Case study- Iron deficiency anemia | Biochemistry for Medics – Lecture Notes

 

iron deficiency anemia case study

Year-Old Woman With an Obscure Case of Anemia. Chronic blood loss usually leads to iron deficiency anemia, which is classically microcytic in nature; however, a normocytic anemia may also be seen. Hemolytic anemias usually result in a normocytic picture. Anemia of chronic disease is usually normocytic and is possible because of this Author: Shanique R. Palmer, Gita Thanarajasingam, Alexandra P. Wolanskyj. In iron-deficiency anemia, iron studies usually show decreased ferritin and serum iron levels, an elevated serum transferrin level and a high total iron binding capacity. Unless there is clear history of low dietary intake of iron, the clinician should initiate evaluation for a source of bleeding or a malabsorptive ipvcitysa.cf by: 1. Case Discussion- The most likely diagnosis is iron deficiency anemia. Generalized weakness, exercise intolerance, dyspnea, palpitations, history of blood loss during menstruation, tachycardia and low Hb, all are suggestive of iron deficiency anemia. Iron deficiency is the .


Case Study - Iron Deficiency Anemia


A year-old woman was referred to our institution for evaluation of anemia. She was known to have multiple comorbidities and had a baseline hemoglobin concentration of approximately About 6 months before her referral, the patient began having recurrent episodes of severe anemia, with hemoglobin values as low as 3. She had become transfusion-dependent and had received about 30 units of packed red blood cells RBCs in the preceding 3 months. The patient denied any history of easy bruisability, menorrhagia, or overt evidence of bleeding from any site.

Additionally, she denied any change in the appearance or color of her urine and had no history of jaundice, iron deficiency anemia case study. There was no family history of anemia or any other hematologic disorder. As an outpatient, she had undergone an extensive evaluation at another institution, but results failed to provide an explanation for her anemia. The patient's medical history was remarkable for severe asthma, thought to be due to Churg-Strauss syndrome.

She had a tunneled central venous catheter for self-administration of intravenous corticosteroids at the earliest sign of an asthmatic exacerbation, iron deficiency anemia case study. Her other medications included bronchodilators, weekly erythropoietin injections, intravenous iron therapy, an antidepressant, and an anxiolytic.

At presentation, the patient's vital signs were normal. Iron deficiency anemia case study examination was unremarkable except for mild generalized pallor. A complete blood count on the day of admission revealed the following reference ranges shown parenthetically : hemoglobin, 4. These results were obtained within 24 hours of her last transfusion. Which one of the following is the least likely in the differential diagnosis of this patient's anemia? Anemia can be categorized as microcytic, normocytic, or macrocytic by examining the MCV.

This patient clearly has a normocytic anemia, with her MCV of Normocytic anemias are classically due to premature destruction or acute loss of RBCs or to decreased bone marrow production.

With this in mind, we can approach the proposed list of differential diagnoses. Chronic blood loss usually leads to iron deficiency anemia, which is classically microcytic in nature; however, a normocytic anemia may also be seen. Hemolytic anemias usually result in a iron deficiency anemia case study picture. Anemia of chronic disease is usually normocytic and is possible because of this patient's complicated medical history. The myelodysplastic syndromes refer to a heterogeneous group of stem cell disorders characterized by abnormal cellular maturation and, most commonly, chronic cytopenias.

They result in macrocytosis, which is classically marked, with MCV sometimes greater than fL. This is the only condition listed that classically results in a macrocytic anemia, rather than iron deficiency anemia case study, and was therefore least likely to be the cause of the patient's anemia.

Acquired pure red cell aplasia is a primary bone marrow disorder characterized by decreased reticulocytes and the virtual absence of erythroid precursors in the bone marrow. It is often idiopathic but may occur in association with various diseases, such as systemic lupus erythematosus and hematologic malignancies.

Regardless of the underlying cause, the anemia is usually normocytic with absolute reticulocytopenia. With the observation that the patient's anemia was normocytic with an MCV of Which one of the following would be the next best test to narrow the list of differential diagnoses? The peripheral blood smear provides useful information that cannot be obtained with the usual complete blood count and can provide clues to a variety of bone marrow disorders, as well as systemic disorders that can have hematologic manifestations.

