Cautopyreiophagia as a Rare Variant of PICA in a Female Adolescent: A Case Report

Dear Sir,

The term pica is derived from the word “pica pica,” and in Latin, it is used for the bird Magpie.¹ DSM-5 defines it as “persistent eating of non- nutritive substances for at least one month, that is inappropriate to the developmental level of an individual and is not a part of culturally supported or socially normative practise.”² The most common form described in the literature is geophagy (earth), followed by amylophagy (raw starch) and pagophagy (ice).³ The consumption of burned matchsticks, which is also known as Cautopyreiophagia, is rarely reported in the existing literature. To date, only two cases have been reported among adults.^4,5 The causative factors for pica range from psychosocial such as parental deprivation, mental problems, or developmental disorder to biochemical, including anemia, low zinc level, and malnutrition.⁶ Here we report a case of Cautopyeriophagia, first from India, in a female adolescent aged 16 years and from the rural area.

Case Report

The patient presented to the gynecology community clinic with complaints of pain in the abdomen and was referred to the psychiatry community clinic. She reported that she has been consuming burned matchsticks for the last 4–5 years. Initially, she would take 1–2 burned matchsticks/day. She likes the taste of the tip of the matchstick, that is, the burned part. Gradually, the amount increased to 10–20 matchsticks/day. If she could not get matchsticks, she would search for them in their neighbor’s home or near the “chulha” (homemade fire stove). Gradually, she started to pick the burned matchsticks from the ground. On occasions of festivals like Diwali, she would gather all the burned matchsticks and firecrackers, which the patient herself found to be distressful. She would have an irresistible desire to eat burned matchsticks and was not able to control it. The patient was aware that burned matchsticks are not good for health. Her grandmother corroborated the history and also reported that the patient had started stealing matchsticks, for which the family members had beaten her up several times. The patient denied symptoms like low mood, a ritualistic pattern of behaviors or thoughts, panic attack, or fear of others.

On examination, she was thin and had dry skin, discoloration of teeth, poor oral hygiene, and pallor. In the rural community clinic, only hemoglobin, liver function test, chest and abdomen x-ray, and ultrasound of the abdomen were possible, on which Hb was found 8.5 gm/dl, BMI was 17.74 (weight 41 kg, height 151 cm), and other investigations were within normal limits. On clinical evaluation, the intelligence quotient appeared to be appropriate to age. The diagnostic possibilities were kept as pica, iron deficiency anemia, and obsessive-compulsive (OC) spectrum disorder. On further exploration, it was found that there was no marked feeling of anxiety or a need to complete ritualistic behavior or thoughts in order to quell the bad feelings or keep them in check. There were no intrusive thoughts or impulses that drove the patient to consume burned matchsticks. Hence, OC disorder was ruled out. We started Tab iron-folic acid, multivitamins, calcium with vitamin D, and tab escitalopram 5 mg/day.

Expressed emotions were identified among the family members in the form of blaming her for the illness, slapping and thrashing her, passing critical comments in the presence of other relatives and neighbors, talking at raised volume, commenting continuously on not following family members’ advice, shouting, etc. The clinician assessed the family members’ knowledge and attitude towards the patient’s illness. In psychoeducation, promotion of positive attitude and behaviors toward the patient was done. Supportive psychotherapy was also started simultaneously. Gradually, expressed emotions decreased significantly, and the family members became more supportive. After two months, she improved significantly and stopped consuming burned matchsticks, Hb improved to 11.0 gm/dl, and she had proper dental hygiene.

Discussion

Pica is a separate diagnostic entity in DSM-5, but it is still under-recognized and ignored by the parents and clinicians. There are only a few case reports of pica, especially from developing countries like India.⁶ In contrast to the previous cases, the present case was an adolescent child. In the previous case reports, the adverse consequences reported were anemia, hemodialysis, liver dysfunction, and hyperbilirubinemia.^4,5 In the present case, the patient had anemia and discoloration of teeth, along with emotional problems. This could be because the previous reports were about adult persons suffering from physical illness along with “cautopyreiophagia.”^4,5 In the present case, pica was associated with anemia; iron deficiency anemia is the most commonly reported cause of pica.⁷ Second, improvement in symptoms with supplementation of nutrition further strengthens the association of nutritional deficiency with pica.

Pica can be a source of a significant amount of embarrassment and criticism. The patient can become a victim of hostility, as highlighted in the index case. For management, a holistic approach is required. A supportive and positive attitude towards the child and parents may help them. Family counselling, supportive sessions, psychoeducation, and supervision of the child are essential.⁸ As we did in the index patient, a clinician should identify the expressed emotions among the family members and emotional problems in the child, and manage accordingly.

With respect to phenomenology and psychobiology, it can be said that pica at times falls or appears in the category OC spectrum disorders. But the presence of atypical eating behavior, absence of marked anxiety and ritualistic thoughts and behaviors, and association with nutritional deficiency make it a separate entity. It can be concluded that a clinician should be aware of atypical variants of pica like cautopyreiophagia, and proactively seek information about the children presenting with nutritional deficiency, emotional problems, or atypical eating behavior. These children should be referred for detailed psychological evaluation so that an effective intervention can be done.