Hematology Case: Iron-Deficiency Anemia

Hematology Case:
Iron-Deficiency Anemia
Group E
Jaclyn Millar – Hx questions, Management, Narrator
Jaime Teran-Rocha – Lab Interpretation
Jimmy Misurka – Diagnosis, Pathophysiology
Navin Tajuddin – DDx, Prognosis/Patient Education
Friday June 13, 2014
Hematology Case 2
Overview
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History
Physical Examination
Lab Investigations: results and interpretation
Assessment: DDx and most likely Dx
Management
Prognosis and Patient education
History
67 year old female with shortness of breath on exertion, easy
fatigability, and lack of energy for the past 2 to 3 months.
Denies GI, or vaginal bleeding. Denies hemoptysis. Described a
good diet but variable appetite.
Additional Relevant History
Questions
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Any recent weight loss, fever, or cold intolerance?
Any neurological symptoms?
Do you chew or suck on ice (pagophagia)?
Does anything improve/worsen symptoms?
Social history including alcohol, travel and dietary history
Past medical history including surgical history
Medication use
Family history
Have you recently had tinnitus, anorexia, abdominal pain, indigestion,
change in bowel habits?
• Do you suffer from GERD or peptic ulcer disease?
• Do you have hemorrhoids?
• Have you ever been diagnosed with diverticulitis, IBD or colitis?
Physical Exam
Skin pallor noted. The rest of the physical examination is
unremarkable.
Laboratory Investigations
RBC 3.72 x 1012/L
Hgb 58 g/L
Hct 0.208
MCV 56.1 fL
MCHC 285 g/L
RDW 0.204
WBC 5.8 x 109/L
Neutrophils 82 %
Lymphocytes 13 %
M onocytes 1 %
E osinophils 4 %
B asophils 0 %
Platelets 387 x 109/L
serum ferritin <10 µg/L
serum iron 4.5 µmol/L
TIBC 127.5 µmol/L
transferrin saturation 4 %
Fecal occult blood negative
Blood smear analysis
RBC morphology
1+ anisocytosis
2+ elliptocytes and target cells
2+ hypochromasia
2+ microcytosis
WBC morphology normal
Platelet morphology normal
Interpretation of Lab Results
(Key Findings)
• Patient has a low erythrocyte count, even adjusted for her age. Her Hb level
(5.8 g/dL) and Hct (21%) levels are low enough to explain SOBE
• MCV is small, as well as her Ferritin level is markedly low. These findings are
consistent with ferropenic, microcytic anemia
• Microcytosis (2+), Elliptocytosis (2+) with hypochromasia (2+) are all
suggestive of iron deficiency
• On blood smear, she presents with slight anisocytosis (1+) which is likely
due to her anemia, which is coherent with RDW of 20% (slightly elevated)
• Her Ferritin level is low (<10 ng/ml, normal 12-150 ng/ml), indicating total
amount of iron stores is depleted
• Looking at her low serum iron, increased total iron binding capacity (TIBC)
and low transferrin saturation, all three are consistent with an IronDeficiency Anemia
• WBC shows no leukocytosis and differential does not show any left shift,
therefore infection is unlikely; platelets are within normal range and shape
Differential Diagnosis
with brief explanation of rationale
These are all included as differentials, as all present with chief
complaint of SOBE, easy fatigability and lack of energy
• Iron deficiency anemia due to insufficient diet or malabsorption
– common in elderly and can occur due to malabsorption or
underlying condition
• Hypothyroidism – common in women and elevated TSH can
lead to increased fatigue and lack of energy
• Neoplasm – can cause fatigue, decreased RBCs and changes in
appetite
• Lung Disease or Heart Failure (Class I-II) – both can lead to
presenting symptoms; a past history of smoking, exposure to
environmental toxins or previous myocardial infarction can
strengthen this diagnosis
Most Likely Diagnosis
with brief explanation of rationale
• Iron deficiency anemia is the most likely diagnosis resulting from
insufficient dietary requirements
– Can also result from: hemorrhage or malabsorption
• Since the patient has no signs of bleeding we can exclude causes
from blood loss
• However, malabsorption is unlikely in the absence of small bowel
disease or previous bowel surgery
• Because of this fact, the patient should be worked up to ensure
she does not have:
– Celiac Disease or Regional Enteritis
• GI endoscopy, colonoscopy and possible intestinal biopsy can
help confirm a diagnosis
Pathophysiology
• Iron is essential for multiple metabolic processes
– Oxygen transport
– DNA synthesis
– Electron transport
• There are three separate pathways for iron absorption: (1) for
Heme and (2) distinct pathways for ferric and ferrous iron
• Iron absorption can be affected by 3 different factors:
– Intraluminal, mucosal and corporeal
• Typically, iron concentration is maintained by alteration in
absorption to match losses
• Iron deficient anemia results from insufficient dietary intake in
absorbable form
– However, usually uncommon in the absence of small bowel
disease or previous GI surgery
Management
• Overall: management plan consists of establishing the etiology of the
iron deficiency and correcting it so the deficiency does not recur
• In our patient, treatment with oral iron therapy
– Ferrous sulfate
– Parenteral Iron Therapy – if unable to absorb oral iron
• Dietary measures
– Nutritional counselling with Dietician
• Activity restriction
– Tailored, gradual exercise as per tolerated
• 1-3 month monitoring to assess adequate response to iron therapy
• Management of hemorrhage (unlikely in our patient)
– Surgical treatment to help correct blood loss
Prognosis/Patient Education
• Prognosis: For our patient, iron deficiency anemia caused by
insufficient dietary intake generally has a good prognosis. In the
unlikely chance that her anemia is being caused by an underlying
comorbid condition the prognosis may be worse
• Patient Education:
– What is anemia? – occurs when there is a decrease in the
number of RBCs; iron-deficiency is when there is an insufficient
amount of iron in the body to make hemoglobin
– Signs and symptoms – fatigue, SOBE, weakness
– Dietary sources of iron – meat, green leafy vegetables, ironfortified cereals, enriches breads/grains, dried fruits; increased
absorption when taken with Vitamin C; decreased absorption
when taken with coffee or tea
– Prevention – oral iron supplements in addition to dietary
modification; treatment of underlying cause
References
Anemia Assessment Questionnaire. [Right Diagnosis]. [updated 2014
April 22; cited 2014 June 5]. Available from:
http://www.rightdiagnosis.com/symptoms/anemia/questions.htm
Harper, J. Iron Deficiency Anemia. [Medscape]. [updated 2013 Dec;
cited 2014 June 6]. Available from:
http://emedicine.medscape.com/article/202333overview#aw2aab6b2b6
Maakaron, J. Anemia. [Medscape]. [updated 2013 July 30; cited 2014
June 5]. Available
from:http://emedicine.medscape.com/article/198475-overview
Schrier, S. Patient Information: Anemia caused by low iron (Beyond
the Basics). [UpToDate]. [updated 2013 May; cited 2014 June 10].
Available from:
http://www.uptodate.com.myacess.library.utoronto.ca/contents/anemia
-caused-by-low-iron-beyond-the-basics?source=see_link#H22