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A Review of the Forensic Implications of Pica

Article in Journal of Forensic Sciences June 2014

DOI: 10.1111/1556-4029.12520

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 J Forensic Sci, 2014
doi: 10.1111/1556-4029.12520
CASE REPORT Available online at: onlinelibrary.wiley.com

PATHOLOGY/BIOLOGY

Roger W. Byard,1,2 M.B.B.S., M.D.

A Review of the Forensic Implications of Pica

ABSTRACT: Pica is characterized by the persistent eating of non-nutritive substances over some time that is inappropriate for the maturation
stage of the individual and is not culturally sanctioned. A 9-year-old boy with Goldenhar syndrome, significant developmental delay and pica,
collapsed and died after a short history of diarrhea and vomiting. Death was due to a sigmoid volvulus resulting from filling of the distal colon
with feces containing dirt, stones, and rice with evidence of ischemic intestinal necrosis. Lethal complications of pica include intestinal obstruc-
tion and perforation with peritonitis and generalized sepsis. Other findings at autopsy may include airway obstruction, heavy metal poisoning,
and parasitic infestation. Presenting symptoms and signs of such complications may be subtle or masked given the nature of underlying condi-
tions, and so careful evaluation of the medical histories of individuals with pica may be necessary to provide pertinent details of associated
medical and psychiatric conditions.

KEYWORDS: forensic science, pica, developmental delay, sudden death, intestinal obstruction, perforation, Goldenhar syndrome

Pica, an eating disorder first documented by Hippocrates in
the fourth century BC, refers to the compulsive ingestion of non-
food material over a period of time (1,2). The name derives from
the Latin for magpie (pica pica), a bird that collects and/or
ingests a wide variety of objects. Pica was described in the med-
ical literature of the sixteenth century as an unnatural appetite
that gave rise to a desire for hurtful thinges, such as coles,
erthe, salt and other suche, and eighteenth century names for
affected individuals included: wax-nibblers, trash-eaters, chalk
lickers, and gravel diggers (3). Pica may include lithophagia
(stone eating), geophagia (dirt eating), and trichophagia (hair eat-
ing). Despite recognition of this condition for centuries, the etiol-
ogy remains uncertain and little has been written on the lethal or
potentially lethal manifestations. In the following study, a case
of pica that resulted in the death of a young boy with Goldenhar
syndrome is described, and a review is undertaken of the possi-
ble lethal effects that compulsive ingestion may have.
Case Report
A 9-year-old boy with a diagnosis of Goldenhar syndrome
and significant developmental delay collapsed and died after a
short history of diarrhea and vomiting. He had been born at
38-week gestation by normal vaginal delivery with an uncompli-
cated pregnancy. His neonatal period was complicated by apnea
and seizures, and examination revealed a cleft palate, a mal-
formed left pinna, mild left hemi-facial microsomia, vertebral
anomalies (specifically, a hemivertebra at T3 with mild cervico-
thoracic scoliosis convex to the right), left partial facial palsy, an
1 syndrome, is a rare congenital disorder of unknown etiology that
The University of Adelaide Medical School, Frome Road, Adelaide, SA
5005, Australia.
2
Forensic Science SA, 21 Divett Place, Adelaide, SA 5000, Australia.
Received 26 April 2013; and in revised form 4 Aug. 2013; accepted 8
Sept. 2013.
atrial septal defect, and possibly bilateral deafness. A diagnosis
of Goldenhar syndrome was made. Cytogenetic studies were
unremarkable. Subsequently, he demonstrated significant devel-
opmental delay and engaged in pica, particularly eating dirt.
At autopsy, in addition to features of Goldenhar syndrome,
there was evidence of pica with numerous fecal masses contain-
ing soil and mineral material. Specifically, on opening the perito-
neal cavity, the intestines protruded markedly from the incision
(Fig 1). Closer examination revealed dilated intestines (Fig 2)
with a plum-colored sigmoid volvulus where the sigmoid colon
had twisted around the mesenteric root (Fig 3). The large intes-
tine was filled with dark green fluid feces that contained
uncooked rice and large amounts of dark sand. Formed feces
consisted of an amalgam of feces, dirt, uncooked rice, and stone
(Fig 4). The mucosa of the sigmoid colon was necrotic with
dark red discoloration and ulceration (Fig 5). The small intestine
proximally demonstrated light green/pale mucoid feces and dis-
tally was packed with rice grains. Histologically, the sigmoid
colon demonstrated transmural necrosis with an early acute inter-
stitial inflammatory infiltrate.
Death was due to a sigmoid volvulus resulting from filling of
the distal colon with feces containing dirt, stones, and rice with
evidence of ischemic intestinal necrosis, complicating Goldenhar
syndrome. There were no other underlying organic diseases pres-
ent, which could have caused or contributed to death. There was
no evidence of trauma. Subsequently, it was determined that he
had access to soil, stone, and uncooked rice in a playing area.
Discussion
Goldenhar syndrome, also known as occulo-auriculo-vertebral
is characterized by incomplete development of the ear, nose, soft
palate, and oral structures. Developmental delay may occur
(4,5). Pica is a complex disorder that is made up of a range of
conditions related to a variety of predisposing factors (2). It is

