ASH Image Bank (2002); doi:10.1182/ashimagebank-2002-100325
Copyright © 2002 by the American Society of Hematology.
Iron Deficiency
Stanley Schrier
Stanford University School of Medicine
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Clinical Summary
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History of present illness: You are asked to consult on a 24-year-old white female medical student who has just done her own complete blood cell count (CBC) in the lab medicine course and believes that she has found the cause of her symptoms of progressive fatigue. The feeling of fatigue and reduced exercise tolerance is quite recent and has been progressing over the past 6 to 12 months. She is a serious runner, running over 50 miles each week. Because of the accompanying aches and pains, she takes nonsteroidal anti-inflammatory drugs (NSAIDs) daily. Her periods are irregular and last 8 to 9 days with heavy flow on the first 2 days. She avoids eating meat.
Physical examination; She is a pale but otherwise healthy muscular young woman
Labs: White blood cells (WBC) 7,500, nl differential, platelets 305,000, hemoglobin (Hgb) 6.0 gm/dL, hematocrit (Hct) 18, red blood cells (RBC) 2.5M, mean corpuscular volume (MCV) 72, mean corpuscular hemoglobin (MCH) 24, mean corpuscular hemoglobin concentration (MCHC) 33, retics 2.4%, serum iron 15, transferrin 420, percentage of saturation 3.6, and ferritin 7ng/mL.
Peripheral smear (Figure 1).
Sex
Female
Age
24
Ethnicity
White
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Diagnosis
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Iron Deficiency Anemia
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Discussion
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Pathophysiology: There are several causes of her iron deficiency. Use of NSAIDs likely causes gastrointestinal (GI) irritation and we should collect stools for detection of occult GI bleeding. Her periods are irregular and long and she is possibly losing more than the normal menstrual blood loss of 30 ml per month. Lastly, her diet very much limits sources of iron to replace that lost, which is about 0.5mg/per ml whole blood. In the absence of iron, hemoglobin can not be made, but in addition iron deficiency causes an erythropoeitic production defect. Thus even though erythropoeitin (EPO) levels are elevated, there is usually minimal reticulocytosis, and marginal if any marrow erythroid hyperplasia, all of which reverses when iron is supplied.
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Differential Diagnosis
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She has a profound hypochromic microcytic anemia, and her symptoms of anemia are of recent origin. While the differential diagnosis includes thalassemia, lead toxicity, sideroblastic anemia/ myelodysplastic syndrome (MDS), and even anemia of chronic disease (ACD), her iron measurements are diagnostic of severe iron deficiency (Figure 2).
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Chapter 5: Acquired underproduction anemias
Copyright © 2002 by the American Society of Hematology.
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