IRON DEFICIENCY ANEMIA

1

case-• An 18 year old female reported to the physician for

consultation . She complained of --• generalised weakness, lethargy and inability to do

routine work from the previous few month.• On further questioning she revealed that she was

having excessive bleeding during mensturation from the previous six months.

• She complained of breathlessness and palpitation while climbing stairs for her house .

• She also had experienced periods of light-headedness , though not to the point of fainting.

• there was no history of any fever , drug intake or abdominal discomfort . Her appetite had also decreased and she was taking meals only once a day.

On examination • She had tachycardia , pale gums and nail beds and

her toungue was swollen.• Her blood examination show-• Red blood cell count – 3.5millon/mm3• Hemoglobin – 7g/dl• Haematocrit - 30%• Serum iron - low• Mean corpuscular volume (MCV)- low• Mean corpuscular Hb concentration (MCHC)-low• Total iron binding capacity in blood (TIBC) - high

Case discussion • The most likely diagnosis is Iron Deficiency Anemia.

• Generalised weakness, exercise intolerance, dyspnoea, palpitaion, history of blood loss during menstruation, tachycardia and low Hb, all suggestive of iron deficiency anemia.

Clinical features

• Symptoms:• fatigue, dyspnoea, palpitaion

-Dizziness , headache, vertigo

-Sleep disturbance , lack of concentration

-Nausea , bowel disturbance

-Symptoms of cardiac failure

signs pallor of skin, palms, oral mucous membrane , nail

beds and palpebral conjunctiva.

- koilonychia

- odema

-Glossitis

- Angular chelitis

DIAGNOSIS• History• CBC: low Hb, low

hematocrit, low MCV, MCH,MCHC

• PS: hypochromic microcytic RBCs. May also show poikilocytosis and anisocytosis. Target cells, elliptical cells are often present.

• Serum iron & TIBC:Serum iron represents the amount of circulating

iron bound to transferrin.TIBC is an indirect measure of circulating

transferrin.Normal serum iron: 50 - 150 µg/dl normal TIBC range: 300- 360 µg/dl

• Serum ferritin:Most convenient test to estimate iron stores.Serum ferritin level falls as iron stores are

depleted.Normal range: 15 – 300µg/L

• Red cell protoporphyrin level:Intermediate in patheway of heme synthesis.Accumulates inside RBC when heme synthesis is

impaired.Normal value: <30µg/dl, in iron deficiency

>100µg/dl• Serum level of transferrin receptor protein:

Erythroid cells have highest no of transferrin receptors.

Normal value 4-9µg/LRaised in iron deficiency due to its release in

circulation.• bone marrow iron store:

Provides info about effective iron delivery to developing erythroblasts.

TESTS VALUE

smear Microcytic / hypochromic

Serum iron(µg/dl) <30

TIBC(µg/dl) >360

Percent saturation <10%

Ferritin (µg/L) <15

MANAGEMENT• Depends on severity and causes of iron deficiency.• Oral iron therapy:

Simple iron salts to complex iron compounds designed for sustained release.

Upto 200mg of elemental iron per day is given in divided doses.

S/E: nausea, abdominal discomfort, diarrhoea

Iron salts Iron content Elemental ironFerrous sulfate 325mg 65mg

Ferrous fumarate 325mg 107mg

Ferrous gluconate 325mg 39mg

Polysaccharide iron 150mg 150mg

Ferrous sulphate 200mg 3 times daily is adequate and should be continued for 3-6 months to replete iron stores.

Ferrous gluconate 300mg twice daily(70mg elemental iron per day)

The Hb should rise by around 10g/L every 7-10 days and a reticulocyte response will be evident in a week.

• Parenteral iron therapy:Patient with malabsorption or chronic gut disease

may need parenteral iron.The total dose is calculated by a simple formula: body wt(kg) X 2.3 X (15 - pt’s Hb) + additional

500mg for building up iron stores.Commonly used iron dextran, iron sucrose.Newer preparation: iron isomaltose and iron

carboxymaltose.Either given in a single large dose to correct Hb

and replenish iron stores or given in small divided doses for a longer period of time.

Anaphylaxis is commonly seen in case of iron dextran. Test dose of 25mg is given prior to it.

• Red cell transfusion: Not commonly used.Reserved for individual who have symptoms of

anemia, cardiovascular instability and excessive blood loss.