Case 1: Recurrent iron-deficiency anemia in a teenager

A 16-year-old girl was referred by her paediatrician for evaluation

of persistent microcytic anemia. Two years previously, she
presented to her local hospital complaining of fatigue and
weakness. At that point, her hemoglobin level was 46 g/L, with a
low mean corpuscular volume and decreased iron and ferritin
levels. She had no evidence of gastrointestinal bleeding and was
otherwise healthy. Furthermore, she reported a regular
menstruation cycle without increase in blood loss. She received a
blood transfusion and was started on iron supplements, to which she had a good response
as her hemoglobin level rose up to 129 g/L. Her clinical symptoms also resolved and iron
supplementation was discontinued one year later. However, on follow-up, her hemoglobin
level dropped to 85 g/L. Again, her iron stores were considerably low. A hemoglobin
electrophoresis was normal. She still had no history of overt bleeding, but one of three fecal
occult blood tests was positive. She was then evaluated in our centre.

Figure 1

The physical examination was unremarkable apart from a small hemangioma of the tongue.
Both upper endoscopy and colonoscopy showed no source of bleeding. A small bowel
follow-through was normal.
Further investigations revealed the diagnosis.
Given the positive fecal occult blood test, we elected to proceed with a videocapsule
endoscopy to better assess the small intestine. Capsule endoscopy showed a bluish
subepithelial mass in the mid-jejunum. To better evaluate the lesion, the patient then
underwent single-balloon enteroscopy. This procedure showed a 2.5 cm-wide purple-red
polypoid lesion of the mid-jejunum (Figure 1). Because the patient had a small hemangioma
of the tongue, a small bowel hemangioma was suspected. No biopsy was attempted during
single-ballon enteroscopy. A paediatric surgeon resected the affected segment of small
bowel. Pathological examination confirmed a 3.0 cm x 1.8 cm capillary hemangioma. The
recovery was uneventful. (Trucotte, Prasil, Gagnon, & Julie, 2012)

Case study
Learning Activity I
W/ro Hawa is a 35-year-old mother from Kero Deda Village which is 15 km away from
Alemaya Health Center. The village has no access to the main road. There is also no safe
water supply and school in the village. It is a drought affected area and out-breaks of
malaria occur frequently. Sorghum is the staple diet in the area. Hawa lives with her
husband Ato Hassen, who is a farmer, and her six children. Her last child was born at home
a year back. The family lives in poor housing condition with their domestic animals
including pets in a single roomed hut with no window. The small plot of land Ato Hassen
tills couldnt produce enough money to buy clothes and shoes for the family. Open field
disposal of waste is the usual practice in the village.

Since she gave birth to the last child Hawa feels poor health. She feels tired and as a result
the routine activities like fetching water from the nearby river progressively became very
difficult. She also has headache and loss of appetite. She repeatedly went to the traditional
healer in her locality who gave her bitter dark plant juices every time. But there was no
change in her problems; rather her sickness worsened.
Two weeks back she developed fever and chills on top of the other symptoms.
Noticing that this is malaria, which she had many times before, Ato Hassen took her to the
community health post where she was given tablets. The fever and chills disappeared, but
the other symptoms persisted. The tiredness and fatigue worsened and she started to feel
shortness of breath. Preparing food for the family became very difficult. She spent most of
the day lying in bed. Five days back she was taken back to the health post supported by
her husband, but the Community Health Worker (CHW) was out of the village. When he
came back after a day, Ato Hassen brought him home, and the CHW advised them to go to
the health center immediately. The next day Ato Hassen sold two of his goats. Leaving the
care of the house to the eldest daughter, Ato Hassen and some of his relatives carried Hawa
all the way to Alemaya Health Center. (Alemayehu, et al., 2003)

Iron deficiency anemia

Case history
Hannah Dalton is 24 years old and has come to the clinic with her mother Penny, who has
come along to support and help Hannah answer questions because Hannah has Down
syndrome (DS).
Hannah went to the family doctor a few months ago because she was feeling very tired and
Penny noticed she was looking quite pale. Hannah was prescribed some iron tablets, but
she is finding they make her nauseous and constipated. Penny is hoping we can prescribe
some form of iron that does not make Hannah feel unwell.
With Pennys help Hannah tells you she has been feeling tired for a while and wants to feel
better. Penny explains that Hannah has regular periods, which last for around seven days.
They have become heavier and more painful in the past few years and she thinks this is
why Hannah is feeling tired and needs iron. Penny reveals that Hannah has not been doing
much exercise lately because she gets so tired easily and has consequently gained weight.
Apart from the fatigue, Hannahs health is generally good. Penny tells you Hannah has had
regular medical investigations since birth and does not have visual or hearing problems and
her heart is also fine. Hannah had most of the childhood illnesses you would expect any
child to have and there were some problems with earache in early childhood, but she hasnt
had problems with her ears for many years. Hannah does have a tendency to constipation,
which has been worsened by the iron tablets and her skin has a tendency to dryness. Penny
also mentions she is aware that people with Down syndrome are at higher risk of
developing Alzheimers disease, but she hasnt noticed any signs of that yet.