2014 American Academy of Forensic Sciences 1

2 JOURNAL OF FORENSIC SCIENCES

FIG. 1Bulging of a discolored and dilated segment of sigmoid colon

through the autopsy incision.

FIG. 3Sigmoid volvulus with twisting of the sigmoid colon on the discol-
ored mesenteric attachment.

FIG. 2Opened peritoneal cavity revealing marked dilation of the sigmoid

colon with less severe proximal small intestinal dilation.

defined by the American Psychiatric Association as the persistent

eating of non-nutritive substances for a period of at least a
month with the eating behavior being inappropriate for the
developmental level of the affected individual and not culturally
sanctioned. It is found in children with developmental disorders
and in pregnant women (6). There is a strong association with
autism, with pica being found in 60% of 70 autistic patients,
compared to only 4% of a control group of 70 Down syndrome
patients (7). Pica was also found in 26% of patients in one study
of 991 institutionalized individuals, with nonfood pica occurring
in 17% (8), although it has been suggested that this high rate
was due to a fairly loose definition used by the authors (9).
Fronto-temporal atrophy has been found in some adult patients
(10). The incidence decreases with increasing age and IQ (11).
The exact etiology of pica is unclear although animal studies
have linked this behavior to dietary deficiencies and stress (7).
Clay eating that has been observed in Africa has been attributed
to iron deficiency derived from malnutrition and parasitic infes-
tation (3,8). However, while there has been an association pro-
FIG. 4Formed feces from the colon containing a mixture of dirt, stones,
and uncooked rice.
posed between pica and iron deficiency anemia, it is unclear
whether the anemia results in pica, or whether pica causes ane-
mia because of iron chelation or the displacement of other nutri-
ents by the ingested material (1,12,13). Pagophagia, the
compulsive eating of ice has particularly been associated with
iron deficiency anemia (8), and zinc deficiency and delayed
growth have been associated with pica in a group of Chinese
children (1).
Geophagia has been reported among 57% of Afro-American
women in rural Holmes County, Mississippi, in the Southern

