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Unusual presentation of pica in iron-deficiency anaemia associated with primary biliary cholangitis
  1. Nneoma Kate-Joan Onuorah1,
  2. Melinda Wayde2 and
  3. Gregory Beck2
  1. 1 Internal Medicine, Wright State University, Dayton, Ohio, USA
  2. 2 Gastroenterology, Wright State University, Dayton, Ohio, USA
  1. Correspondence to Dr Nneoma Kate-Joan Onuorah, nnomikay{at}


A 50-year-old woman presented with worsening fatigue and shortness of breath. For 2 months, she has been having increased craving for unpeeled lemons and was seen in clinic about a month prior to presentation at the emergency room. At that time, she was asymptomatic except for endorsing craving for lemons. Physical exam findings at presentation noted obesity, sinus tachycardia, pallor, mild scleral jaundice and no other stigmata for chronic liver disease. Her labs suggested iron-deficiency anaemia (IDA), elevated liver enzymes and positive antimitochondrial antibody titre. Abdominal ultrasound and CT scan showed mild scarring. She was diagnosed with primary biliary cholangitis with portal hypertension complicated by oesophageal varices and IDA. Interventions included blood transfusion, oesophageal banding and treatment with ursodeoxycholic acid. Her craving for lemons, shortness of breath and fatigue resolved within 1 week. With ongoing outpatient follow-up and oesophageal variceal surveillance, she continues to do well.

  • GI bleeding
  • varices
  • liver disease
  • pancreas and biliary tract

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  • Contributors NK-JO is the corresponding author who drafted the entire case including the literature review and is accountable for all aspects of the work. MW is a co-author who revised it critically for important intellectual content. GB is also a co-author who reviewed the case report and gave the final approval of the version published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Obtained.