IRON DEFICIENCY ANEMIA

Symptoms of iron deficiency anemia can involve general symptoms of anemia

 Body weakness
 Fatigue
 Palpitation
 Dizziness
However the most specific symptom for iron deficiency anemia is PICA(pagophagia)

Signs of iron deficiency anemia

 Glossitis
 Angular cheilitis
 Angular stomatitis
 Koilonychia

Other cormobidities associatied with iron deficiency anemia

 Plummer vinson syndrome
 Restless leg syndrome

CASES ON IRON DEFECIENCY ANEMIA

Mr. Smith, a 52-year-old male, presents to the clinic with a complaint of persistent fatigue and
weakness over the past several months. He mentions that he used to be an active individual
who enjoyed playing tennis and going for long hikes on weekends. However, he has noticed a
significant decrease in his energy levels and stamina lately, to the point where even routine
tasks feel exhausting.

History:
Upon further inquiry, Mr. Smith reports a gradual onset of symptoms, denying any sudden
illness or trauma. He has experienced increased shortness of breath, especially when climbing
stairs or engaging in physical activity. He admits to occasional headaches and dizziness,
particularly when he stands up quickly. He also recalls a general feeling of "being unwell" and a
slight pallor in his skin.

Medical History:
Mr. Smith has a history of gastroesophageal reflux disease (GERD), which is managed with over-
the-counter antacids as needed. He has no known allergies and takes no prescription
medications. His last routine medical check-up was two years ago, and all his lab results were
within normal limits at that time.
Social History:
He is a non-smoker and drinks alcohol socially, about two drinks per week. He works as a
software engineer and spends most of his day sitting at a desk.

Physical Examination:
On examination, Mr. Smith appears fatigued. His conjunctiva is pale, and his mucous
membranes are dry. Vital signs show a heart rate of 100 bpm and blood pressure of 110/70
mmHg. His lung and cardiac exams are unremarkable. Abdominal examination reveals no
masses or tenderness. There is no edema in the extremities.

Laboratory Results:

Hemoglobin: 8.5 g/dL (normal range: 13.5-17.5 g/dL)

Hematocrit: 27% (normal range: 38.8-50.0%)
Mean Corpuscular Volume (MCV): 60 fL (normal range: 80-100 fL)
Mean Corpuscular Hemoglobin Concentration (MCHC): 32 g/dL (normal range: 32-36 g/dL)
Serum Iron: 20 mcg/dL (normal range: 60-170 mcg/dL)
Total Iron-Binding Capacity (TIBC): 380 mcg/dL (normal range: 240-450 mcg/dL)
Ferritin: 10 ng/mL (normal range: 30-400 ng/mL)

Additional Information:
Further questioning reveals that Mr. Smith's diet is mostly composed of processed and fast
foods due to his busy work schedule. He rarely consumes fruits, vegetables, or red meat. He
reports occasional heartburn, but no overt gastrointestinal bleeding or melena.

a) what is the mostly likely diagnosis and why

b) how will you manage the patient

a) The most likely diagnosis for Mr. Smith's condition is iron deficiency anemia. Iron deficiency
anemia occurs when there is an inadequate supply of iron to support the body's normal red
blood cell production. The clinical presentation and laboratory findings in this case are
consistent with iron deficiency anemia:

Fatigue, weakness, and decreased stamina are common symptoms of anemia due to reduced
oxygen-carrying capacity of the blood.
Shortness of breath, especially during physical activity, is a result of the body's attempt to
compensate for low oxygen levels by increasing respiratory rate.
Headaches and dizziness upon standing quickly (orthostatic hypotension) are related to the
body's inability to deliver sufficient oxygen to the brain.
Pallor of the skin and conjunctiva is indicative of reduced red blood cell concentration and
hemoglobin content.
Laboratory results show a low hemoglobin level (8.5 g/dL) and hematocrit (27%), which are
below the normal ranges. The mean corpuscular volume (MCV) is elevated (60 fL), indicating
microcytic red blood cells, a characteristic feature of iron deficiency anemia. Additionally, the
low serum iron levels (20 mcg/dL), elevated total iron-binding capacity (TIBC) (380 mcg/dL), and
low ferritin levels (10 ng/mL) further support the diagnosis.
Mr. Smith's dietary history, particularly his lack of consumption of iron-rich foods like red meat
and limited intake of fruits and vegetables, combined with his busy work schedule and
occasional heartburn, suggests a potential cause for his iron deficiency. The inadequate intake
of dietary iron and potential gastrointestinal irritation from his diet could lead to reduced iron
absorption and subsequent iron deficiency.