Hannah tells you she works in a plant nursery four days a week and volunteers at an
animal shelter every Friday. She goes to Friendship Club on some Saturdays and her
brothers and cousins visit her and take her out with them or play on the Wii with her.
Hannah says her favourite things to do are the Wii and scrapbooking, which she does with
her cousin Amy. Hannah is very excited to tell you she is moving into her own house soon.
Penny explains that she and her husband are planning for Hannah to live independently in
about six months. They are in the process of selling their family home and buying a duplex,
with Hannah living in one side and them living in the other.
Hannah is very outgoing and communicative and obviously living a productive and happy
life. Penny tells you she and her husband believe every child is a gift from God and Hannah
is a wonderful person who enriches their lives in ways they never could have imagined, and
she brings positive energy to all who will receive it. (Galvin & Bishop, 2010)

A Case of Iron Deficiency Anemia

Case Presentation
Dolores Welborn is a 28-year-old attorney living in
Portland, Oregon. Dolores is in the second trimester of
pregnancy with her first child, and though her pregnancy
had been progressing normally, recently she has noticed that
she tires very easily and is short of breath from even the
slightest exertion. She also has experienced periods of lightheadedness, though not to the point of fainting. Other
changes she has noticed are cramping in her legs, a desire to
crunch on ice, and the fact that her tongue is sore. She
doubts that all of these symptoms are related to one another,
but she is concerned, and she makes an appointment to see
her physician.

Table 1

Upon examining Dolores, her physician finds that she has

tachycardia, pale gums and nail beds, and her tongue is
swollen. Given her history and the findings on her physical
exam, the physician suspects that Dolores is anemic and
orders a sample of her blood for examination. The results are
shown in Table 1.

A diagnosis of anemia due to iron deficiency is made and oral iron supplements prescribed.
Dolores symptoms are eliminated within a couple of weeks and the remainder of her
pregnancy progresses without difficulty. (Dean, 2006)

Case Summary
A 40 year-old African American woman was admitted to the intensive care unit for heavy
vaginal bleeding that lasted 4 days. Vaginal bleeding was associated with lightheadedness,
palpitation, weakness and fatigue. She reported a seven year history of uterine leomyomas
that caused recurrent episodes of menorrhagia. Due to inadequate iron supplemention, she
consequently developed iron deficiency.
Physical examination revealed a blood pressure 110/70 mmHg, a heart rate of 105 bpm, a
respiratory rate of 18 breaths/min, and a temperature of 98 degrees Fahrenheit.
She appeared pale; no icterus, petechiae, ecchymosis, or purpuric lesions noted. She had no
lymphadenopathy. Lungs were clear to auscultation. Cardiac examination revealed cardiac
grade 2/6 to 3/6 systolic flow murmur. The liver span was 9 cm and spleen was not
palpable. Pelvic examination showed vaginal bleeding. No bleeding from any other site was
observed.
Initial laboratory data is summarized in Table 1. Her Hemoglobin level was 3.5 g/dL
(normal range; 12.115.1 g/dL) and platelet count was 30,000/mm3 (normal range: 150400
109 per liter). Mean corpuscular volume (MCV) was 56.6 femtolitre (normal range; 80
100 femtolitre) and Red cell distribution width (RDW) was 37.6; (normal range; 11%
15%). Reticulocyte count on admission was 1.3% (normal range; 0.5%1.5%).
Iron studies revealed serum iron 27 g/dL (normal range; 50170 g/dL) serum ferritin 7.79
ng/dL (normal range; 12150 ng/mL), serum transferring
419.9 mg/dL (normal range 204360 mg/dL), percent saturation was 4%. Results of the
iron studies were consistent with iron deficiency anemia. The peripheral blood smear
showed marked microcytic hypochromic cells with decreased numbers of platelets. No
platelet clumping was noticed (Figure 1A and B).

Her coagulation parameters were normal. Work up for systemic lupus erythematosus,
HIV, immune and non-immune mediated thrombocytopenia, thrombotic
thrombocytopenic purpura was unremarkable. Ultrasound of pelvis showed an anteverted
uterus with heterogenous parenchyma and calcified anterior myoma and 0.44 cm
ecchodense wall thickness with adenomyosis.

The patient was administered four units of packed red blood cells, two doses of
intravenous iron sucrose complex 125 mg for two consecutive days, oral iron sulphate
tablets 325 mg three time a day, vitamin C 500 mg orally daily and Northindorne 10 mg
orally three times a day.
On day 5, she was discharged home with hemoglobin of
10.3 and platelet count 79,000/mm3. Upon discharge the
patient was advised to take oral iron supplements and
proceed with hysterectomy.
Sixty days after iron supplementation and posthysterectomy, platelet count improved to 4,47000/mm3,
hemoglobin increased to 10.9 g/dL and reticulocyte
count 2.8% (normal range; 0.5%1.5%). Figure 2A and B
describes the platelets counts and hemoglobin trend
after inititating iron therapy.
The resolution of severe symptomatic anemia along with thrombocytopenia following iron
supplementation strengthens the hypothesis that iron therapy plays an important role in
improving iron deficiency anemia associated thrombocytopenia. (Ibrahim, et al., 2012)

Referencias
Alemayehu, G., Belay, A., Fethi, M., Jemal, S., Haji, K., Melake, D., et al. (2003). Iron Deficiency Anemia.
Ethiopia: Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia
Ministry of Health, and the Ethiopia Ministry of Education.

Dean, D. F. (2006, Agosto 9). A case of Iron Deficiency Anemia. Retrieved Noviembre 15, 2014, from
http://www.sciencecases.org/ida/ida.asp
Galvin, K., & Bishop, M. (2010). Case Studies for Complementary Therapists: A Collaborative Approach.
Australia: Elsevier Australia .
Ibrahim, R., Khan, A., Raza, S., Kafeel, M., Dabas, R., Haynes, E., et al. (2012). Triad of Iron
Deficiency Anemia, Severe Thrombocytopenia and MenorrhagiaA Case Report and
Literature Review. Clinical Medicine Insights, 23-27.
Trucotte, J.-F., Prasil, P., Gagnon, P., & Julie, C. (2012, January). Case 1: Recurrent iron-deficiency
anemia in a teenager. Paediarics & Child Health, 21-22.