Case report of sideroblastic anemia caused by ingestion of coins

This is a report of a 54-year-old schizophrenic patient with a 15-year history of ingesting metal objects (pica). He presented with severe anemia (hemoglobin of 3 g/dl and hematocrit of 8.3%) and leukopenia (white blood count of 1,300/mm3). Work-up revealed copper deficiency (copper level of <0.05 microg/ml) and elevated zinc levels (280 microg/ml). The zinc toxicity was produced by the zinc content in the coins ingested by the patient over a period of many years. He was initially treated with -acetylcysteine and sodium bicarbonate followed by intravenous copper sulfate. He was also placed on Adolph's meat tenderizer and pancreatin thrice a day orally to loosen the massive amount of metallic objects including coins in his bowel and allow them to pass out in his feces. He was also continued on oral copper sulfate. His copper levels began to rise and reached a maximum of 0.72 microg/ml, and his zinc level fell to 153 microg/ml. However, as he refused surgery to remove the metal objects from his bowel and continued to ingest more coins, there was continued absorption of zinc, which later overcame the efforts to reduce the zinc level and increase copper levels in his blood. He finally succumbed to sepsis and multiorgan failure. Autopsy revealed a coin mass in the stomach weighing 1,870 grams in addition to a sigmoid volvulus caused by another coin bezoar in the colon.