b) Management of Mr. Smith would involve addressing the underlying cause of his iron
deficiency anemia and providing appropriate treatment:

Dietary Modification: Educate Mr. Smith about the importance of incorporating iron-rich foods
into his diet. Encourage him to increase his consumption of lean meats, poultry, fish, beans,
lentils, leafy greens, and fortified cereals to boost his iron intake.
Iron Supplementation: Given the severity of his anemia, iron supplementation may be
necessary. Prescribe an oral iron supplement and provide instructions on how to take it properly
to optimize absorption. It's important to counsel him about potential gastrointestinal side
effects and ways to mitigate them.

Address GERD: Since Mr. Smith has a history of GERD, advise him to manage his symptoms
effectively to minimize any potential gastrointestinal irritation that could further impair iron
absorption. This may involve lifestyle modifications, such as avoiding large meals before
bedtime, elevating the head of the bed, and considering antacid or acid-reducing medications
as needed.

Monitoring and Follow-up: Schedule regular follow-up appointments to monitor Mr. Smith's
progress. Repeat blood tests should be performed to track his hemoglobin, hematocrit, MCV,
serum iron, TIBC, and ferritin levels. Adjust the management plan as needed based on his
response to treatment.

Counseling: Provide education about the importance of balanced nutrition, the impact of iron
deficiency on overall health, and the need for compliance with the treatment plan. Emphasize
the gradual resolution of symptoms as his iron levels improve.

Investigate Underlying Causes: If the response to iron supplementation is inadequate or there

are signs of chronic blood loss, further investigation may be necessary to rule out potential
underlying causes such as gastrointestinal bleeding from sources like peptic ulcers,
inflammatory bowel disease, or malignancy.

HAEMOLYTIC ANEMIA
Triad of haemolytic anemia
 Anemia
 Splenomegaly
 Jaundice

CASE
A 32-year-old male presents to the emergency department with complaints of increasing
fatigue, pale skin, and shortness of breath for the past few weeks. He reports that he has been
feeling generally unwell and has noticed dark-colored urine on several occasions. He denies any
recent illnesses or infections. His medical history is unremarkable, and he is not taking any
medications.

Physical Examination:
Upon examination, the patient appears pale and slightly jaundiced. Vital signs are stable, with a
heart rate of 95 bpm, blood pressure of 120/80 mmHg, and a respiratory rate of 18 breaths per
minute. His conjunctiva are pale, and there is no lymphadenopathy. Examination of the
cardiovascular and respiratory systems is within normal limits. Abdominal examination reveals
mild hepatomegaly without splenomegaly. Neurological examination is unremarkable.

Laboratory Findings:

Hemoglobin: 6.2 g/dL (normal range: 13.5-17.5 g/dL)

Hematocrit: 18.5% (normal range: 38.8-50.0%)
Reticulocyte count: 8.6% (normal range: 0.5-2.5%)
Total bilirubin: 3.8 mg/dL (normal range: 0.2-1.2 mg/dL)
Direct bilirubin: 1.2 mg/dL (normal range: 0.0-0.4 mg/dL)
Indirect bilirubin: 2.6 mg/dL
LDH (lactate dehydrogenase): 1200 U/L (normal range: 140-280 U/L)
Haptoglobin: <10 mg/dL (normal range: 30-200 mg/dL)
Coombs test: Negative
Peripheral blood smear: Presence of schistocytes
Questions:

a)What is the most likely underlying pathophysiology causing this patient's anemia?
b)What laboratory findings support the suspected diagnosis?
c)What is the significance of the elevated LDH and low haptoglobin levels?
d)What additional diagnostic tests might be necessary to confirm the diagnosis?
e)What are the potential complications associated with this condition, and how would you
f)manage this patient's current presentation?
 ANSWERS
a) The most likely underlying pathophysiology causing this patient's anemia is intravascular
hemolysis. The presence of schistocytes on the peripheral blood smear and the combination of
low hemoglobin, elevated reticulocyte count, elevated LDH, and low haptoglobin levels are
indicative of red blood cell destruction within the blood vessels.

b) The laboratory findings that support the suspected diagnosis of intravascular hemolysis
include:

 Low hemoglobin and hematocrit levels.