However, it would not be the single best test to provide the necessary information at this point. We needed to establish whether there was an adequate or inadequate ie, hypoproliferative bone marrow response. An adequate response is usually due to hemolysis or acute loss of RBCs. The reticulocyte count is a good indicator of this and is the only test listed that could have directly provided this necessary piece of information.

The region between these 2 limits remains a gray zone, and other clinical and laboratory parameters should be used to interpret the overall picture. The plasma ferritin level generally reflects overall iron storage and is typically used iron deficiency anemia case study a part of the panel to evaluate for iron deficiency anemia in a patient with microcytosis. Therefore, it would not be most useful in this patient with a normocytic anemia. Erythropoietin is a growth factor that is the primary stimulus for erythropoiesis.

It would not be useful at this juncture in revealing whether the anemia is due to decreased production or increased loss of blood cells or premature destruction. A bone marrow biopsy would show erythroid hyperplasia, a nonspecific finding, if erythropoiesis is increased in response to the anemia.

If there is a hypoproliferative state, the marrow may reveal a variety of findings, depending on the underlying diagnosis. Therefore, a bone marrow biopsy would be premature at this point.

However, a bone marrow biopsy would be indicated if there was pancytopenia or if the peripheral smear showed abnormal cells, such as blast forms or dysplastic changes. Our patient had a reticulocytosis of At this time, which one of the following series of tests would be most helpful in further narrowing the differential diagnosis?

In this patient with an absolute reticulocytosis, ie, an adequate bone marrow response, the next step would be in differentiating between hemolysis and acute blood loss. Hemolysis is usually characterized by elevated indirect bilirubin concentrations, decreased serum haptoglobin concentrations with intravascular hemolysis in particularand increased serum LDH levels, and iron deficiency anemia case study series of tests would be most useful in narrowing the differential diagnoses at this point.

The peripheral blood smear is less specific, but in the presence of hemolysis, it may reveal abnormally shaped RBCs, including fragmented RBCs schistocytes, helmet cellsspherocytes, elliptocytes, or RBC inclusions, which may be seen in certain hemolysis-producing infections, such as malaria, babesiosis, and Bartonella.

Hemolytic anemias may be acquired and immune, in which case there is immunologic destruction of RBCs mediated by autoantibodies directed against antigens on the patient's RBCs. The direct and indirect Coombs tests detect antibodies on the surface of the patient's RBCs and in the patient's serum, respectively. However, the presence of hemolysis must first be established, especially since a patient may have a mildly positive Coombs test that is clinically insignificant if not associated with ongoing hemolysis.

A peripheral blood smear showed no abnormally shaped RBCs. The overall picture was not in keeping with hemolysis. On the first day of her evaluation, the patient's hemoglobin concentration was By day 2 of her outpatient work-up, it had decreased to 5. Despite the transfusions, her iron deficiency anemia case study concentration decreased further within 24 hours to 4, iron deficiency anemia case study.

At this point, the patient was admitted and received 3 more units of packed RBCs, iron deficiency anemia case study. During this iron deficiency anemia case study, she was asymptomatic, and her vital signs remained stable. At this point, which one of the following would be the best step in the management of this patient?

The patient had no overt signs or symptoms of bleeding, and it would be unlikely for her to have occult GI bleeding that resulted in such dramatic decreases in her hemoglobin concentration. Also, results of fecal occult blood testing were negative.

Therefore, neither upper nor lower GI endoscopy would be expected to reveal any useful information. However, the patient could have occult intra-abdominal bleeding, and noncontrast CT of her abdomen and pelvis would be crucial in ruling this out, iron deficiency anemia case study.

The patient's mental status remained normal, and she was exhibiting no overt evidence of decreased perfusion or hemodynamic instability other than mild tachycardia. Therefore, she could be deemed clinically stable, and transferring her to the intensive care unit would be unnecessary at this time.

She was well compensated despite the severity and acuteness of the anemia, iron deficiency anemia case study, no doubt in part due to her age and lack of other cardiac comorbidities. In this patient who is exhibiting no overt evidence of GI bleeding, angiography would not be the next best step.

