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

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

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.

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?

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

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+ 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

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 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

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

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

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

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

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.

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 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