A recently published report describes the case of a 50-year-old female patient with a nontraditional presentation of pica who was diagnosed with primary biliary cholangitis (PBC) with portal hypertension confounded by esophageal varices and iron deficiency anemia (IDA).

The patient, whose past medical history was unremarkable, presented to the emergency room complaining of worsening fatigue and shortness of breath of 2 months duration. At a routine follow-up visit at the clinic a month prior, she reported consuming at least 2 bags of unpeeled lemons per day.

Physical examination revealed the patient was tachycardic, displayed severe pallor, and had mild scleral jaundice. Esophagogastroduodenoscopy (EGD) revealed the patient had multiple esophageal varices as well as a large column of red spots, however, no active bleeding was observed. “Her labs suggested iron deficiency anemia, elevated liver enzymes and positive antimitochondrial antibody titer,” the study authors stated. Mild scarring was also observed via abdominal ultrasound and CT scan.

The patient was diagnosed with “primary biliary cholangitis with portal hypertension complicated by esophageal varices and IDA.” The study authors stated, “The presence of bleeding esophageal varices due to portal hypertension is a common cause of IDA in PBC.”

Treatment was initiated and included banding of the esophageal varices, transfusion with packed red cells, ursodeoxycholic acid, and supplementation with oral iron. Within 1 week of treatment initiation, the patient reported resolution of her cravings for lemons, shortness of breath, and fatigue.

Pica, an abnormal craving for nutritive or non-nutritive substances, is commonly caused by IDA. This case highlights an unusual presentation of pica based on the patient’s craving. To date, only 1 other pica case for unpeeled lemons has been reported. “The abnormal craving is not always for a strange article, this case hopes to shed light on a craving for ordinary food associated with iron deficiency,” the study authors emphasized.

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This article originally appeared on MPR