Diagnosis dilemma: a woman continued to taste bleach – and the doctor found a hidden cause in her blood

Patient: A 36-year-old woman from Michigan

Symptoms: The woman went to the emergency department after experiencing shortness of breath, abdominal pain and fatigue for about a day. She had a complex history of illnesses including obesity, sleep apnea, vitamin defects, anxiety, depression, and mental illnesses such as post-traumatic stress disorder (PTSD).

Two times before, she was hospitalized for a psychiatric episode. However, recently she was undergoing treatment — daily antidepressants and monthly long-acting antipsychotic injections — seem to keep further episodes at bay.

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What happened next: The patient was being given oxygen on his way to the hospital. While there, the doctor stabilized her with multiple blood transfusions after the lab test pointed to anemia. There, there are too few healthy red blood cells for the body to carry oxygen to the body.

Her blood was low in hemoglobin and platelet levels, each of which helped carry oxygen and form blood clots. Her heart also shows signs of x-ray expansion, indicating that it compensates for the blood’s ability to carry insufficient oxygen.

Because these nutrients are essential for the formation of red blood cells, doctors tested the levels of iron and folic acid in patients’ blood. Although the results of these tests were normal, the levels of vitamin B12, a micronutrient important for red blood cell formation, were dangerously low. Subsequent tests revealed that she carried antibodies that prevented B12 absorption.

Diagnosis: These findings were consistent with harmful anemia, a condition in which the body’s immune system attacks the gastric cells needed to absorb vitamin B12. Without sufficient B12, the body is unable to produce healthy red blood cells, and long-term deficiency can cause cognitive and behavioral changes, such as mood disorders and, in some reports, psychosis.

Given the patient’s mental history, the emergency room doctor consulted the psychiatry team after she was stable. At that point, she reported that she had tasted powdered household bleach two or three times a day for over a month, due to her being attracted to its sharp smell and rough texture. She licked her fingers, soaked the tip in the powder, put it in her mouth, spit it out, spit it out and rinsed it, and she denied swallowing it.

Her family was worried, she said, but she “wasn’t worried or annoyed by her behavior,” her doctor said in the report.

Behavior pointed to PICA, a disorder in which people forced to eat and taste non-food substances such as dirt, ice, and starch. In this case, her B12 deficiency appeared to be at the root of both blood disorders and behavioral changes, and obsessiveness was associated with anemia in the patient.

Treatment: Instant care of patients focused on intensive monitoring and blood transfusions to stabilize vital signs, restore blood levels and relieve heart strain. When deemed stable and suitable for discharge, she was prescribed vitamin B12 supplements and medications to reduce stomach acid. She also agreed to have an endoscopy at the outpatient clinic and to check for gastritis or inflammation of the lining of the stomach.

Harmful anemia “requires lifelong vitamin B12 supplementation, reverses deficiency and relieves corresponding psychiatric symptoms,” doctors said in the report. However, after leaving the hospital, the patient did not return for follow-up, so doctors don’t know if she continued treatment or if her symptoms were resolved.

What makes the case unique is that in other cases, pika is often, but not always, linked to defects in vitamins and nutrients, especially iron and zinc. In this case, the behavior is derived from severe vitamin B12 deficiency. The clinician called it “the first of its kind and remarkable for the anemia underlying B12 deficiency.”

The report also noted that patient presentations focused attention on a rare and recently identified variant of PICA called desideosmia.

This case is a reminder that psychiatry and medicine need to be evaluated against each other in order to provide holistic care for patients. Her psychiatric history may have easily been dismissed as a patient’s craving for bleach only having psychological causes, the authors argued.

This case highlights how such behavioral changes should encourage careful medical evaluation along with psychiatric consultation. Because they could be the first clue to a hidden, life-threatening illness, doctors concluded.