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Clinical complaints
- Male, 45 years-old
- 3 weeks before presentation
- shortness of breath
- fatigue, dizziness
- very active person, but with recent lack of appetite
and weight loss
- chronic NSAIDs consumer
Clinical examination
- Skin pallor
- Dry skin
- Nails: breaking easily (friable), flat, thin, without glow
(koilonychia)
- Atrophy of the lingual papillae, dysphagia (PlummerVinson sd)
- Intermitent peri-umbillical pain
- Non-specific heart murmur.
Koilonychia
Laboratory - CBC
- RBC = 3.800.000/mm
- Hb = 8,5 g/dl
- Htc = 26%
- MCV = 71 fl ; MCV = Htc(%) x 10 /
RBC(mil/mm)
- MCHC = 25 g/dl ; MCHC = Hb(g/dl) x 100 / Ht
(%)
- WBC = 10.600/mm (Sg-72%, Eo-1%, Ly-20%,
Mo - 7% )
- PLT = 600000/mm
- PBS microcytosis, hypochromia, poikilocytosis
Laboratory tests
-
reticulocytes = 1,0 %
Fe = 10 g/dl (v.n. 50-150 g/dl)
TIBC = 600 g/dl (v.n. 250-450 g/dl)
Saturation of transferin = 1.6%
ST = Fe x 100/ TIBC (v.n. 20-60%)
- ferritin = 5 ng/ml
NOW WHAT?
Hemocult test
Positive!
Discussion: diaphragmatic hernia?
Remember he was a chronic NSAIDs consumer!
Positive diagnosis
Positive diagnosis
Iron deficiency anemia (IDA) due to
chronic digestive tract hemorrhage from
large intestine neoplasia
- microcytic hypochromic anemia
(Hb, MCV, MCHC)
- non-regenerative ( Rtc )
- low serum iron
- TIBC , CST
- ferritin + BM
- source of hemorrhage tumor
Positive diagnosis
BONE MARROW HEMOSIDERIN - absent
(Perls staining)
Remember!
IDA is the only type of anemia with negative Perls staining in
BM.
All other anemias: normal or increased BM iron.
IDA is not a disease in itself, but an effect and a sign of
another condition.
Differential diagnosis
IDA is the main cause of hypochromic
microcytic anemia, but not the only cause
Differential diagnosis
Test
Iron
deficiency
anemia
Thalasse
mia
Chronic
anemia
Sideroblastic
anemia
Fe
Decreased
Normal or
increased
Decreased Increased
TIBC
Increased
Normal
Decreased Normal
Ferritin
Decreased
Normal
Increased
Increased
HbA2
Decreased
Increased
Normal
Decreased
Treatment
1) Iron therapy remarkably efficient; therapeutic
test of diagnosis
2) Secondary:
- transfusion in emergency cases, severe
anemia, associated cardiovascular pathology,
elderly patients
- the patient should not receive complementary
treatment with vitamin B12, folic acid, etc, with
the possible exception when malabsorbtion is the
cause of anemia and other deficits are associated.
- oral (safer and less expensive) or iv route
TREATMENT OF THE CAUSE!!!
Treatment
dosage
100-200 mg/day (3-4 times/day) both during
meals (in order to ameliorate tolerance) and
between meals (to increase absorption);
associate vitamin C
As the anemia is corrected, the absorption
diminishes progressively.
Reticulocyte crisis: 7-10 days
Lack of reticulocyte crisis misdiagnosis? Bad
dosage? Lack of absortion?
Treatment
Side effects: nausea, abdominal pain,
diarrhea/constipation, black stool, headache, dizziness
Doses are adapted to individual tollerance reduce
doses / administration during meals / etc
Treatment
I.V. / (I.M.) - indications:
Insufficient absorption of oral Iron
Digestive intolerance
The patient does not cooperate (e.g. psychiatric
disorder)
Rapid treatment is necessary (e.g. pregnancy)
Treatment
- IM ex: Maltofer
- IV ex: Venofer
Only in the hospital important risk of allergic reactions up to
anaphylactic shock.
Follow-up
- Correction of anemia starts in 1-2 weeks, may
last for 2 months
- Correction of anemia is not sufficient; TIBC and
ferritin must also normalize total time of
treatment in 6 months!!! (after the cause is
corrected)
- Persistent anemia with correction of the
biochemistry another cause of anemia (e.g.:
thalassemia)
- Persistent anemia with the same biochemic
profile lack of absorption? Treatment is not
taken? Cause persists?