Sometimes we encounter a patient with a strange symptom that is ignored by the standard medical textbooks. Recently, I was presented with such a patient, whose rare symptom I had read about but had never encountered myself. This curious case may be of clinical interest to others.
A 37-year-old woman consulted me for vague symptoms of tiredness and mild depression that were not in any way preventing her from working. She was not on any regular medication and had no medical history. Detailed history and physical examination were unremarkable and a few routine blood tests were arranged.
Making the diagnosis
Surprisingly, her blood tests revealed iron deficiency anaemia: haemoglobin 9.3g/dl, haematocrit 0.29 (0.37-0.47), MCV 66.8fl/l (76-100), MCH 21.5pg (27-34), MCHC 32.2g/dl (30-36.9), platelets 434x109/L. Fasting blood sugar, TFTs, calcium, LFTs, urea and electrolytes were all normal. The patient needed iron therapy. Before starting her on oral iron, I investigated her dietary history in detail to see if she was losing blood in any form.
I was looking for hints to the possible loss of blood and asking her specific questions to ascertain the aetiology and to decide if she needed any further tests. These questions were met with negative answers.
After a thorough search, I concluded that it was nutritional deficiency and prescribed iron tablets. During the second consultation, following her negative replies to each and every question, with embarrassment and hesitation she asked whether what she had been doing in the past six months would be of any interest to me. She revealed that she was eating about 60 ice cubes every day. She was chewing ice cubes all day and could not control this urge.
She was not, however, waking up during the night to eat ice cubes and was not excessively thirsty. She did not drink excessive amounts of water and had no desire to eat ice cream.
This is a rare symptom known as pagophagia, and it is a form of pica. People eating substances that are not food is a well-known symptom, people might eat clay, chalk etc. Pica associated with pregnancy is well known.
Geophagia (eating clay, soil), xylophagia (wood), hyalophagia (glass) and amylophagia (starch) are well-documented pica. Most sufferers of excessive ice cube eating are thought to be suffering from obsessive-compulsive disorder. However, there is anecdotal evidence in the literature that pagophagia can be a symptom of iron deficiency anaemia. Pagophagia is believed to be the most specific pica to iron deficiency.1
The patient was treated with oral iron, which corrected her iron deficiency anaemia. Her haemoglobin is 13.1g/dl, MCV 81.3fl/l, MCH 27.4pg, haematocrit 0.389 and platelets 260x109/L. She has been treated for two months with oral iron and her habit of eating ice cubes has subsided.
Obviously one wouldn't ask a patient with iron deficiency anaemia if they had the symptom suggestive of pagophagia.
However, if the patient volunteers such a symptom, it is worth checking their FBC and serum iron status before dismissing it as a compulsive disorder.
- Dr Deshpande is a GP in Westhoughton, Lancashire
1 Goldman L, Ausiello DA, Arend W, et al (eds). Cecil Medicine (23rd edition). Philadelphia, Saunders Elsevier, 2008.