History

The clinical presentation of pica is highly variable and is associated with the specific nature of the resulting medical conditions and the ingested substances. In poisoning or exposure to infectious agents, the reported symptoms are extremely variable and are related to the type of toxin or infectious agent ingested. Gastrointestinal (GI) tract symptoms may include constipation, chronic or acute abdominal pain that may be diffuse or focused, nausea and vomiting, abdominal distention, and loss of appetite.

Patients may withhold information regarding pica behavior and deny the presence of pica when questioned. This secretiveness frequently interferes with accurate diagnosis and effective treatment. The broad range of complications arising from the various forms of pica and the delay in accurate diagnosis may result in mild–to–life-threatening sequelae.

Physical Examination

The physical findings associated with pica are extremely variable and are related directly to the materials ingested and the subsequent medical consequences. These findings may include the following:

Manifestations of toxic ingestion (eg, lead poisoning)

Manifestations of infection or parasitic infestation

GI manifestations

Dental manifestations

Physical manifestations associated with lead poisoning (the most common poisoning associated with pica) are nonspecific and subtle, and most children with lead poisoning are asymptomatic. These manifestations can include neurologic symptoms (eg, irritability, lethargy, ataxia, incoordination, headache, cranial nerve paralysis, papilledema, encephalopathy, seizures, coma, or death) and GI tract symptoms (eg, constipation, abdominal pain, colic, vomiting, anorexia, or diarrhea).

Toxocariasis (including visceral larva migrans and ocular larva migrans) and ascariasis are the most common soil-borne parasitic infections associated with pica. Manifestations of toxocariasis are diverse and appear to be related to the number of larvae ingested and the organs to which the larvae migrate. Physical findings associated with visceral larva migrans may include fever, hepatomegaly, malaise, coughing, myocarditis, and encephalitis. Ocular larva migrans can result in retinal lesions and loss of vision.

GI tract manifestations may be evident secondary to mechanical bowel problems, constipation, ulcerations, perforations, and intestinal obstructions caused by bezoar formation and the ingestion of indigestible materials into the GI tract.

Dental abnormalities may be evident on physical examination, including severe tooth abrasion, abfraction, and surface tooth loss. [7, 8]

Complications

Lead toxicity has neurologic, hematologic, endocrine, cardiovascular, and renal effects. Lead encephalopathy is a potentially fatal complication of severe lead poisoning, presenting with headache, vomiting, seizures, coma, and respiratory arrest.

Ingestion of high doses of lead can cause significant intellectual impairment and behavioral and learning problems. It has been demonstrated that neuropsychologic dysfunction and deficits in neurologic development can result from very low lead levels, even levels once considered safe. A hypochromic microcytic anemia resembling iron deficiency anemia can also be seen with lead toxicity; lead interferes with heme synthesis, beginning at blood lead concentrations of about 25 µg/dL.

GI tract complications associated with pica range from mild (eg, constipation) to life threatening (eg, hemorrhages secondary to perforations or ulcerations).

Various infections and parasitic infestations, ranging from mild to severe, are associated with the ingestion of infectious agents via contaminated substances, such as feces or dirt. In particular, geophagia has been associated with soil-borne parasitic infections, such as toxocariasis, toxoplasmosis, and trichuriasis.

Nutritional effects may also be evident. Theories regarding the direct nutritional effects of pica are related to characteristics of specific ingested materials that either displace normal dietary intake or interfere with the absorption of necessary nutritional substances. Nutritional effects that have been linked to severe cases of pica include iron and zinc deficiency syndromes; however, the data are only suggestive, and there is no firm empiric evidence to support these theories. [9]

A meta-analysis of 43 studies including 6,407 individuals with pica behaviors and 10,277 controls found pica to be associated with 2.35 greater odds of anemia and low hemoglobin (Hb), hematocrit (Hct), or plasma zinc (Zn) concentrations. [10]