Вы находитесь на странице: 1из 8


William H. Crosby and Marcel E. Conrad
Department of Hematology,
Walter Reed A r m y Institute of Research,
Washington, D.C.

Iron balance resembles any other metabolic balance: it is the difference

between the amount of iron taken in by the body and the amount of iron
lost. In the normal state the two are equal. Negative balance occurs, f o r
example, when one bleeds and loses hemoglobin iron a t a greater rate than
he absorbs dietary iron. Positive balance supervenes in the same person
when the bleeding stops and absorption of iron then exceeds obligatory
iron loss, that small decrement which is shed with epithelium and other
deciduous cells.
Thalassemia is characterized by several aberrations of iron metabolism.
The plasma iron concentration is elevated, and the turnover of hemoglobin
iron is accelerated. The problem of iron balance has not received definitive
attention, and good information on this point is difficult to get. Patients
with thalassemia are often treated by transfusion or because of hypo-
chromia they are given oral or parenteral iron.' Such artificial loading of
the iron stores interferes with studies of iron absorption and leads to
erroneous conclusions regarding the effect of the disease on the iron stores.'
Some case reports fail to mention the history relative to transfusion and
therapeutic iron.
Most information concerning iron absorption in humans has been derived
from artificial experimental situations which may or may not represent the
conditions of normal absorption of dietary iron. For example, i t is reason-
ably certain that the iron deficiency of blood loss is corrected in the usual
case by increased absorption of dietary iron. Studies of iron absorption
which compare such iron-deficient subjects with normal iron-replete sub-
jects should demonstrate a clear difference between the two conditions. Most
methods show a statistically significant difference between groups but are
not sufficiently discriminating to permit the assignment of subjects to
one category or another on the basis of test results.:' Methods which fail
in such a clean-cut situation a r e unsatisfactory to determine iron balance
in conditions which may be less well delineated. A deficiency of method
may account for the finding of normal iron absorption in thalassemia
major' which is certainly an iron-loading disease.'
The cumulative effect of an iron metabolism imbalance can be determined
by its effect upon the total iron load of the body. Negative balance empties
the iron stores and this is reflected by absence of iron in samples of liver

Crosby & Conrad: Iron Balance 617
or marrow. Positive balance results in siderosis, but the total overload can-
not be quantified by examining such samples. These a r e some of the prob-
lems which encumber the study of iron balance.
A discriminating method for measurement of iron absorption? and a
method for measurement of the total body store" have provided quantita-
tive information about iron balance in several disorders of iron metabolism.
We wish to report the beginnings of a study which, it is hoped, may clarify
the condition of iron balance in thalassemia minor.
Clinical Material
Three adult patients with thalassemia minor were the subjects of this
study. The criteria upon which the diagnosis was based were hypochromic,
microcytic anemia with normal or increased plasma iron, increased con-
centration of fetal and Az hemoglobin, and splenomegaly. In all three,
family history or studies suggested the hereditary nature of the red cell



RBC indices Indirect Fetal A2 Iron

Case Age and sex Hb'
MCV MCH MCHC '2' bilirubin Iron TIBC
mg./100 ml. lrg,loo m,
% of dose

1 34 d 13.2 70 21 30 3.3 1.0 234 245 3.6 6.2 19

2 35 d 11.2 74 22 29 0.9 1.2 175 256 2.8 5.1 22
3 45 11.2 74 21 29 0.8 0.8 175 260 3.2 5.7 17

