,5/1,9, zinc (mg): 7,1/8,1, calcio (mg): 625/612. En ambos grupos las carnes fueron los principales alimentos fuentes de hierro y zinc y su ingesta resultó inferior en el grupo con pica. Las cantidades diarias que se consumieron en promedio fueron de 117 + 53 g en las mujeres con pica y de 154 + 71 g (p < 0,03) en el grupo control. Solo el 22% de las embarazadas con el trastorno refirió el uso de suplementos de hierro durante el curso del embarazo. Conclusiones: La alimentación de las mujeres con pica en comparación con la de gestantes sin el trastorno reveló una ingesta inferior en nutrientes tradicionalmente marginales como el hierro y el zinc. Estos resultados señalan la necesidad de diagnosticar tempranamente este trastorno durante el embarazo a fin de poder revertirlo ó corregirlo, orientando adecuadamente a las embarazadas respecto a la selección de alimentos y las pautas de suplementación

Objective: The aim of this investigation was to know and assess the characteristics of nutrient intake in pregnant women diagnosed with pica (consumption of nonnutritive substances).Materials and Methods: We studied a group of 71women presenting pagophagia (compulsive consumption of ice) and other forms of pica, which was compared to a control group including the same number of women with similar socio-cultural and anthropometrical characteristics but without the eating disorder. Both groups were randomly selected among women assisted at the Hospital de la Matanza, province of Buenos Aires, Argentina. Results: we did not observed statistically significant differences in energy, total proteins, iron, and calcium consumption. However, women with pica showed lower intakes (p < 0.03) of carbohydrates, animal proteins, hemic iron, and zinc. The median values for women with and without the disorder were, respectively: carbohydrates (g): 379/426; animal proteins (g): 35/39;hemic iron (mg): 1.5/1.9; zinc (mg): 7.1/8.1, calcium(mg): 625/612. In both groups, meat was the main source of iron and zinc, and its intake was lower in the group with pica. The daily average amounts consumed were117 + 53 g for women with pica and 154 + 71 g (p < 0.03)for the control group. Only 22% of pregnant women with the disorder referred using iron supplements during their pregnancy. Conclusions: As compared with control women, pregnant women with pica disorder showed lower intake intraditionally marginal nutrients such as iron and zinc. These results show the need for early diagnosing this disorder during pregnancy in order to prevent or correct it and properly counseling pregnant women about food selection and supplementation regimens

Combined exchange transfusion and chelation therapy for neonatal lead poisoning.

OBJECTIVE: To describe the results of combined exchange transfusion and chelation therapy in a neonate with an elevated blood lead level (BLL). CASE SUMMARY: A 34-year-old Latina woman with a long history of pica (eating glazed pottery) gave birth to a healthy-appearing girl at 40 weeks of gestation. The mother's preconception BLL was 117 microg/dL and remained elevated throughout pregnancy. At parturition, the mother's BLL was 87 microg/dL and the infant's cord BLL was 100 microg/dL. The infant underwent single-volume exchange transfusion within 12 hours of birth. BLL was 28 microg/dL following the exchange, and a 5-day course of chelation with dimercaprol and CaNa2 ethylenediamine tetraacetic acid was initiated at 36 hours of life. The infant's BLL was 37 microg/dL at the end of inpatient chelation. DISCUSSION: Long-term neurologic disability from in utero lead exposure is well described, but the optimal treatment of elevated neonatal BLLs in healthy-appearing infants at the time of birth is not established. This strategy of combined chelation and exchange transfusion therapy was well tolerated and resulted in decreased lead levels, but the long-term neurologic efficacy of our combination strategy remains to be seen. CONCLUSIONS: Combined exchange transfusion and chelation therapy resulted in rapidly decreased lead levels in a neonate with chronic in utero lead exposure.

Pica and the elephant's ear.

This is a case report of an otherwise healthy 2-year-old boy with a history of pica, associated with iron deficiency anemia. This boy was referred to our department for a neurologic evaluation because of an acute episode of sialorrhea, difficulty in speaking, dysphagia, and repeated swallowing movements. An uncertain episode of a brief-duration still gaze was also reported. In addition, the history revealed that the child had earlier ingested a leaf from a poisonous houseplant called Colocasia esculenta, also known as "elephant's ear." The habit of pica subsided after treatment with iron supplements. A 9-month follow-up period was uneventful. Neurologic manifestations can accompany accidental intoxications of some non-nutrient substances. Thus, pica must be suspected in children with acute behavior alterations.

The effects of a vitamin supplement on the pica of a child with severe mental retardation.

The effects of a common multiple vitamin on the pica of a child with severe mental retardation and anemia were evaluated. A BAB design revealed that pica was decreased by the vitamin. The results suggest that pica can be effectively treated by implementation of a simple nutritional or biological intervention. Further research investigating the generality of this finding and the effects of combining biological and behavioral interventions are discussed.

Severe lead poisoning from an imported clothing accessory: "watch" out for lead.

CASE REPORT: A case of severe lead poisoning following ingestion of an imported clothing accessory is reported. The child presented with abdominal pain, vomiting, and anemia but did not develop encephalopathy. RESULTS: Prompt removal of the object in conjunction with whole bowel irrigation and chelation therapy led to a favorable outcome.

Clinical application of in vivo tibial K-XRF for monitoring lead stores.

We used in vivo tibial K-x-ray fluorescence for clinical evaluation of bone lead stores in 31 patients suspected of excessive lead absorption. Four clinical situations were examined: (1) postchelation therapy, (2) renal failure, (3) home exposure, and (4) occupational exposure. K-x-ray fluorescence assisted in determining the magnitude of body lead stores in patients with known excessive lead exposure. Serial measurements revealed a reduction in bone lead that occurred over the years, during which there was an absence of continued exposure; this reduction occurred more rapidly during chelation therapy. Sustained high bone lead levels following chelation therapy in two children were consistent with elevated lead stores from prior pica. In a patient with renal failure, K-x-ray fluorescence demonstrated massive lead stores at a time when chelation testing was not possible. In other cases, bone lead levels indicated the possible contribution of lead nephropathy to renal diseases of other etiologies. In individuals exposed to lead during home renovations, K-x-ray fluorescence provided reassurance that past exposure did not result in elevated body lead stores decades later. In the occupational setting, K-x-ray fluorescence documented cumulative lead stores in workers whose exposures varied in intensity and duration. The examples discussed here show how physicians can use K-x-ray fluorescence to deal with practical questions of patient management. As the test becomes more generally available, its safety, specificity, and simplicity should make it an important alternative to cumbersome chelation tests and potentially misleading blood lead measurements.