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 mm 3 (normal: 80–95 mm
3 )
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/mm 3 (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/mm 3 )
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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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/mm 3
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 right-
side 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?
- The cause of this patient’s iron-deficiency anemia appears to be multifactorial. The key factors contributing to his anemia are:
a. Blood Loss: The presence of occult blood in his stool and the subsequent diagnosis of right-side colon cancer suggest that chronic gastrointestinal bleeding from the tumor contributed significantly to his anemia. The slow and chronic nature of this bleeding led to a gradual depletion of iron stores.
b. Inadequate Dietary Iron Intake: The low iron levels seen in the iron studies (low serum iron, low transferrin saturation, and low ferritin) indicate that his dietary iron intake was insufficient to meet his body’s iron needs, exacerbating the anemia.
c. Blood Transfusion Reaction: While receiving a blood transfusion, the patient developed a transfusion incompatibility reaction, which resulted in hemolysis of the transfused red blood cells. This episode further worsened his anemia.
- The relationship between anemia and angina lies in the reduced oxygen-carrying capacity of the blood due to low hemoglobin levels in anemic individuals. Hemoglobin is responsible for transporting oxygen to the body’s tissues, including the heart muscle. In cases of severe anemia, like this patient’s, the blood’s ability to deliver sufficient oxygen to the heart is compromised. As a result, the heart may not receive an adequate oxygen supply during increased physical activity, leading to chest pain or angina. This pain typically subsides when the activity is stopped because the heart’s oxygen demand decreases. Therefore, in this case, the patient’s angina was likely a consequence of his severe iron-deficiency anemia.
- Regarding vitamin B12 and folic acid supplementation:
a. Vitamin B12: This patient’s vitamin B12 levels are low (140 pg/mL), indicating a deficiency. However, it’s essential to address the underlying cause of the anemia first, which is primarily iron deficiency and gastrointestinal bleeding from colon cancer. Treating the underlying cause, which includes surgical removal of the cancer and iron supplementation, should improve the anemia. Therefore, immediate vitamin B12 supplementation may not be necessary, but monitoring for B12 deficiency-related symptoms should continue.
b. Folic Acid: The patient’s folic acid levels (12 mg/mL) are within the normal range. Since there is no evidence of folate deficiency, and the primary cause of anemia is iron deficiency and gastrointestinal bleeding, supplementation with folic acid may not be required at this time.
- Additional questions to ask the patient:
a. Gastrointestinal Symptoms: Ask about any gastrointestinal symptoms such as abdominal pain, changes in bowel habits, or black, tarry stools to further assess the extent of gastrointestinal bleeding and the need for additional diagnostic tests or interventions.
b. Medical History: Inquire about any past medical conditions, surgeries, or family history of gastrointestinal disorders or anemia to gain a more comprehensive understanding of the patient’s health.
c. Medication and Allergies: Ask about the patient’s current medications and any known drug allergies, as these may have relevance to the treatment plan.
d. Dietary Habits: Explore the patient’s dietary habits, especially regarding iron-rich foods and any dietary restrictions or preferences that might have contributed to his iron-deficiency anemia.
e. Symptoms: Inquire about any other symptoms he may be experiencing, such as fatigue, weakness, dizziness, or shortness of breath, to assess the overall impact of anemia on his daily life.
f. Follow-Up Plans: Discuss the need for ongoing monitoring of his anemia and the importance of adhering to treatment plans, including follow-up appointments and potential nutritional counseling.
g. Social and Lifestyle Factors: Ask about the patient’s lifestyle factors, such as alcohol consumption and smoking, as these can impact anemia and recovery.
These questions aim to gather a more comprehensive medical history and aid in tailoring the patient’s treatment plan and follow-up care.