1. Explain "tasting for eating ice". Spooning of nails.

 

 

 

 

 

 

 

 

 

2. How reliable is physical examination in diagnosing anemia?

Obviously patient is anemic. Her red cell mass is decreased. In order to understand and manage this patient we need to have some basic knowledge about Red cells..

 

 

 

 

 

 

 

 

 

3. What is the normal

Maturation stages

Morphological characteristics

Hemoglobin synthesis involves 2 biosynthetic pathways

Red cell turnover

Control of erythropoiesis

 

 

 

 

 

 

 

 

 

4. What is the main function of RBC's?

Transport of oxygen is influenced by pH, 2-3-DPG level and valence of iron.

Let us go through the steps in evaluation of a patient with anemia.

  1. Distinction between hypo and hyperproliferative anemia

  2. Use of red cell size to further narrow down the possibilities

  3. Review the blood smear

 

 

 

 

 

 

 

 

 

5. First step is to make a distinction between hypo- and hyperproliferative anemia. How will you decide that? What is your understanding of  those terms?

Reticulocyte count helps to categorize the anemia into hypo-or hyper-proliferative type.

Hypoprolifearative: 

Hyperproliferative: 

 

 

 

 

 

 

 

 

 

6. How will you recognize reticulocytes in the peripheral smear?

 

 

 

 

 

 

 

 

 

7. How do you count and express reticulocyte count? 

There are three ways to express retic response

  1. Retic count

  2. Corrected retic count

  3. Absolute retic count

Retic count: Reticulocytes are counted as the number of NMB-reactive cells per 1,000 red cells and expressed as percent reticulocytes (absolute number per 100 red cells).

Her  reticulocyte count  is 2.5%. 

Corrected reticulocyte count  = %reticulocyte X (Patient's Hct/Expected normal Hct of 40)

Our patient's Corrected reticulocyte count is 2.5 x 23 / 40. It is 1.2%. 

Less than 2% =  hypoproliferative type. This means that her anemia is due to underproduction of red cells by the bone marrow. 

Absolute Reticulocyte count

The absolute reticulocyte count in our patient is 69,000/mm3. 

Now we know that we are dealing with hypoproliferative anemia. The next step is to evaluate the size of RBC's

 

 

 

 

 

 

 

 

 

8. How do MCV and RDW help you in the diagnostic work-up of anemia? Do the other indices-Mean Corpuscular Hemoglobin (MCH) and Mean Corpuscular Hemoglobin Concentration (MCHC)-add anything?

In our patient the MCV is 74 fl  indicating that we are dealing with microcytic anemia. 

The next step is to review the peripheral smear. 

She has microcytic hypo chromic anemia.

 

 

 

 

 

 

 

 

 

9. What is the differential for microcytic hypo chromic anemia.

 

 

 

 

 

 

 

 

 

10. Does microcytic anemia represents a maturation defect or abnormal hemoglobin synthesis?

 

 

 

 

 

 

 

 

 

11. Iron deficiency leads to faulty heme synthesis. What are the consequences?

 

 

 

 

 

 

 

 

 

12. How would you proceed to differentiate between the different possibilities for  microcytic anemia?

 

 

 

 

 

 

 

 

 

13. What further tests would you like to do  to confirm iron deficiency in this patient? 

  1. Serum Iron

  2. Total Iron-binding capacity

  3. Saturation

  4. Ferritin

Serum Iron measures Transferrin-associated ferric ion  Normal Range: 12.7 to 35.9 µmol/L (60 to 180 µg/dl) Decreased serum iron levels may precede changes in red cell morphology or in red cell indices All transport iron in the plasma is bound in the ferric form to the specific iron-binding protein, transferrin. Serum iron refers to this transferrin-bound iron. Serum iron concentration is increased in the sideroblastic anemia's and in some cases of thalassemia.

Total Iron-binding capacity  Normal Range: 45.2 to 77.7 µmol/L (250 to 410 µg/dl) TIBC, the concentration iron necessary to saturate the iron-binding sites of transferrin, is a measure of transferrin concentration.

