Anemia Case Presentation Presented by Hanadi Basha 6 th year Med student Damascus Uni

58 y/o Male presented with general fatigue, palpitation for 2 months duration with no other complaints. PMH :IHD, previous inferior MI (the pt was hospitalized and stent was placed in LAD artery on 11/3/2008), later the pt was discharged on Clopidogrel, ASA,Metoprolol, Statin. Social hx: ex-smoker,quit 12 years ago. Employment, live in al-mafrak area. On physical examination the patient was pallor without other findings.

Investigation( positives only) CBC : RBC *6/mm*3 normal values (4-6.20) RBC *6/mm*3 normal values (4-6.20) Hgb 9.40 g/dl (11-18) Hgb 9.40 g/dl (11-18) Hct 29% (35-55) Hct 29% (35-55) MCV 112 um*3 (80-100) MCV 112 um*3 (80-100) LDH 2410 U/L ( ) LDH 2410 U/L ( )

Low Hct + low Hgb + high MCV = Macrocytic Anemia DDx vitB12 or Folic acid deficienc vitB12 or Folic acid deficienc Toxic effects of alcohol,liver disease, chemotherapeutic agents (MTX,AZT). Toxic effects of alcohol,liver disease, chemotherapeutic agents (MTX,AZT).

LFTs, KFTs were within normal limits. LFTs, KFTs were within normal limits. TFTs accomplished euthyroid state TFTs accomplished euthyroid state Vit B12 : 90 pg/ml ( ) Vit B12 : 90 pg/ml ( ) Anti parietal cell AB + Anti parietal cell AB + Anti microsomal TPO IU/ml (+ <34 ). Anti microsomal TPO IU/ml (+ <34 ). The pt was diagnosed as pernicious anemia and hashimoto thyroditisi. The pt was diagnosed as pernicious anemia and hashimoto thyroditisi.

Vit B12 deficiency Causes : Causes : The most common cause is pernicious anemia. The most common cause is pernicious anemia. Other causes : Other causes : Nutritional deficiency: This is a rare etiology Nutritional deficiency: This is a rare etiology Food-cobalamin malabsorption Food-cobalamin malabsorption Gastrectomy Gastrectomy Zollinger-Ellison syndrome Zollinger-Ellison syndrome Severe abnormalities in the terminal ileum due to ileal resection, regional ileitis, or lymphoma Severe abnormalities in the terminal ileum due to ileal resection, regional ileitis, or lymphoma Diphyllobothrium latum (ie, fish tapeworm) Diphyllobothrium latum (ie, fish tapeworm) Blind loop syndrome Blind loop syndrome Nitrous oxide Nitrous oxide

Work up for macrocytic anemia A CBC count, RBC indices, platelet count, differential count, reticulocyte count, and microscopic examination of the peripheral blood smear should be performed. A CBC count, RBC indices, platelet count, differential count, reticulocyte count, and microscopic examination of the peripheral blood smear should be performed.

LDH and indirect bilirubin assays should be ordered. LDH and indirect bilirubin assays should be ordered. Wat do u suspect ? High,low,normal ? Why ? Serum iron and ferritin assays should be ordered initially and during the treatment of megaloblastic anemia. Serum iron and ferritin assays should be ordered initially and during the treatment of megaloblastic anemia. High or low ? Why ? Vit B12 level. Vit B12 level. Schilling test. Schilling test.

Antiparietal cell antibodies are rarely ordered in current practice. Of patients with pernicious anemia, 90% are positive for these antibodies. However, antiparietal cell antibodies are also present in patients with thyroid disease and other autoimmune disorders. Antiparietal cell antibodies are rarely ordered in current practice. Of patients with pernicious anemia, 90% are positive for these antibodies. However, antiparietal cell antibodies are also present in patients with thyroid disease and other autoimmune disorders. Anti-IF antibodies (type I and II) are highly specific for pernicious anemia. However, tests for these are rarely ordered to diagnose or treat patients with megaloblastosis. Anti-IF antibodies (type I and II) are highly specific for pernicious anemia. However, tests for these are rarely ordered to diagnose or treat patients with megaloblastosis.

