1. Hematology Case: Iron-Deficiency Anemia
Group E
Jaclyn Millar – Hx questions, Management, Narrator
Jaime Teran-Rocha – Lab Interpretation
Jimmy Misurka – Diagnosis, Pathophysiology
Navin Tajuddin – DDx, Prognosis/Patient Education
Friday June 13, 2014
Hematology Case 2 – Iron Deficiency Anemia
Presented by Group E: Jaclyn, Jaime, Jimmy and Navin

2. Hematology Case 2 Overview
History
Physical Examination
Lab Investigations: results and interpretation
Assessment: DDx and most likely Dx
Management
Prognosis and Patient education
Overview of the Presentation
History
Physical Examination
Investigations: including results and interpretation
Assessment: including DDx and the 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.
Patient History
67 year old female with shortness of breath on exertion, easy fatigability, and lack of energy for the past 2 to 3 months
She 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?
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 (vegetarian)
Past medical history including surgical history
Medication use
Family history
Have 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 Exam
Skin pallor noted. The rest of the physical examination is unremarkable.
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 µmol/L
transferrin 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 normal
Laboratory Investigations
Complete 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 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 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
Interpretation of Lab Results – Key Findings
This patient has a low erythrocyte count, even adjusted for her age and sex
Her Hemoglobin and Hematocrit levels all are low enough to explain her shortness of breath with exertion
Her mean corpuscular volume (MCV) and Ferritin levels are markedly low; both consistent with ferropenic, microcytic anemia
Microcytosis, Elliptocytosis, and Hypochromasia are consistent with Iron deficiency
The blood smear shows slight anisocytosis and elevated red cell distribution width, which is likely due to her anemia
Her Ferritin level is low indicating her total amount of iron stores are depleted
Low serum Iron, increased Total Iron Binding Capacity and low transferrin saturation are consistent with an Iron deficiency anemia, which confirm our previous findings
WBCs show no leukocytosis and differential does not show any left shift, therefore infection is unlikely
Platelets are normal
No 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 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 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
Differential Diagnosis
These 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 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
Most Likely Diagnosis
The 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 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
Iron 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. Management
Overall: management plan consists of establishing the etiology of the iron deficiency and correcting it so the deficiency does not recur
In our 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 month monitoring to assess adequate response to iron therapy
Management of hemorrhage (unlikely in our patient)
Surgical treatment to help correct blood loss
Our management plan consists of establishing the etiology of the iron deficiency and correcting it so the deficiency does not recur
The 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 iron
Our patient should be counseled on an individual basis with a Dietician, emphasizing the importance of improving her diet
Her physical activity should be tailored, gradual exercise as is tolerated
Monitoring her for 1-3 months to asses an adequate response to iron therapy is also necessary
Although 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 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
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
In 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. References
Anemia 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