Transferrin Normal range170-370 mg/dl 

Saturation of transferrin is calculated by the following formula % Transferrin Saturation = Serum Iron (mol/L) X 100.: Normal mean transferrin saturation is approximately 30%. Normal range 20% to 50%

A normal plasma iron level and iron-binding capacity do not rule out the diagnosis of iron deficiency when the hemoglobin level of the blood is above 90 g/L (9 g/dl) (females) and 110 g/L (11g/dl) (males). 

Her serum iron is 21 microgram/dl and total iron binding capacity 408 microgram/dl.  Her iron saturation is about 5%. 

 

 

 

 

 

 

 

 

 

14. What is ferritin? How do you interpret low and high ferritin values?

Her Serum Ferritin is 3 

 

 

 

 

 

 

 

 

 

15. Is there a need to obtain a hemoglobin electrophoresis?

Hemoglobin electrophoresis should not be ordered at this time. She could have an alpha thalessemia trait but hemoglobin electrophoresis is not of any help in diagnosing that condition. In iron deficiency, levels of Hg A2 and F may also be low, making diagnosis of ß-thalassemias more difficult.

 

 

 

 

 

 

 

 

 

16. Should one do a bone marrow test in this patient? If one did , what would you expect to see?

The bone marrow should not be done. There is already strong evidence for iron deficiency anemia. If it is done , stains for iron will show depletion of Iron stores. There will be erythroid hyperplasia.

 

 

 

 

 

 

 

 

 

17. Could she have 'anemia of chronic disorder'? What are the known mechanisms of anemia of chronic disorder?

 

 

 

 

 

 

 

 

 

18. Your intern wants you to order a B12 and folate level also, for sake of completeness. Is that justifiable?

This patient has iron deficiency anemia due to multiple pregnancies in a short period of time. It is not justifiable to order a B12 and folic acid level in this patient.

Now that we have confirmed that this patient has iron deficiency anemia, let us understand few basics.

 

 

 

 

 

 

 

 

 

19. What tissues /cells require Iron for normal development?

 

 

 

 

 

 

 

 

 

20. What are the normal resource for iron in diet?

Vitamins and many food items (Cereal) are fortified with iron.

 

 

 

 

 

 

 

 

 

21. What is the daily requirement of iron for a normal adult? Is it different for females or pregnant women?

 

 

 

 

 

 

 

 

 

22. This patient's old records indicate that she did not have a murmur in the past. Should one obtain an echocardiogram to rule out valvular heart disease?

She very likely has a flow murmur due to her anemia. If her murmur persist after iron therapy, further studies can be undertaken.

 

 

 

 

 

 

 

 

 

23. What are the common causes of iron deficiency anemia? Children, Young adult, Older adult. Males, Females.

Most important cause is chronic blood loss.

Menstruating women:

Males and Post menopausal women

GI tract blood loss

Nutritional deficiency (Not in USA)

Malabsorption (Sprue, gatrectomy)

Rare causes

 

 

 

 

 

 

 

 

 

24. What are the clinical sequelae to iron deficiency anemia?

 

 

 

 

 

 

 

 

 

25. What is your therapeutic strategy for treatment of iron deficiency anemia?

 

 

 

 

 

 

 

 

 

26. What treatment would you prescribe for this patient?  How soon should you expect a response?

 

 

 

 

 

 

 

 

 

27. How long will you treat her with iron supplement and why?

 

 

 

 

 

 

 

 

 

28. In which part of GI tract is iron absorbed? What else is necessary for iron absorption?

 

 

 

 

 

 

 

 

 

29. Are there any problems associated with iron therapy?

 

 

 

 

 

 

 

 

 

30. Is there a role for Blood transfusion?

You do not need blood transfusions even in severe chronically anemic patients. Patients adapt to chronic anemia extremely well and Iron replacement therapy can correct the problem gradually. You can do harm from transfusion  by throwing them into heart failure, for already they have a high output state.