disorder. There was no evidence of gastrointestinal blood loss or other

Case 1. A 34-year-old male of Italian extraction at the age of 14 was
told he was anemic prior to appendectomy and was transfused with one
unit of blood. Around 20 years of age he was treated with iron by mouth
and took 75 to 100 pills. For previous five to eight years there had been a
moderate to heavy intake of beer. The patient's mother had heart disease
and an anemia which was treated with iron. Two sisters were dead (pneu-
monia and appendicitis) ; father and seven other siblings were said to be
well. Physical examination of the subject was negative except the liver and
spleen were palpable two cm. below the costal margin on inspiration. Hema-
tologic studies revealed the picture of thalassemia minor (TABLE 1). Bone
marrow smears showed a moderate erythroid hyperplasia with mild to
moderate increase of stainable iron. After a course of nine phlebotomies
there was no stainable iron. Liver biopsy prior to the phlebotomies showed
618 Annals New York Academy of Sciences
a slight increase of collagenous fibers about t h e portal a r e a s ; there was
scattering of stainable iron granules in t h e hepatic cells.
Case 2. A 35-year-old white male of English and Italian extraction was
referred f o r evaluation of anemia. At the age of 20 h e was first told he was
anemic and was treated with iron pills f o r a month. He took about 30
tablets. Family history was negative except f o r a paternal uncle with
anemia and gallstones. Physical examination revealed a spleen one cm.
below the costal margin on inspiration. Hematology demonstrated the char-








0 C 1
4 8 12 16 20 24

FIGURE 1. Intestinal absorption of orally administered radioiron. Left. Results

in 25 noimal subjects and 10 subjects with uncomplicated iron deficiency:; The
descending slope represents loss of radioactivity in the feces. The flat component
after cessation of fecal loss represents the percentage of iron absorbed. Right.
Results in three cases of thalassemia minor compared with the normal subjects.
In thalassemia minor about 20 per cent of the iron was absorbed.

acteristic pattern of thalassemia minor (TABLE 1) . Bone marrow showed

mild erythroid hyperplasia and a slight increase of stainable iron.
Case 3. A 45-year-old female of Italian extraction was referred f o r eval-
uation of anemia. During two pregnancies 10 to 15 years before, she took
iron tablets. Family history was essentially negative, b u t her two daughters
were examined and both presented the characteristic blood picture of thalas-
Crosby & Conrad: Iron Balance 619
semia minor. Her husband was hematologically normal. On physical exam-
ination the woman was normal except for splenomegaly of one cm. on
inspiration. Hematology was characteristic of thalassemia minor (TABLE 11 .
Bone marrow showed a moderate increase of erythroid hyperplasia and a
slight increase of stainable iron.
Met Ii od s
Iron absorption was measured using a human, whole-body, liquid scin-
tillation counter as described elsewhere.: A dose of one pc. of Fe''!' in a
carrier of one mg. of FeSOl was administered orally in 50 ml. of water at
eight A . M . a f t e r fasting all night. About four hours later body radioactivity
was measured ; the counts per second above a preliminary background
count represented 100 per cent of administered radioactivity. A 2.5 liter
flask containing 50 per cent of the administered dose was counted as a
control of physical decay and variation of counter sensitivity. I t was found
that fecal loss of radioactivity was virtually complete at the end of two
weeks. In normal subjects the residual activity, representing the amount
absorbed, was 10 per cent or less; in iron-deficient subjects it ranged from
30 to 75 per cent (FIGURE 1) . These two groups may be regarded a s con-
trols in the present study.
As hemoglobin is removed from the body by bleeding the storage iron
is used to replace the lost hemoglobin iron." To measure the total body
storage iron, one of the thalassemic subjects (Case 1 ) was submitted to
repeated phlebotomies until he developed unmistakable evidence of iron
deficiency : persisting low plasma iron with high iron-binding capacity and
persisting anemia well below the original level of hemoglobin. The amount
of hemoglobin removed was measured and the corresponding amount of
iron was computed using 0.338 per cent to represent t h e concentration
of iron in hemoglobin. The amount of storage iron removed was t h e total
less the amount represented by the subject's hemoglobin deficit a f t e r t h e
course of nine phlebotomies (TABLE 2 ) .

A Hb removed by 9 phlebotomies 470 g.

