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Case presentation

Dr. Minodora Onisi

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?

SUPERIOR DIGESTIVE TRACT


ENDOSCOPY
Small diaphragmatic hernia

INFERIOR DIGESTIVE TRACT


ENDOSCOPY
Patient refuses

Hemocult test
Positive!
Discussion: diaphragmatic hernia?
Remember he was a chronic NSAIDs consumer!

CT scan of the abdomen


Small tumor of the ascending large bowel, located only
on the ceccum.
No signs of spreading to surrounding tissues.
No signs of metastases.
No enlarged lymph nodes.

INFERIOR DIGESTIVE TRACT


ENDOSCOPY
The ceccum presented an ulcerated tumor with recent
bleeding signs, with a malignant aspect.
No risk of occlusion (small tumor) hence the patient
never presented diarrhea / constipation.
Multiple biopsies are taken.

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 oral iron


- Pills, syrup
- Iron is absorbed as Fe ++
- Fe+++ is reduced in the duodenum to Fe ++
- Ex: Ferro-Gradumet , Tardyferon, Fumafer, Ascofer,
Tothema, etc

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.

Total Iron (mg) =


weight (kg) x (aimed Hb present Hb)(g/l) x 2.4 +
500 mg

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?

Treatment in this case


I.V. Iron 5 administrations
Packed red cells transfusion (pre-op)
Surgery the ceccum is removed along with the tumor,
without any incidents.
The patient is referred to an oncologist for further
therapy and followup.

Proteina transportatoare a fierului este :


a) Hemosiderina
b) Feritina
c) Transferina
d) Albumina
e) Haptoglobina

Pe un frotiu de sange periferic se constata


microcitoza si hipocromie importanta cu prezenta
de anulocite. Care din urmatoarele se pot asocia
acestui aspect hematologic :
a)Disfagia
b)Paloarea cu tenta icterica
c)Sideroblasti 5%, hemosiderina medulara
absenta
d)Sideroblasti inelari 20 %
e)Splenomegalia

Cu referire la anemia sideropenica din


infectiile cronice sunt corecte afirmatiile:
a)Sideroblastii inelari sunt patognomonici
b)Fierul este prezent in macrofagele
medulare
c)Microcitoza eritrocitara este un semn
constant
d)Fierul va fi administrat numai pe cale
parenterala
e)Tratamentul cu fier este contraindicat

Care din urmatoarele afirmatii diferentiaza


in mod cert anemia prin carenta de fier de
anemia inflamatorie pura ?
a)Numarul de eritrocite
b)Nivelul feritinei
c)Nivelul reticulocitelor
d)Sideremia scazuta
e)Mielograma

Terapia parenterala cu Fe este indicata in:


a) Malabsorbtia intestinala severa
b) Ulcerul gastric
c) Gravide in primele doua trimestre de sarcina
d) Donatorii de sange
e) Pierderi de sange necontrolate prin tratamentul oral

Deficienta de fier la barbatul adult este cauzata , cel mai


adesea de:
a)Carenta alimentara prelungita
b)Aclorhidria gastrica
c)Malabsorbtia intestinala
d)Hemoragia gastro-intestinala
e)Hemoragia traumatica

Care din urmatoarele afirmatii, cu referire la


anemia feripriva , NU sunt corecte :
a)Hemosiderina medulara este absenta
b)Sideroblastii medulari >10% sunt prezenti
intotdeauna
c) Coef de saturare este <16%
d)Terapia cu Fe se face pana la
normalizarea Hb
e)Koilonichia dispare cu normalizarea
fierului

Care din urmatoarele elemente intalnite in anemia


feripriva sunt reale :
a)Saturatia transferinei >30%
b)Feritina plasmatica normala
c)Feritina plasmatica scazuta
d)TIBC scazuta
e)TIBC crescuta