 Elevated reticulocyte count, which indicates an increased rate of red blood cell
production in response to the hemolysis.
 Elevated LDH, which is released from damaged red blood cells.
 Low haptoglobin levels, indicating its consumption in binding free hemoglobin released
from hemolyzed red blood cells.
 Presence of schistocytes on the peripheral blood smear, suggesting mechanical
destruction of red blood cells as they pass through narrowed or damaged blood vessels.

c) The elevated LDH and low haptoglobin levels are significant because they indicate increased
red blood cell breakdown. LDH is released from damaged cells, including red blood cells, and its
elevation reflects the ongoing hemolysis. Haptoglobin is a protein that binds free hemoglobin
released from ruptured red blood cells, preventing kidney damage due to hemoglobinuria. Low
haptoglobin levels suggest that hemoglobin binding capacity is overwhelmed due to excessive
hemolysis.

d) Additional diagnostic tests that might be necessary to confirm the diagnosis and identify the
underlying cause of the intravascular hemolysis could include:

Serum bilirubin fractions to assess for unconjugated hyperbilirubinemia.

Serum iron studies and serum ferritin levels to evaluate for hemolysis-associated iron overload.
Coagulation studies to assess for disseminated intravascular coagulation (DIC) if suspected.
Reticulocyte indices to determine if the reticulocytosis is appropriate for the degree of anemia.

e) Potential complications associated with this condition include:

 Acute kidney injury due to hemoglobinuria and subsequent nephrotoxicity.

 Development of thrombotic microangiopathy, which can lead to organ damage.
 Increased risk of gallstone formation due to elevated bilirubin levels.
 Hemodynamic instability and tissue hypoxia due to severe anemia.
Management of this patient's current presentation would involve addressing the underlying
cause of the intravascular hemolysis, supportive care to manage anemia and potential
complications, and determining the appropriate treatment strategy based on the confirmed
diagnosis. This may involve blood transfusions, addressing any underlying infections or
 triggering factors, and potentially using therapies to reduce hemolysis if there's an
appropriate target identified.

CASE 3
Patient Information:

Age: 28
Gender: Male
Occupation: IT Programmer
Medical History: None
Medications: None
Allergies: None known

Presenting Complaint:
The patient presents to his primary care physician with a chief complaint of persistent fatigue
and weakness that has been occurring on and off for the past year. He mentions that even after
a full night's sleep, he wakes up feeling tired, and this fatigue persists throughout the day.

History of Present Illness:

The patient describes feeling generally unwell for the past year. He reports that he used to be an
avid runner but has found it increasingly difficult to maintain his exercise routine due to the
fatigue. He denies any changes in appetite, weight loss, fevers, or other noticeable symptoms.
However, he does mention that his concentration and focus at work have been impaired, and he
often feels mentally foggy.

Social History:
The patient lives alone and leads a relatively active lifestyle. He enjoys hiking and playing soccer
with his friends on weekends. He does not smoke and rarely drinks alcohol. He maintains a
balanced diet and tries to get regular exercise despite his current limitations.

Family History:
His mother has a history of rheumatoid arthritis, and his father had type 2 diabetes. There is no
known family history of blood disorders or chronic illnesses related to anemia.

