Hematology Case: Iron-Deficiency Anemia

1. Hematology Case:Iron-Deficiency Anemia Group E Jaclyn Millar – Hx questions, Management, Narrator Jaime Teran-Rocha – Lab Interpretation Jimmy Misurka – Diagnosis, Pathophysiology NavinTajuddin – DDx, Prognosis/Patient Education Friday June 13, 2014

2. Hematology Case 2Overview • History • Physical Examination • Lab Investigations: results and interpretation • Assessment: DDx and most likely Dx • Management • Prognosis and Patient education

3. 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.

4. Additional Relevant History Questions • 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?

5. Physical Exam Skin pallor noted. The rest of the physical examination is unremarkable.

6. 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+ anisocytosis2+ elliptocytes and target cells 2+ hypochromasia2+ microcytosis WBC morphology normal Platelet morphology normal

7. 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 Iron-Deficiency Anemia • WBC shows no leukocytosis and differential does not show any left shift, therefore infection is unlikely; platelets are within normal range and shape

8. 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 Diseaseor 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

9. Most Likely Diagnosiswith 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

10. 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

11. Management • Overall: management plan consists of establishing the etiology of the iron deficiency and correcting it so the deficiency does not recur • Inour 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 monthmonitoring to assess adequate response to iron therapy • Management of hemorrhage (unlikely in our patient) • Surgical treatment to help correct blood loss

12. 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, iron-fortified 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

13. 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/202333-overview#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