![]() Computed tomography of head and electroencephalogram were normal. She had normal renal function and no anion gap. Vitamin B12, folate, cortisol, and thyroid-stimulating hormone (TSH) were all normal. Her laboratory tests revealed a hemoglobin of 9.2 grams/deciliter and mean corpuscular volume (MCV) of 75 femtolitres. Iron deficiency with pica was considered, and an iron panel revealed: iron level 9 micrograms/deciliter (normal value 60-160 micrograms/deciliter), transferrin saturation 2% (normal value 20-50%), iron binding capacity 377 micrograms/deciliter (normal value 250-460 micrograms/deciliter), and ferritin level 4.8 nanograms/milliliter (normal value 15-200 nanograms/milliliter). She had no abdominal tenderness, palpable organomegaly, or any neurologic deficits. Chest was clear with normal heart sounds, no murmur or gallop. She had mild pale conjunctiva and non-icteric sclera. On physical examination, the patient was alert and oriented vital signs were normal. The patient also mentioned she had abnormal uterine bleeding for which she was treated by a gynecologist. She had no history of similar craving and chewing of ice in the past and denied any current stress or psychiatric illness. She stated she was craving and chewing multiple bags of ice, which was unusual for her. Upon further evaluation and lab reviews for anemia, the patient was asked if she was eating too much ice. In our hospital, she was admitted to the MICU with possible psychogenic polydipsia, her laboratory test revealed serum sodium 128 mmol/L, serum osmolality 254 mOsm/kg, urine sodium 11 mmol/L and urine osmolality of 100 mOsm/kg. She was placed on normal saline, her serum osmolality and sodium were gradually corrected, and the patient was transferred to our medical center for high level of care. Psychogenic polydipsia was considered and desmopressin was discontinued at outside hospital, but the patient stated she was not drinking too much water and her water intake was 3-4 Liter/day. Based on her outpatient laboratory results, diabetes insipidus seemed unlikely. Her outpatient osmolality was always 260-280 mOsm/kg, she also had mild hyponatremia (133-136 mmol/L), urine sodium 14 mmol/L and urine osmolality of 110 mOsm/kg. Her endocrinologist did not find the exact cause for her symptoms, and empirically the patient was started on desmopressin for polyuria. She was investigated for possible causes of polyuria by her primary care physician and finally referred to an endocrinologist. Her serum sodium was as low as 120 millimoles/litre (mmol/L), serum osmolality 242 milliosmoles/kilogram (mOsm/kg), urine sodium 9 mmol/L and urine osmolality of 70 mOsm/kg. Prior to that hospital admission, the patient was complaining of excessive and frequent urination for several months. On presentation to the outside hospital, she was weak and had a generalized tonic clonic seizure. Ī 54-year-old Caucasian woman was transferred to our MICU from an outside hospital due to altered mental status, seizures, and hyponatremia. Studies have indicated most physicians are unaware of pica and most cases are missed. Ice pica leading to hyponatremia and seizures is rare in clinical practice, and to our knowledge from literature review, prevalence is unknown. We report a case of a patient admitted to medical intensive care unit (MICU) due to severe hyponatremia and seizure, who was found to have iron deficiency-associated pagophagia as the underlying cause. ![]() Pagophagia can have significant health risks, including electrolyte abnormalities and metabolic disorders. The reasons why these patients crave ice is unclear, but some studies have indicated that chewing ice might increase alertness in people with iron deficiency anemia. Less commonly, other nutritional disorders may cause craving and chewing ice. ![]() Pagophagia (craving and chewing ice) is the excessive consumption of ice cubes or iced drinks it is often associated with iron deficiency with or without anemia. Pica was referenced by the Greeks and Romans in 13th-century but was not addressed in medical texts until 1563. The term pica originates from the Latin word for magpie (Picave), a bird that is famed for its unusual eating behaviors, mainly it is known to eat almost anything. Pica is described as an unusual condition in which patients crave and chew substances (such as ice, clay, soil, dirt, raw rice, or paper) that have no nutritive value. ![]()
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