Eur J Pediatr (2007) 166:623–624
DOI 10.1007/s00431-006-0282-1
SHORT REPORT
Pitfalls in the approach to pica
Maria Fotoulaki & Paraskevi Panagopoulou &
Ioannis Efstratiou & Sanda Nousia-Arvanitakis
Received: 4 July 2006 / Accepted: 27 July 2006 / Published online: 29 September 2006
# Springer-Verlag 2006
Keywords Celiac disease . Obsessive-compulsive disorder
(OCD) . Persistent iron deficiency anaemia
We report here a case of pica with the aim of illustrating
how a common gastrointestinal problem may be masked
and treated as a psychiatric condition.
A 12-year-old male was referred to our hospital for
anorexia, nausea, vomiting, stool discoloration and weight
loss. At 2.5 years of age, he manifested persistent iron
deficiency anaemia. At 4 years, he started eating paper and
was referred for psychiatric evaluation and follow-up. Six
months prior to admission, he underwent psychotherapy.
Upon admission, his weight, height and head circumfer-
ence were 33 kg (5–10th%), 147 cm (25th%), and 53 cm
(75th–95th%), respectively. He had pallor, mild finger
clubbing and dry skin. The liver, spleen and other organ
masses were not palpable.
M. Fotoulaki : P. Panagopoulou : S. Nousia-Arvanitakis
Department of Pediatrics, Medical School,
Aristotle University of Thessaloniki,
Thessaloniki, Greece
I. Efstratiou
Pathology Laboratory, Papageorgiou General Hospital,
Thessaloniki, Greece
M. Fotoulaki (*)
41 Alexandrou Michailidi,
54641 Thessaloniki, Greece
e-mail: mfotoul@otenet.gr
Emergency child-psychiatric evaluation advised treat-
ment of his anaemia and psychiatric monitoring. Small
quantities of paper were permitted as the symptoms on
admission were attributed to the abrupt cessation of paper
eating. Iron supplementation was started. The results of
laboratory tests included the following abnormal measure-
ments: haemoglobin (Hb), 10 gr/dl; mean corpuscular
volume (MCV), 62.8 fl; Fe,12 mg/dl; ferritin, 2.03 ng/ml;
folic acid, 2.2 ng/ml; reticulocytes, 1.75%; positive faecal
haemoglobin; a bone age of 8 years. Mercury and Pb levels
were normal (to rule out poisoning from the paper
additives).
Persistent anaemia and delayed bone age prompted
celiac disease evaluation. Subsequent tests revealed that
the level of IgA anti-gliadin antibodies was 126.6 IU
(normal: <20) and that of tissue tranglutaminase antibodies,
111.8 IU (normal: <20); the patient tested positive for
endomycial antibodies. Jejunal biopsy confirmed celiac
disease. After a gluten-free diet was initiated, paper eating
stopped promptly.
Twelve months later, his weight had reached the 50th%,
the anaemia had resolved (Hb=12.6 g/dl, MCV=73 fl) and
the antibody titres were normal. The gluten-free diet alone
had cured the boy_s pica (Fig. 1).
Pica is an obsessive-compulsive disorder [4] and may be
the presenting feature of celiac disease [1–3, 5]. In this
case, pica was treated as a psychiatric condition for a period
of 8 years before the correct diagnosis of celiac disease was
made. This report emphasizes the need to exclude organic
causes of pica before psychiatric therapy.
624 Eur J Pediatr (2007) 166:623–624

Fig. 1 Growth curve showing

the drastic change in growth of
the patient following initiation
of the gluten-free diet

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