Physical Examination:

Vital Signs: Blood pressure 118/76 mmHg, heart rate 82 bpm, respiratory rate 16 breaths/min,
temperature 98.4°F (36.9°C)
General: The patient appears fatigued but is cooperative and engaged during the examination.
Skin: No pallor, jaundice, or rashes noted.
Cardiovascular: Regular rhythm, no murmurs or extra heart sounds.
Respiratory: Lungs clear to auscultation.
Abdomen: Soft, non-tender, no organomegaly.
Neurological: Cranial nerves intact, no focal deficits.
Diagnostic Workup:

Complete Blood Count (CBC):

Hemoglobin: 11.0 g/dL (reference range: 13.5-17.5 g/dL)
Hematocrit: 32.5% (reference range: 38.8-50.0%)
Mean Corpuscular Volume (MCV): 80 fL (reference range: 80-100 fL)
White Blood Cell Count (WBC): 6,200/mm³ (reference range: 4,500-11,000/mm³)
Platelet Count: 220,000/mm³ (reference range: 150,000-450,000/mm³)
Further Investigations:

Iron Studies:
Serum Iron: 45 mcg/dL (reference range: 50-170 mcg/dL)
Total Iron Binding Capacity (TIBC): 370 mcg/dL (reference range: 240-450 mcg/dL)
Ferritin: 70 ng/mL (reference range: 12-150 ng/mL)

Given the clinical scenario and laboratory results,

a)what is the mostly likely diagnosis
b)what steps would you take next to determine the underlying cause of the patient's
symptoms?

a) Likely Diagnosis: Anemia of Chronic Disease (ACD)

b) Next Steps for Determining Underlying Cause:

Based on the clinical scenario and laboratory results, the most likely diagnosis is Anemia of
Chronic Disease (ACD), also known as anemia of inflammation. ACD is a type of anemia that
commonly occurs in individuals with chronic illnesses such as infections, autoimmune disorders,
and inflammatory conditions. It is characterized by a mild to moderate decrease in hemoglobin
and hematocrit levels, as well as changes in other parameters such as MCV, often resembling
iron-deficiency anemia. However, in ACD, the primary underlying cause is not iron deficiency but
rather the disruption of iron metabolism due to chronic inflammation.

To determine the underlying cause of the patient's symptoms and ACD, further steps could
include:

Thorough Medical History: Obtain detailed information about the patient's medical history,
including any recent infections, autoimmune disorders, inflammatory conditions, or chronic
illnesses.
Inflammatory Markers: Conduct blood tests to measure inflammatory markers such as C-
reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Elevated levels of these
markers can provide evidence of ongoing inflammation.
Additional Laboratory Tests: Depending on the results of inflammatory markers and clinical
suspicion, other tests such as serum ferritin, transferrin saturation, and soluble transferrin
receptor (sTfR) levels could be considered to differentiate ACD from other causes of anemia like
iron-deficiency anemia.

Further Evaluation of Underlying Condition: If the diagnosis remains uncertain, or if the

patient's symptoms suggest a specific underlying condition, further evaluation of that condition
might be necessary. This could involve consultations with specialists, imaging studies, and
additional targeted tests.

Review of Medications: Assess any medications the patient might be taking, as certain
medications can contribute to or exacerbate anemia or inflammation.
Monitoring and Follow-up: Since ACD is often a secondary condition, close monitoring of the
patient's underlying chronic illness is crucial. Adjustments to treatment plans or therapies for
the primary condition might help manage or improve the anemia.

Treatment of Underlying Condition: Managing the underlying chronic illness is essential to

addressing ACD. Treating the inflammation or underlying cause can potentially improve the
patient's anemia and overall well-being.

CASE 4
Patient Information:

Age: 28
Gender: Male
Occupation: Graphic Designer
Medical History: None
Medications: None
Allergies: None known
Presenting Complaint:
The patient is brought to the emergency department by his family due to severe fatigue, pallor,
and multiple episodes of easy bruising and gum bleeding over the past few weeks.

History of Present Illness:

The patient reports feeling increasingly weak and tired over the last two months. He mentions
that he has been experiencing shortness of breath even with minimal exertion. Additionally, he
recalls that small cuts and bruises have taken longer to heal than usual, and he has had several
instances of nosebleeds. He denies any recent infections, fever, weight loss, or joint pain.

Social History:
The patient lives with his parents and younger brother. He is a non-smoker and drinks alcohol
occasionally during social gatherings. He enjoys outdoor activities such as hiking and cycling.

