Case studies |
Summary |
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Case study one MIKE, a 41-year-old Caucasian man, presents with a history of several weeks of increasing fatigue, intermittent palpitations and progressive shortness of breath on exertion. He has no past medical history and is not on any regular medications. On examination, he is pale and tachycardic( heart rate 110bpm). Examination is otherwise unremarkable.
Mike’ s bloods reveal the following:
• Full blood count: Hb: 57g / L, WCC: 5.0x10 9 / L, platelets: 253x10 9 / L MCV: 59fL reticulocytes: 66x10 9 / L
• Iron studies: iron: 18 µ mol / L, transferrin: 3.9 µ mol / L, transferrin saturation: 18 %, ferritin: 3 µ g / L
Case study two Liz, aged 30, and pregnant with her second child, is referred to a haematologist during her third trimester of pregnancy. She has been diagnosed with a marked anaemia due to mixed nutritional deficiencies following barometric sleeve gastrectomy in late 2011.
Her first pregnancy was conceived several months after the operation in 2012 and was complicated by early PV bleeding. She was induced at 37 weeks’ gestation for fetal failure to thrive, at which stage she was found to have a normocytic anaemia, with haemoglobin of 98g / L. Her iron studies were borderline, with
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• Blood film: Peripheral blood film shows microcytic, hypochromic anaemia with occasional elliptocytes, pencil cells and tear drops cells.
• EUC and LFTs: normal
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Peripheral blood film shows microcytic, hypochromic anaemia with occasional elliptocyes, pencil cells and tear drops cells.
Mike undergoes panendoscopy and colonoscopy. Endoscopy identified a large, invasive adenocarcinoma in the distal oesophagus as the cause of his iron deficiency anaemia.
a ferritin of 18 µ g / L, and her vitamin B12 level was extremely low at 38pmol / L. She received intramuscular hydroxocobalamin injections and‘ multivitamins’, which successfully treated the anaemia.
She spontaneously conceived her second pregnancy in mid-May 2016 and her obstetrician referred her to the haematologist at 33 weeks’ gestation. Liz’ s haemoglobin was 82g / L and she had a reduced MCV of 73fL. She had virtually absent iron stores, with a ferritin of less than 5 µ g / L and a low vitamin B12 level of 75pmol / L. As per the Patient Blood Management Guidelines: Module 5 Obstetric and Maternity recommendations
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( see online resources) she was offered intravenous iron carboxymaltose to replete her iron stores prior to delivery. She also received aggressive vitamin B12 replacement.
Liz was induced at 37 weeks’, again for fetal failure to thrive. At this stage her haemoglobin had increased to 115g / L, her MCV had improved to 78fL and her iron stores had increased to 68 µ g / L. She was advised to continue lifelong iron and vitamin B12 supplementation because of her reduced ability to absorb adequate iron and vitamin B12 following sleeve gastrectomy.
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IRON deficiency is a frequent problem in primary care. It occurs in all age groups for a variety of reasons. Iron deficiency is prevalent in infancy, adolescence and during pregnancy due to increased physiological needs, nutritional deficits and social factors. However, iron deficiency still requires investigation, as it may reveal pathological menstrual blood loss or an occult gastrointestinal malignancy.
Oral iron supplementation with preparations that contain adequate amounts of elemental iron( 100- 210mg daily) is the cornerstone of treatment. Oral iron supplementation should continue for 3-6 months after the normalisation of the serum ferritin in adults, and for 2-3 months after the normalisation of the serum ferritin in children.
Some patients may require parenteral iron replacement because of intolerance or inadequate response to oral iron supplementation.
Intravenous iron preparations have become increasingly safe and easier to administer over the past decade, such that intramuscular parenteral iron should be avoided, if possible.
Blood transfusion for compensated anaemia due to iron deficiency is inappropriate and should only be considered in those with end-organ compromise due to severe anaemia or rapid, ongoing blood loss.
Key points
• Iron deficiency is common and can occur in all ages.
• Iron deficiency needs to be investigated and treated.
• Oral iron supplementation is the cornerstone of treatment.
• Ensure oral iron supplementation contains adequate amounts of elemental iron( 100-210mg daily).
• Oral iron supplementation should continue for several months after normalisation of serum ferritin.
• Parenteral iron replacement may be required because of intolerance or inadequate response to an adequate trial oral iron supplementation.
• Blood transfusion for compensated iron deficiency anaemia is inappropriate.
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1. Which TWO statements regarding iron homeostasis are correct? a) A typical, healthy adult will have a total body iron store of 3-4g. b) Adult males and non-menstruating women lose 2mg of iron per day, while menstruating women can lose an additional 2mg per day through menstrual blood loss. c) The only mechanism by which humans maintain iron homeostasis is the regulation of oral iron absorption from the gastrointestinal tract via hepcidin. d) The homeostasis of iron is regulated by ghrelin and leptin.
2. Which THREE statements regarding the epidemiology and pathogenesis of iron deficiency are correct? a) There is considerable variation in individuals’ iron requirements based on age, sex and comorbidities. b) Weaned infants can be placed on cows milk from around three months of age, as it contains sufficient iron to meet their needs. c) The rates of iron deficiency and iron deficiency anaemia appear disproportionately high in Indigenous Australians.
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d) Iron deficiency in adult men and postmenopausal women is always pathological and needs to be investigated. |
3. Which TWO may be features of iron deficiency anaemia in infants and young children? a) Vomiting. b) Poor feeding. c) Failure to thrive. d) Pneumonia.
4. Which THREE may be presenting features in adults with iron deficiency anaemia? a) Weight gain. b) Non-specific features such as fatigue. c) Reduced exercise tolerance. d) Pica.
5. Which TWO investigations are appropriate to assess for iron deficiency? a) Serum iron. b) Soluble serum transferrin receptor. c) Iron staining of bone marrow particles. d) Serum ferritin.
6. Which THREE conditions of the differential
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diagnoses of iron deficiency anaemia? a) Alpha-thalassaemia trait. b) Wilson’ s disease. c) Beta-thalassaemia. d) Anaemia of chronic disease.
7. Which TWO statements regarding the treatment of iron deficiency are correct? a) Consider oral iron supplementation as firstline treatment for all causes of uncomplicated cases of iron deficiency. b) Change infants younger than six months who are still solely breastfed or using non-fortified infant formula to cows milk as it assists in the absorption of oral iron. c) High doses of supplemental iron can be toxic or even fatal in children. d) Oral iron is best absorbed if taken with food.
8. Which THREE are indications for parental iron? a) Failure of an adequate trial of oral iron supplementation. b) Proximal small bowel resection. c) The lingering metallic taste in the mouth following ingestion of oral iron supplementation.
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d) Chronic renal failure patients receiving erythropoietin-stimulating agents.
9. Which TWO statements regarding pregnancy and iron are correct? a) All women require iron supplementation during pregnancy because of the increased iron need. b) Parenteral iron administered between 8 and 12 weeks of pregnancy will usually correct iron deficiency anaemia, with no need for continued oral iron supplementation. c) A dose of oral iron supplementation( 100- 200mg elemental iron daily) is recommended in all maternity patients with confirmed iron deficiency anaemia. d) Iron supplementation should continue for a minimal of three months after the normalisation of the haemoglobin, or for at least six weeks post-partum.
10. Which THREE may be reasons for nonresponse to oral iron supplementation? a) Laboratory error. b) Incorrect diagnosis. c) Continued, excessive blood loss. d) Non-adherence to oral iron.
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CPD POINTS |