Tests for folate deficiency (Serum folate is the earliest indicator of folate deficiency (. Tests for folate deficiency (Serum folate is the earliest indicator of folate deficiency (. Imaging Studies Imaging Studies Abdominal x-ray films, upper and lower GI series, and CT scans may be useful for detecting and evaluating blind loop syndromes, strictures, and other gastrointestinal tract abnormalities that may cause a blind loop syndrome. Abdomen CT was ordered but the pt didn ’ t do it. Abdomen CT was ordered but the pt didn ’ t do it.

Procedures Procedures Bone marrow aspiration and biopsy results are useful to confirm the diagnosis, to rule out myelodysplasia, and to assess the iron stores. Marrow is cellular with erythroid hyperplasia. Megaloblastic RBC precursors are abundant, and giant metamyelocytes are present. Iron stores may vary from high to low. The bone marrow begins to convert from megaloblastic to normoblastic within 12 hours, and normalization is complete within 2-3 days. Therefore, bone marrow aspiration should be performed as soon as possible and preferably before therapy if the procedure is considered useful for the patient's treatment. Bone marrow aspiration and biopsy results are useful to confirm the diagnosis, to rule out myelodysplasia, and to assess the iron stores. Marrow is cellular with erythroid hyperplasia. Megaloblastic RBC precursors are abundant, and giant metamyelocytes are present. Iron stores may vary from high to low. The bone marrow begins to convert from megaloblastic to normoblastic within 12 hours, and normalization is complete within 2-3 days. Therefore, bone marrow aspiration should be performed as soon as possible and preferably before therapy if the procedure is considered useful for the patient's treatment.

Pernicious anemia overview Pernicious anemia is a chronic illness caused by impaired absorption of vitamin B-12 because of a lack of intrinsic factor (IF) in gastric secretions. Pernicious anemia is a chronic illness caused by impaired absorption of vitamin B-12 because of a lack of intrinsic factor (IF) in gastric secretions. Pernicious anemia occurs as a relatively common adult form of anemia that is associated with gastric atrophy and a loss of IF production and as a rare congenital autosomal recessive form in which IF production is lacking without gastric atrophy. Pernicious anemia occurs as a relatively common adult form of anemia that is associated with gastric atrophy and a loss of IF production and as a rare congenital autosomal recessive form in which IF production is lacking without gastric atrophy.

Clinically signs of anemia + neuro complaints due to Vit B12 deficiency(may involve almost any level of the CNS )

Work up Same as macrocytic anemia Same as macrocytic anemia EGD should be done to confirm gastric atrophy and to rule out malignancy EGD should be done to confirm gastric atrophy and to rule out malignancy Our pt had an EGD and biopsy was taken Our pt had an EGD and biopsy was taken There was gastric atrophy with complete absence of rugae (folds ). There was gastric atrophy with complete absence of rugae (folds ). Biopsy showed chronic gastritis with intestinal metaplasia. Biopsy showed chronic gastritis with intestinal metaplasia. Atrophy was severe with absence of parietal cells. Atrophy was severe with absence of parietal cells.

Treatment Cyanocobalamin (Crystamine, Cyomin) Deoxyadenosylcobalamin and hydroxocobalamin are active forms of vitamin B-12 in humans. Deoxyadenosylcobalamin and hydroxocobalamin are active forms of vitamin B-12 in humans. 100mcg IM qd for 1 wk, followed by 100 mcg IM qwk for 5-6 wk, then 100 mcg IM qmo for life; alternatively, PO mcg/d. 100mcg IM qd for 1 wk, followed by 100 mcg IM qwk for 5-6 wk, then 100 mcg IM qmo for life; alternatively, PO mcg/d.

Thanx for your listening Hanadi