Family History:
There is no significant family history of blood disorders or chronic illnesses. Both parents are
healthy and have no known medical conditions.

Physical Examination:

Vital Signs: Blood pressure 120/80 mmHg, heart rate 92 bpm, respiratory rate 18 breaths/min,
temperature 98.4°F (36.9°C)
General: The patient appears pale and fatigued.
Skin: Multiple petechiae and ecchymoses noted on arms and legs.
Cardiovascular: Regular rhythm, no murmurs or extra heart sounds.
Respiratory: Lungs clear to auscultation.
Abdomen: Soft, non-tender, no palpable masses.
Neurological: No focal deficits.
Diagnostic Workup:

Complete Blood Count (CBC):

Hemoglobin: 7.8 g/dL (reference range: 13.5-17.5 g/dL)
Hematocrit: 23.6% (reference range: 38.8-50.0%)
Mean Corpuscular Volume (MCV): 85 fL (reference range: 80-100 fL)
White Blood Cell Count (WBC): 2,200/mm³ (reference range: 4,500-11,000/mm³)
Platelet Count: 20,000/mm³ (reference range: 150,000-450,000/mm³)
Further Investigations:

Bone Marrow Aspiration and Biopsy:

Hypocellular bone marrow with markedly decreased cellularity across all lineages.

Peripheral Blood Smear:

Decreased number of red blood cells, white blood cells, and platelets. No abnormal cells
observed.

a)what is the most likely diagnosis based on the clinical scenario and laboratory results,
b)what would be your approach to further evaluation and management of this patient's
condition?

a) Most Likely Diagnosis: Aplastic Anemia

Based on the patient's clinical presentation and laboratory results, the most likely
diagnosis is aplastic anemia. Aplastic anemia is a rare disorder characterized by a
deficiency of hematopoietic stem cells in the bone marrow, leading to decreased
production of red blood cells, white blood cells, and platelets. The patient's symptoms of
severe fatigue, pallor, easy bruising, gum bleeding, shortness of breath, and prolonged
healing of cuts are consistent with the hematologic deficiencies seen in aplastic anemia.

The key findings supporting this diagnosis include:

Severe Anemia: Low hemoglobin and hematocrit levels.

Thrombocytopenia: Very low platelet count, explaining the bleeding tendencies.
Leukopenia: Low white blood cell count, making the patient susceptible to infections.
Hypocellular Bone Marrow: Bone marrow aspiration and biopsy revealing a decrease in
cellularity across all blood cell lineages.
b) Approach to Evaluation and Management:

Confirm the Diagnosis:

The diagnosis of aplastic anemia is largely clinical and supported by laboratory findings.
However, further investigations might include ruling out other potential causes of
pancytopenia (low counts of all blood cell types), such as viral infections, medications,
and autoimmune disorders.

Identify the Cause:

It's important to identify potential causative factors, such as exposure to toxins,
medications, or underlying genetic predispositions. A detailed history and review of any
recent exposures or changes in the patient's routine are essential.

Consultation with Hematologist:

Given the severity of the patient's condition, a hematologist should be involved for
specialized evaluation and management. The hematologist will guide the appropriate
tests to determine the underlying cause and provide further recommendations.

Supportive Care:
Patients with severe aplastic anemia are at risk of serious infections and bleeding. In the
short term, supportive care measures include strict infection control, platelet
transfusions to manage bleeding, and potential antibiotic or antifungal prophylaxis.

Treatment Options:
Treatment strategies for aplastic anemia aim to restore hematopoiesis. Options include:
Immunosuppressive Therapy: Using medications like antithymocyte globulin (ATG) and
cyclosporine to suppress the immune system and allow bone marrow recovery.
Hematopoietic Stem Cell Transplantation: If a suitable donor is available, a transplant
can replace the defective bone marrow with healthy stem cells.

Long-Term Management:
Regular follow-up with the hematologist is crucial to monitor blood counts and adjust
treatment as needed. Lifestyle modifications to minimize infection risk and bleeding
precautions are important.
Psychosocial Support:
The patient's emotional well-being should not be neglected. Aplastic anemia can be a
life-altering condition, and patients might benefit from counseling and support groups.