Iron Deficiency Anemia, Pica, and Restless Legs Syndrome in a Teenage Girl

occurred at age 12. Since that time, the patient had regular menses without any episodes of heavy bleeding. She was described by her mother as a finicky eater, and her diet consisted in large part of corn, applesauce, and potatoes. She ate approximately 2 ounces of meat each day. Just prior to the clinic visit, the patient had been referred to a neurologist who diagnosed RLS and ropinirole was prescribed. On physical examination, her weight was 47.8 kg (20th percentile) and her height was 152.0 cm (5th percentile). Vital signs were unremarkable. The conjunctivas were pale, and there was angular cheilitis. There was also speech delay. The examination was otherwise normal. The patient was admitted to the hospital for upper endoscopy. Blood was obtained for testing. The hemoglobin was 7.1 g/dL (NL, 11.2-15.5 g/dL) and hematocrit 23.5% (NL, 32.9%-46.2%). The MCV was 57 fL (NL, 78-98 fL), MCH 17.2 pg/cell (NL, 25.8-33.7 pg/cell) and the RDW 17.6 (NL, 10.7-13.9). A peripheral smear showed hypochromia and microcytosis. Her serum iron level was 17 ug/dL (NL, 25-153 ug/dL), iron saturation 3% (NL, 15%50%), TIBC 507 ug/dL (NL, 250-450 ug/dL), transferrin 425 mg/dL (NL, 200-400 mg/dL), and ferritin <1.0 ng/mL (NL 13-300 ng/mL). Esophagogastroduodenoscopy was then performed. Gross and microscopic examination was negative for inflammation, ulceration, mass lesions and Helicobacter pylori gastritis. The patient was started on iron therapy and discharged. After 5 weeks of oral ferrous sulfate therapy (130 mg of elemental iron/day), her hemoglobin and hematocrit corrected to 13.3 g/dL and 39.0%, respectively. With iron therapy, the patient’s pica improved dramatically, decreasing to 3 glasses of crushed ice per day. The A16-year-old Caucasian female was brought to the Pediatric Gastroenterology clinic by her mother for the complaint of anemia. Earlier during the week of the clinic visit, blood tests were performed by the patient’s primary care physician. The hemoglobin was found to be 7.3 gm/dL and the hematocrit was 24.2%. Gastrointestinal bleeding was suspected; however, there was no diarrhea, melena or hematochezia, and stools tested negative for occult blood. Questioning the girl and her mother revealed a history of “eating excessive amounts of ice” and having difficulty sleeping. The patient’s habit of eating ice had gradually increased over the previous 2 years until she consumed an average of 10-15 twelve-ounce glasses of crushed ice each day. It was common for her to empty the automatic ice machine in the family’s refrigerator. Her sleep problems began approximately 2 weeks prior to evaluation when she complained of worsening leg pain, which was relieved with movement. She had similar discomfort in her legs during the daytime, especially when riding in the car to school. For the past 3 years, the girl had experienced similar but milder symptoms that had not interfered with sleep. There was a family history of restless legs syndrome (RLS). The girl’s medical history was significant for mild cerebral palsy, which did not limit ambulation. She had gross motor and speech delays and was in special education classes at school. Menarche had