Presentation on theme: "Hematology Case: Iron-Deficiency Anemia"— Presentation transcript:
1 Hematology Case: Iron-Deficiency Anemia Group EJaclyn Millar – Hx questions, Management, NarratorJaime Teran-Rocha – Lab InterpretationJimmy Misurka – Diagnosis, PathophysiologyNavin Tajuddin – DDx, Prognosis/Patient EducationFriday June 13, 2014Hematology Case 2 – Iron Deficiency AnemiaPresented by Group E: Jaclyn, Jaime, Jimmy and Navin
2 Hematology Case 2 Overview HistoryPhysical ExaminationLab Investigations: results and interpretationAssessment: DDx and most likely DxManagementPrognosis and Patient educationOverview of the PresentationHistoryPhysical ExaminationInvestigations: including results and interpretationAssessment: including DDx and the most likely DxManagementPrognosis and Patient education
3 History67 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.Patient History67 year old female with shortness of breath on exertion, easy fatigability, and lack of energy for the past 2 to 3 monthsShe 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 historyPast medical history including surgical historyMedication useFamily historyHave 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?Additional Relevant History QuestionsAny 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 (vegetarian)Past medical history including surgical historyMedication useFamily historyHave you recently had tinnitus, anorexia, abdominal pain, and indigestion, or change in bowel habits?Do you suffer from GERD or peptic ulcer disease?Do you have hemorrhoids?Have you ever been diagnosed with diverticulosis, inflammatory bowel disease or colitis?
5 Physical ExamSkin pallor noted. The rest of the physical examination is unremarkable.Physical ExamSkin pallor noted. The rest of the physical examination is unremarkable
6 Laboratory Investigations RBC 3.72 x 1012/LHgb 58 g/LHct 0.208MCV 56.1 fLMCHC 285 g/LRDW 0.204WBC 5.8 x 109/LNeutrophils 82 %Lymphocytes 13 %M onocytes 1 %E osinophils 4 %B asophils 0 %Platelets 387 x 109/Lserum ferritin <10 µg/Lserum iron 4.5 µmol/LTIBC µmol/Ltransferrin 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 normalLaboratory InvestigationsComplete Blood Count with Differential, a fecal occult blood test and a blood smear analysis was performed
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 SOBEMCV is small, as well as her Ferritin level is markedly low. These findings are consistent with ferropenic, microcytic anemiaMicrocytosis (2+), Elliptocytosis (2+) with hypochromasia (2+) are all suggestive of iron deficiencyOn 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 ng/ml), indicating total amount of iron stores is depletedLooking at her low serum iron, increased total iron binding capacity (TIBC) and low transferrin saturation, all three are consistent with an Iron-Deficiency AnemiaWBC shows no leukocytosis and differential does not show any left shift, therefore infection is unlikely; platelets are within normal range and shapeInterpretation of Lab Results – Key FindingsThis patient has a low erythrocyte count, even adjusted for her age and sexHer Hemoglobin and Hematocrit levels all are low enough to explain her shortness of breath with exertionHer mean corpuscular volume (MCV) and Ferritin levels are markedly low; both consistent with ferropenic, microcytic anemiaMicrocytosis, Elliptocytosis, and Hypochromasia are consistent with Iron deficiencyThe blood smear shows slight anisocytosis and elevated red cell distribution width, which is likely due to her anemiaHer Ferritin level is low indicating her total amount of iron stores are depletedLow serum Iron, increased Total Iron Binding Capacity and low transferrin saturation are consistent with an Iron deficiency anemia, which confirm our previous findingsWBCs show no leukocytosis and differential does not show any left shift, therefore infection is unlikelyPlatelets are normalNo presence of blood in feces
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 energyIron deficiency anemia due to insufficient diet or malabsorption – common in elderly and can occur due to malabsorption or underlying conditionHypothyroidism – common in women and elevated TSH can lead to increased fatigue and lack of energyNeoplasm – can cause fatigue, decreased RBCs and changes in appetiteLung 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 diagnosisDifferential DiagnosisThese are all included as differentials, as all present with chief complaint of Shortness of breath on exertion, 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 an 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
