Correspondence

“Tomatophagia” and Iron-Deficiency Anemia

N Engl J Med 1999; 341:60-61July 1, 1999

Article

To the Editor:

Pica, the craving for unusual foodstuffs or nonfood substances, is occasionally associated with iron-deficiency anemia.1,2 Pagophagia, or the craving for ice, is the most common type of pica, although ingestion of starch, clay, dirt, or other inert substances may also occur.3 The craving for various types of food, typically crunchy or salty foods, has been associated with iron-deficiency anemia as well.1 I report here the case of an elderly woman with iron-deficiency anemia in whom a craving for fresh, whole tomatoes developed; the craving disappeared after iron replacement.

A 66-year-old woman with osteoarthritis and gastroesophageal reflux presented with a four-week history of fatigue and exertional dyspnea. She reported no chest pain, orthopnea, nocturnal dyspnea, vaginal bleeding, hematemesis, melena, or hematochezia. She had had excellent exercise tolerance previously and had no history of cardiopulmonary disease. The patient had recently noted a craving for tomatoes and had been ingesting 6 to 10 fresh, whole tomatoes daily over the previous two-month period. She had been taking nonsteroidal antiinflammatory drugs daily for arthritis pain.

The physical examination was normal except for carotenemia. A complete blood count revealed a hemoglobin level of 5.3 g per deciliter, a hematocrit of 19 percent, a platelet count of 450,000 cells per cubic millimeter, and a normal white-cell count. The mean corpuscular volume was 66 fl and the peripheral-blood smear revealed hypochromic, microcytic red cells, a finding consistent with iron deficiency. Values for creatinine, lactate dehydrogenase, bilirubin, and haptoglobin were normal. The level of serum iron was 8 μg per deciliter (normal range, 25 to 170 μg per deciliter), and total iron-binding capacity was 498 μg per deciliter (normal range, 200 to 450 μg per deciliter). Esophagogastroduodenoscopy revealed ulcerative esophagitis and gastric antral erosions.

Two units of packed red cells were administered. The patient was discharged, receiving oral ferrous sulfate and omeprazole, and was cautioned to avoid nonsteroidal antiinflammatory drugs. Approximately eight weeks later, the patient felt well and no longer craved tomatoes. Repeated testing revealed a hemoglobin level of 11.7 g per deciliter, a hematocrit of 36 percent, and a mean corpuscular volume of 78 fl.

Pica occurs in up to 58 percent of patients with iron-deficiency anemia, and in the vast majority of cases, it is manifested as pagophagia.4,5 Pagophagia accounted for 88 percent of cases of pica in a series of patients with iron-deficiency anemia.5 The ingestion of non-nutritive substances such as clay, dirt, or starch may also occur, especially in children.3 Patients with food pica typically ingest large amounts of crunchy food such as celery, carrots, peanuts, seeds, crackers, and pretzels.1,4

My patient ingested several whole tomatoes daily over a two-month period, which led to carotenemia. After several weeks of iron replacement and resolution of the anemia, the craving for tomatoes disappeared — a result that is diagnostic of pica.1,4 Clinicians should consider the diagnosis of iron-deficiency anemia in any patient with excessive tomato ingestion, or if carotenemia is noted on physical examination, they should inquire specifically about “tomatophagia.”

Mark A. Marinella, M.D.
Wright State University School of Medicine, Dayton, OH 45429

5 References

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   Crosby WH. Pica. JAMA 1976;235:2765-2765
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   Case Records of the Massachusetts General Hospital (Case 37-1998). N Engl J Med 1998;339:1766-1772
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3. 3

   Reynolds RD, Binder HJ, Miller MB, Chang WW, Horan S. Pagophagia and iron deficiency anemia. Ann Intern Med 1968;69:435-440
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   Crosby WH. Food pica and iron deficiency. Arch Intern Med 1971;127:960-961
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   Rector WG Jr. Pica: its frequency and significance in patients with iron-deficiency anemia due to chronic gastrointestinal blood loss. J Gen Intern Med 1989;4:512-513
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Citing Articles (6)

Citing Articles

1. 1

   Grigoris Chatzimavroudis, Petros Christopoulos, Stefanos Atmatzidis, George Papadakis, Panagiota Nalbanti, Basilis Papaziogas, Ioannis Koutelidakis, Konstantinos Atmatzidis. (2011) Pica: An Uncommon Cause of Acute Abdominal Pain in Children. The Indian Journal of Pediatrics 78:7, 886-887
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2. 2

   Mark A. Marinella. (2008) Paraneoplastic Salt Dysgeusia. Southern Medical Journal 101:12, 1275-1276
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3. 3

   Mark A. Marinella. (2008) Anemia Following Roux-en-Y Surgery for Morbid Obesity: A Review. Southern Medical Journal 101:10, 1024-1031
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4. 4

   Mark A. Marinella. (2008) Nocturnal Pagophagia Complicating Gastric Bypass. Mayo Clinic Proceedings 83:8, 961
   CrossRef

5. 5

   M. A. Marinella. (2008) Nocturnal Pagophagia Complicating Gastric Bypass. Mayo Clinic Proceedings 83:8, 961-961
   CrossRef

6. 6

   Satheesh K. Kathula. (2008) Craving Lemons: Another Form of Pica in Iron Deficiency. The American Journal of Medicine 121:7, e1
   CrossRef