FIG. 5Dark red discoloration and ulceration of the necrotic mucosa of
the dilated sigmoid colon.
United States, involving the consumption of c. 50 gm of clay a
day. This activity was related to deeply embedded cultural con-
ditions and attitudes and was not correlated with hunger, ane-
mia, or helminth infestations (1). Rarely, clay has been used as a
bulking agent to supplement poor diets, as occurred among Aus-
trian miners in the last century who used earth, mountain tal-
low, as a substitute for butter (1).
The type of substances that are ingested tends to vary with
age, with adults eating dirt or clay, children eating sand, gravel,
animal droppings or leaves, and infants and young children eat-
ing paint flakes, hair, cloth, string, and plaster (6). In a study of
56 developmentally delayed individuals in a state institution who
engaged in pica, the objects/materials ingested consisted of
clothes (30.5%), floor dust or fluff (16.6%), toys (10.1%), paper
(8.3%), grass (5.5%), metal, plastic or concrete (4.6%), cigarettes
and cigarette butts (4.6%), string (4%), buttons (4%), wood
(2.7%), hair (2.7%), soil (2.7%), and straw, wire, and feces
(2.7%) (11). Cautopyreiophagia refers to the eating of burnt
matches and amylophagia to the eating of laundry starch (14).
Pica in adults may be a feature of schizophrenia and schizoaf-
fective disorders and may involve the ingestion of a variety of
quite bizarre materials (15). For example, a 75-year-old woman
with a 40-year history of schizophrenia and a 20-year history of
pica had 175.32 of loose change surgically removed from her
stomach (10). Coprophagia, or the compulsive eating of feces,
has been associated with a lethal outcome due to airway obstruc-
tion (16), with affected individuals usually being older adults
suffering dementia and significant cognitive impairment (15).
Rarely, however, such behavior may occur in younger individu-
als with normal intelligence (17).
While pica has been regarded by some researchers as harmless
(14), nonfood pica has been associated with more severe side
effects due to the inability to digest much of the ingested mate-
rial (9). For example, in a study of 35 patients with developmen-
tal delay and pica, 75% of the pica episodes required surgery,
with a 30% complication rate and a mortality of 11% (18). A
variety of lethal mechanisms have been identified at autopsy fol-
lowing ingestion of foreign material that includes airway
obstruction, hemorrhage and tamponade from vessel and heart
perforation, and sepsis (1921). The rapidity of death following
so-called caf
e coronary syndrome also suggests that vagal
stimulation with resultant cardiac arrhythmia may occur in some
cases (22). Intestinal causes of unexpected death include perfora-
tion by foreign objects, as in the case of a 7-year-old boy with
BYARD . PICA 3
TABLE 1Reported associations/complications of pica that should be con-
sidered at autopsy.
Intestinal obstruction
Luminal obstruction
Volvulus
Stercoral ulceration
Sepsis
Intestinal perforation
Peritonitis/sepsis
Airway obstruction/choking
Poisoning
Lead
Mercury
Nicotine
Phosphorus
Infections
Parasitic
Electrolyte disturbances
Hyperkalemia
Hypokalemia
Trace metal deficiencies
Iron
Zinc
Hemolytic anemia
Dental injury
an ingested wood screw that lodged in the retroperitoneal space
(23), or intestinal obstruction, demonstrated by the volvulus in
the reported case that was associated with packing of the intes-
tines with feces containing gravel, dirt, and rice. Large amounts
of fecal material in developmentally retarded individuals can
result in twisting of a filled intestine causing volvulus, with
sometimes quite rapid death. It is also well recognized that cer-
tain children, in particular those with developmental disabilities,
may not manifest symptoms of intestinal obstruction until termi-
nal collapse occurs.
Intestinal obstruction may also be caused by bezoars from
ingestion of hair or from paper. It is thought that accumulation
of paper with absorption of fluid in the colon may result in
impacted hard-dried stool that then causes complete obstruction
(24). Matted hair in bezoars may extend all the way from the
stomach to the colon in Rapunzel syndrome (23). It should be
noted that the finding of foreign material within the aerodiges-
tive tract of children at autopsy does not always indicate pica, as
infants may have been fed material, either deliberately or inad-
vertently (25).
Other uncommon findings that have occurred in individuals
with pica include lead poisoning from eating paint flakes, mer-
cury poisoning from tissue box and cigarette packages, nicotine
poisoning from cigarettes and cigarette butts, hemolytic anemia
from mothballs and toilet bowl fresheners, and electrolyte distur-
bances from clay (7,26). Phosphorus poisoning and dental dam-
age may also occur (27). Toxocara infections in children have
been associated with pica involving ingestion of feces, soil, or
grass (28) (Table 1). Aggressive periodontitis was reported in
one young woman with a long history of dirt eating (29).
Polyphagia should be differentiated from pica as this refers to
an eating disorder where there is excessive hunger and/or inges-
tion of food, although on occasion pica may be associated with
polyphagia and other eating disorders such as anorexia nervosa
(30,31). Polyphagia may occur in conditions such as Prader-Willi
syndrome where death has been reported from gastric rupture
and necrosis due to over-ingestion or to choking associated with
voracious eating habits (32,33). Gastric rupture may also occur
in developmentally delayed individuals associated with air
swallowing and marked gastric distention (34). Other lethal
4 JOURNAL OF FORENSIC SCIENCES
mechanisms may be similar to individuals with pica and include
sepsis from intestinal perforation (35). Ingested material may
also be quite bizarre; for example, Redpath and Sauvageau
reported a 39-year-old woman with bipolar disease who asphyxi-
ated after disembowelling and eating her pet cat due to impac-
tion of feline organs in the upper aerodigestive tract (36).
In summary, this study demonstrates the wide range of lethal
mechanisms that may cause death in individuals with pica. If
pica is suspected in those with developmental delay or in those
who have been institutionalized, autopsy examinations should
carefully check for the potential side effects of foreign material
ingestion that may range from upper airway obstruction to intes-
tinal obstruction and sepsis (Table 1). Unfortunately, presenting
symptoms and signs may be minimal, as in the reported case,
due to problems in communication, or nonspecific consisting of
prolonged constipation, vomiting abdominal distention, and fever
(18). Evaluation of medical histories for evidence of pica may
be a useful guide to the autopsy examination and may also pro-
vide pertinent details of associated medical and psychiatric con-
ditions.
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Additional information and reprint requests:
Prof Roger W. Byard, M.B.B.S., M.D.
Discipline of Anatomy and Pathology
Level 3 Medical School North Building
The University of Adelaide
Frome Road
Adelaide, SA 5005
Australia
E-mail: roger.byard@sa.gov.au