Noncontrast CT of her abdomen and pelvis revealed normal findings. During the night of hospital day 2, an astute nurse noticed what appeared to be bloodstains on the patient's gown. The patient reported that she had spilled cranberry juice on the gown. Closer inspection of her room revealed several blood-soaked iron deficiency anemia case study and Styrofoam cups filled with fresh blood in her wastebasket. The patient was also found to have dried, crusted blood all over her fingernails, and a blood-stained mL syringe, most of its labeling worn away by overuse, was found in her gown pocket Figure.

Which one of the following is the most likely cause of this patient's anemia? With the discovery made in the patient's room, in particular the syringe, the patient's self-phlebotomy became evident, leading to a diagnosis of factitious anemia. The most chronic iron deficiency anemia case study extreme form of factitious illness, Munchausen syndrome, iron deficiency anemia case study, typically includes travel from hospital to hospital combined with the willingness to submit to multiple procedures for self-fabricated signs of illness, as occurred with our patient before her presentation at our institution.

In Munchausen by proxy, iron deficiency anemia case study, caregivers usually mothers induce illness in their children to obtain care and support for themselves. In malingering, illness is feigned to gain such external incentives as money or drugs or to avoid such consequences as military service or criminal prosecution.

Factitious disorder, in contrast, has no incentive other than being a patient in the sick role. Since we identified no incentive other than obtaining our care, our patient could not be said to be malingering. Somatization refers to the tendency to experience psychological distress in the form of somatic symptoms not intentionally produced, thus differentiating this disorder from factitious illness or malingering. Hypochondriasis refers to a preoccupation with believing one is ill as a result of misconstruing physical symptoms that are not self-generated.

By her self-phlebotomizing activity, our patient could not be considered hypochondriacal. The patient was seen by iron deficiency anemia case study psychiatry service, and although she was obviously at risk of purposeful self-harm, she denied suicidal or homicidal ideation.

It became evident that she had a history of severe depression, borderline personality disorder, chemical dependency, and a history of repeated episodes iron deficiency anemia case study parasuicide by means of wrist cutting.

She gave consent for her central line to be removed, and this was done before her dismissal. There was direct communication with her primary care physicians and primary psychiatrist, and she was then dismissed from the hospital with a plan for close and consistent medical attention, iron deficiency anemia case study. Several cases of factitious anemia have been reported in the literature.

Patients with this condition often have underlying psychiatric issues and constantly need to assume the sick role. Once the diagnosis is suspected, the patient should be confronted, and removal of any contributing medical device is essential.

Early diagnosis is usually difficult but may prevent repeated hospitalizations and the risks associated with invasive diagnostic procedures. Providing optimal management to an uncooperative patient may be difficult without violating the patient's autonomy.

Therefore, a psychiatric consultation should be arranged as soon as possible, and seeking assistance from the institution's ethics and legal committees may be prudent. The current case provides an opportunity to highlight an approach to the patient presenting with anemia.

Anemia can be classified according to measurement of RBC size, as seen on the peripheral blood smear and as indicated by the MCV. This morphological approach categorizes the anemias as microcytic, normocytic, or macrocytic, providing a useful starting point to narrow the list of differential diagnoses. The presence of a microcytic anemia usually indicates a pathologic process involving hemoglobin synthesis.

The most common cause is iron deficiency, but other classic causes include the thalassemias and other hemoglobinopathies, lead poisoning, sideroblastic anemia, and, less commonly, anemia of chronic disease, iron deficiency anemia case study.

 

Case 1: Recurrent iron-deficiency anemia in a teenager

 

iron deficiency anemia case study

 

What are the common causes of iron deficiency anemia? Children, Young adult, Older adult. Males, Females. What are the clinical sequelae to iron deficiency anemia? What is your therapeutic strategy for treatment of iron deficiency anemia? What treatment would you prescribe for this patient? How soon should you expect a response? Jul 06,  · This case study was limited to biomarkers for the detection of iron deficiency and determination of its severity. A multitude of disorders other than iron deficiency can produce anemia, including other nutritional causes (such as deficiencies of vitamins A and B and folic acid), infection (notably malaria, HIV disease, and tuberculosis. Case Discussion- The most likely diagnosis is iron deficiency anemia. Generalized weakness, exercise intolerance, dyspnea, palpitations, history of blood loss during menstruation, tachycardia and low Hb, all are suggestive of iron deficiency anemia. Iron deficiency is the .