Cause of this Patient’s Iron-Deficiency Anemia

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
Iron-Deficiency Anemia
Case Study
A 72-year-old man developed chest pain whenever he was physically active. The pain ceased on
stopping his activity. He has no history of heart or lung disease. His physical examination was
normal except for notable pallor.
Studies Result
Electrocardiogram (EKG), p. 485 Ischemia noted in anterior leads
Chest x-ray study, p. 956 No active disease
Complete blood count (CBC), p.
156
Red blood cell (RBC) count, p.
396
2.1 million/mm (normal: 4.7–6.1 million/mm)
RBC indices, p. 399
Mean corpuscular volume
(MCV)
72 mm3
(normal: 80–95 mm3
)
Mean corpuscular hemoglobin
(MCH)
22 pg (normal: 27–31 pg)
Mean corpuscular hemoglobin
concentration (MCHC)
21 pg (normal: 27–31 pg)
Red blood cell distribution width
(RDW)
9% (normal: 11%–14.5%)
Hemoglobin (Hgb), p. 251 5.4 g/dL (normal: 14–18 g/dL)
Hematocrit (Hct), p. 248 18% (normal: 42%–52%)
White blood cell (WBC) count, p.
466
7800/mm3
(normal: 4,500–10,000/mcL)
WBC differential count, p. 466 Normal differential
Platelet count (thrombocyte
count), p. 362
Within normal limits (WNL) (normal: 150,000–
400,000/mm3
)
Half-life of RBC 26–30 days (normal)
Liver/spleen ratio, p. 750 1:1 (normal)
Spleen/pericardium ratio <2:1 (normal)
Reticulocyte count, p. 407 3.0% (normal: 0.5%–2.0%)
Haptoglobin, p. 245 122 mg/dL (normal: 100–150 mg/dL)
Blood typing, p. 114 O+
Iron level studies, p. 287
Iron 42 (normal: 65–175 mcg/dL)
Total iron-binding capacity
(TIBC)
500 (normal: 250–420 mcg/dL)
Transferrin (siderophilin) 200 mg/dL (normal: 215–365 mg/dL)
Transferrin saturation 15% (normal: 20%–50%)
Case Studies
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2
Ferritin, p. 211 8 ng/mL (normal: 12–300 ng/mL)
Vitamin B12, p. 460 140 pg/mL (normal: 100–700 pg/mL)
Folic acid, p. 218 12 mg/mL (normal: 5–20 mg/mL or 14–34 mmol/L)
Diagnostic Analysis
The patient was found to be significantly anemic. His angina was related to his anemia. His
normal RBC survival studies and normal haptoglobin eliminated the possibility of hemolysis..
His RBCs were small and hypochromic. His iron studies were compatible with iron deficiency.
His marrow was inadequate for the degree of anemia because his iron level was reduced.
On transfusion of O-positive blood, his angina disappeared. While receiving his third unit of
packed RBCs, he developed an elevated temperature to 38.5°C, muscle aches, and back pain.
The transfusion was stopped, and the following studies were performed:
Studies Results
Hgb, p. 251 7.6 g/dL
Hct, p. 248 24%
Direct Coombs test, p. 157 Positive; agglutination (normal: negative)
Platelet count, p. 362 85,000/mm3
Platelet antibody, p. 360 Positive (normal: negative)
Haptoglobin, p. 245 78 mg/dL
Diagnostic Analysis
The patient was experiencing a blood transfusion incompatibility reaction. His direct Coombs
test and haptoglobin studies indicated some hemolysis because of the reaction. His platelet count
dropped because of antiplatelet antibodies, probably the same ABO antibodies that caused the
RBC reaction.
He was given iron orally over the next 3 weeks, and his Hgb level improved. A rectal
examination indicated that his stool was positive for occult blood. Colonoscopy indicated a rightside colon cancer, which was removed 4 weeks after his initial presentation. He tolerated the
surgery well.
Critical Thinking Questions
1. What was the cause of this patient’s iron-deficiency anemia?
2. Explain the relationship between anemia and angina.
3. Would your recommend B12 and Folic Acid to this patient? Explain your rationale for
the answer
4. What other questions would you ask to this patient and what would be your rationale for
them?

1. What was the cause of this patient’s iron-deficiency anemia?

   The patient’s iron-deficiency anemia was likely caused by chronic blood loss from a right-side colon cancer. The rectal examination indicated positive occult blood in the stool, and the subsequent colonoscopy confirmed the presence of colon cancer. Chronic blood loss is a common cause of iron-deficiency anemia in older adults, especially when associated with gastrointestinal malignancies.

2. Explain the relationship between anemia and angina.

   Anemia leads to a decreased oxygen-carrying capacity of the blood due to the reduced hemoglobin levels. This results in decreased oxygen delivery to tissues, including the heart. During physical activity, the heart requires more oxygen to meet the increased metabolic demands. In the presence of anemia, this increased demand cannot be met, leading to myocardial ischemia and resulting in angina, which is the chest pain experienced by the patient.

3. Would you recommend B12 and Folic Acid to this patient? Explain your rationale for the answer.

   B12 and folic acid supplementation may not be necessary for this patient based on the provided lab results. The patient’s vitamin B12 level is within the normal range (140 pg/mL, normal: 100–700 pg/mL), and the folic acid level is also normal (12 mg/mL, normal: 5–20 mg/mL). Therefore, supplementation with these vitamins is not indicated as there is no evidence of deficiency. The primary focus should be on addressing the iron deficiency and the underlying cause of the anemia.

4. What other questions would you ask this patient, and what would be your rationale for them?
   • Question: Have you noticed any changes in your bowel habits, such as the frequency, consistency, or color of your stools?
     • Rationale: Changes in bowel habits can be indicative of gastrointestinal issues, including bleeding or malignancies, which could be contributing to the anemia.
   • Question: Have you experienced any weight loss, loss of appetite, or fatigue recently?
     • Rationale: These symptoms can be associated with chronic illnesses, including cancer and anemia, and can help in assessing the overall impact of the disease on the patient’s health.
   • Question: Have you had any previous episodes of gastrointestinal bleeding or any known gastrointestinal disorders?
     • Rationale: A history of gastrointestinal bleeding or disorders can provide insight into potential chronic sources of blood loss contributing to the anemia.
   • Question: Are you currently taking any medications, including over-the-counter drugs and supplements?
     • Rationale: Some medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), can cause gastrointestinal bleeding and contribute to anemia. Understanding the patient’s medication history is essential for a comprehensive assessment.
   • Question: Have you noticed any other unusual symptoms, such as dizziness, shortness of breath, or palpitations?
     • Rationale: These symptoms can be associated with severe anemia and help gauge the severity of the patient’s condition and its impact on daily activities.
   • Question: How is your diet, and do you consume foods rich in iron?
     • Rationale: Dietary intake plays a significant role in iron levels. Assessing the patient’s diet can help identify any nutritional deficiencies contributing to the anemia.