|A Case of Geophagia|
A Case of Geophagia
Patrick Yao, M.D.
A 60-year-old female with diabetes, ischemic cardiomyopathy and hypertension came to the office for routine follow-up. The patient reported increasing fatigue and exertional dyspnea, without orthopnea, nocturnal dyspnea, or chest pain. She had a recent stress echocardiogram which indicated stable cardiac function. Interestingly, she mentioned that she recently reacquired an old childhood craving for the soil in her backyard. For the past few months, she would heat up the dirt in the microwave and eat it regularly in place of her regular meals. She denied any abdominal pain, vaginal bleeding, hematemesis, or hematochezia but noted that her stools had been darker in color. Laboratory studies showed a micro-cytic anemia with a mean corpuscular volume of 67.7 fL and hemoglobin of 7.8 g/dL. Her iron studies were consistent with a severely iron-deficient state.
Pica is an eating disorder defined as the persistent craving and compulsive eating of nonnutritive substances for a period of at least one month, without an association with an aversion to food.1 The behavior must not be developmentally inappropriate and not part of a cultural or religious practice. Pica presents in various forms. Some of the most commonly described types involve eating soil or clay (geophagia), ice (pagophagia) and starch (amylophagia). However, pica has also been associ-ated with the ingestion of stones, ashes, hair, paint chips and paper. The definition has been expanded to include unusual and excessive cravings for food substances such as tomatoes.2
The term "pica" originated from the Latin word for magpie, a bird known for its unusual eating habits by showing an indiscriminate preference for foods and nonfood substances. The condition has been recorded as early as the 13th century. Geophagia among children and pregnant women was first described medically in a book in 1563. It has also been described as a common act during the 19th century in the southern United States, primarily among the slaves. The prevalence of pica in the U.S. is unknown because the disease often goes undiagnosed and underreported. Pica is most frequently observed in pregnant women, children and patients of lower socioeconomic class.3 It is also more commonly seen in individuals with psychiatric disease, autism, developmental delay, and mental retardation.
Although pica is often considered a manifestation of iron deficiency, the condition is more commonly discovered in patients who are not anemic.4 The etiology of pica remains unclear. Evidence suggests that there may be several major contributing factors to pica, including nutritional, sensory, physiologic, neuropsychiatric, cultural, or psychosocial factors.5 Nutritional deficiency in iron, zinc, calcium, and other vitamins has been widely purported to be a major cause of pica. Various reports have associated pica with iron deficiency, but it remains controversial whether pica is a consequence rather than a cause of iron deficiency. Kettaneh et al6 have shown that pica in iron deficient individuals stop once adequate iron supplementation is given. A recent case control study further supports that pica is the result rather the cause of iron deficiency.3
Sensory and physiologic mechanisms have been proposed to explain the behavior of pica. Some patients with pica have reported that they enjoy the taste, texture, or smell of the nonfood substance. It has been postulated that the analgesic properties of ice may help reduce the pain from glossitis in the iron-deficient patient.6 Consumption of clay has been used in certain populations to alleviate the symptom of nausea. For example, some African-Americans in the southern U.S. ingest a particular kind of white clay because they believe in its health benefit and its effec-tiveness in reducing morning sickness during preg-nancy. Other studies have indicated that pica may have an underlying psychosocial basis in that it has an association with family stress. The act of pica has been hypothesized to be a way of relieving stress. Lastly, there has been study suggesting that pica can be a part of the obsessive-compulsive disorder (OCD) spectrum and may respond to pharmacological treat-ment for OCD.7
Since the diagnosis of pica is based on self-reporting of behavior, it can be difficult to diagnose in the absence of complications. Patients are less likely to report such behavior either due to embarrassment or the lack of knowledge of its potential health consequences. More often, the diagnosis is made because of its complications, which include anemia, lead poisoning, parasitic infestation, intestinal obstruction, or other metabolic conditions. Once pica is suspected or diagnosed, a comprehensive medical evaluation should be performed. On physical examination, signs such as hepatosplenomegaly, koilonychia (spoon nails), and growth retardation in children should be noted. Laboratory studies should include a complete blood count, peripheral smear for eosinophilia, iron studies, lead, and electrolyte levels. Stool tests can aid in ruling out parasitic infections. Imaging studies can be useful to identify infested materials and evaluate possible abdominal complications of pica.
In most cases, pica does not lead to major health problems, but it can have serious medical implica-tions. Potential complications include metabolic abnormalities such as heavy metal poisoning, elec-trolyte disturbances, vitamin deficiencies, iron and zinc deficiencies. Ingestion of substances such as lead-based paint or mercury-containing paper can progress to toxic heavy metal poisoning. It can also lead to soil-borne parasitic infection, dental injury, and achlorhydria. Furthermore, pica has been asso-ciated with gastric and intestinal obstruction from bezoars, foreign bodies, feces or parasites. Other abdominal complications such as perforation and peritonitis have been reported as well. Excessive caloric intake, especially in the setting of amylophagia, can mimic gestational diabetes in pregnant women.
Although pica spontaneously remits in many cases, the treatment of the condition can be challenging. Successful therapy is dependent on the cause and type of pica. Identification of any potential underlying medical condition or resultant complication such as iron deficiency and lead poisoning is crucial for the proper treatment. In case reports of pagophagia in the setting of iron deficiency, iron therapy resulted in prompt and complete resolution of the eating behavior.8 If no obvious cause or condition is identified, treatment should be focused on counseling, education, and nutritional management. The use of selective serotonin reuptake inhibitors has been tried and should be considered in patients with severe or refractory pica.
Submitted on May 1, 2005