9 Most Likely Diagnosis with brief explanation of rationale Iron deficiency anemia is the most likely diagnosis resulting from insufficient dietary requirementsCan also result from: hemorrhage or malabsorptionSince the patient has no signs of bleeding we can exclude causes from blood lossHowever, malabsorption is unlikely in the absence of small bowel disease or previous bowel surgeryBecause of this fact, the patient should be worked up to ensure she does not have:Celiac Disease or Regional EnteritisGI endoscopy, colonoscopy and possible intestinal biopsy can help confirm a diagnosisMost Likely DiagnosisThe most likely diagnosis is Iron deficiency anemia resulting from insufficient dietary requirements. It is important to remember that anemia is not a disease, but rather a symptom of numerous diseases. There is no sign of bleeding so this cause can be excluded. Malabsorption can also be a cause perhaps due to Celiac Disease or Regional Enteritis. It would be important to consider a GI endoscopy, colonoscopy and possible intestinal biopsy to rule out small bowel disease and confirm our diagnosis
10 Pathophysiology Iron is essential for multiple metabolic processes Oxygen transportDNA synthesisElectron transportThere are three separate pathways for iron absorption: (1) for Heme and (2) distinct pathways for ferric and ferrous ironIron absorption can be affected by 3 different factors:Intraluminal, mucosal and corporealTypically, iron concentration is maintained by alteration in absorption to match lossesIron deficient anemia results from insufficient dietary intake in absorbable formHowever, usually uncommon in the absence of small bowel disease or previous GI surgeryIron is essential for regular function of our bodies, affecting oxygen transport, DNA synthesis and electron transport. With decreased amount of iron, shortness of breath and fatigue are common symptoms due to the decreased oxygen carrying capacity of the RBCs. There are three distinct pathways for the absorption of iron, including one for heme and two separate pathways for ferric and ferrous iron. In the healthy individual, iron absorption is regulated such that body iron loss equals body iron absorption. Iron absorption can be affected by 3 factors: intraluminal, mucosal and corporeal. The Intraluminal refers to the iron itself, the chemical form, the quality and the PH of the environment. Mucosal refers to the cells in the wall of the intestine, and the factors affecting them that can change Iron absorption. Corporeal refers to the conditions in the body including iron stores and iron turnover
11 ManagementOverall: management plan consists of establishing the etiology of the iron deficiency and correcting it so the deficiency does not recurIn our patient, treatment with oral iron therapyFerrous sulfateParenteral Iron Therapy – if unable to absorb oral ironDietary measuresNutritional counselling with DieticianActivity restrictionTailored, gradual exercise as per tolerated1-3 month monitoring to assess adequate response to iron therapyManagement of hemorrhage (unlikely in our patient)Surgical treatment to help correct blood lossOur management plan consists of establishing the etiology of the iron deficiency and correcting it so the deficiency does not recurThe most effective medication in the treatment of iron deficiency anemia is the oral administration of ferrous iron salts. Ferrous sulfate most commonly is used. Our patient should take them with vitamin C pills or orange juice, which helps the body absorb more iron. She should start to feel better within a few days of beginning treatment.Parenteral Iron Therapy can be used if she is unable to absorb the oral iron or is having increasing anemia despite adequate doses of oral ironOur patient should be counseled on an individual basis with a Dietician, emphasizing the importance of improving her dietHer physical activity should be tailored, gradual exercise as is toleratedMonitoring her for 1-3 months to asses an adequate response to iron therapy is also necessaryAlthough highly unlikely for our patient, management of hemorrhage is another form of management
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 worsePatient 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 hemoglobinSigns and symptoms – fatigue, SOBE, weaknessDietary 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 teaPrevention – oral iron supplements in addition to dietary modification; treatment of underlying causeFor 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 worseIn terms of patient education, making our patient aware of what anemia is, the signs and symptoms to look out for, the important dietary sources of iron that she should be consuming, as well as the appropriate prevention methods are of great importance.
13 ReferencesAnemia Assessment Questionnaire. [Right Diagnosis]. [updated 2014 April 22; cited 2014 June 5]. Available from:Harper, J. Iron Deficiency Anemia. [Medscape]. [updated 2013 Dec; cited 2014 June 6]. Available from:Maakaron, J. Anemia. [Medscape]. [updated 2013 July 30; cited 2014 June 5]. Available from:Schrier, S. Patient Information: Anemia caused by low iron (Beyond the Basics). [UpToDate]. [updated 2013 May; cited 2014 June 10]. Available from:This concludes our case study for hematology, a patient with iron-deficiency anemia. Listed on this slide are the references that were used to gather the previous information. Thank you for watching and listening