B Hb deficit (original Hb mass - 190 g.
final Hb mass)
A-B represents Hb formed from storage 280 g.
iron during the course of phlebotomies
Iron equivalent of 280 g. Hb (0.338%) 950 mg.
620 Annals New York Academy of Sciences
All three patients with thalassemia minor absorbed about 20 per cent
of the orally administered dose of iron (TABLE 1,FIGURE 1 ). This represents
a greater absorption than that of any of the normal subjects, but some-
what less than that of the iron-deficient subjects.
The phlebotomies performed in CUSP1 removed approximately 470 g.
of hemoglobin which represents 1.6 g. of iron. The subject was left anemic
with a deficit of hemoglobin mass of approximately 190 gm. or 650 mg. of
iron. Therefore, the amount of storage iron removed was approximately 950

MCM 21

B,y. Mod. hc. h
I,* Ibsm

a a a a I 1 1 a I (Phlebotomy-500m1.1

2 10
z s


FIGURE2. The response to intensive phlebotomy of a patient with thalassemia

minor. After removing sufficient hemoglobin to induce an iron deficiency anemia
it was computed that less than one g. of iron had been present as storage iron
(TABLE 2).

mg. which is an iron store of normal size [TABLE 2, FIGURE 2 ) . It may be

concluded that this subject did not have iron-storage disease.
Thalassemia major is uniformly associated with iron storage disease,
and it is generally conceded that iron absorption is increased. However,
almost without exception the patients whose tissues have been studied
(including Cooleys first cases) have been beneficiaries of extensive trans-
fusion therapy and must certainly have had transfusion siderosis in
addition to any iron loading consequent to increased absorption. An in-
Crosby & Conrad: Iron Balance
complete survey of published pathologic reports has turned up several cases
of thalassemia major in which no therapeutic iron or transfusion was ever
given the patient prior to the time of death.""' It is evident from these
cases that not only is iron loading present early in the disease, even in
infants, but also the siderosis becomes associated with cirrhosis and other
injury of parenchymatous tissues in older patients." It is on the basis
of such information that we can conclude with assurance that thalassemia
major is an iron-loading disease.
Thalassemia minor presents a problem of iron metabolism which also
is badly cluttered by prior administration of iron or blood transfusion.
Where neither has been used there is usually little evidence of iron storage
disease beyond a few granules of iron in the polygonal cells of the liver, or
elevation of the plasma iron concentration and high percentage of saturation
of total iron binding capacity of the plasma. Our single experience in un-
loading the iron from a patient with thalassemia minor (TABLE 2, FIGURE 2 )
supports the supposition that it is not an iron-loading disease: the sub-
ject's iron stores were normal.
Reports of larger series of patients using other methods have not shown
a significantly increased absorption of an oral test dose of iron.'.'' All
three of o u r subjects absorbed more iron from a test dose than did any of
25 normal subjects (FIGURE 1 ) . The results of such a test with iron salt
do not necessarily reflect the behavior of dietary iron, but the consistency
of the three results does suggest the existence of an abnormality of iron
absorption. What is the implication of such evidence of increased absorp-
tion coupled with a lack of evidence of siderosis? To us i t implies the
existence of a compensatory mechanism for iron excretion. Evidence favor-
ing this concept was recently reviewed.':
In hereditary spherocytosis'" and in some sons and siblings of patients
with hemochrornatosis,l' there is also evidence of increased iron absorption
without any serious siderosis. In such circumstances the compensatory
iron-excretory mechanism may rid the body of iron which is absorbed in
excess of requirement. It is evident that the excretory mechanism is limited
in its capacity. In clinical hemochromatosis, for example, the absorption
of iron exceeds this capacity, the patient is in positive iron balance and
iron accumulates as a result. I t seems likely that a similar overloading of
the excretory mechanism occurs in thalassemia major. One might con-
clude that in thalassemia minor and thalassemia major there is an ab-
normality of iron absorption which differs only in degree. In thalassemia
minor the amount of excess absorption is so small that compensatory
excretion prevents accumulation of iron ; in thalassemia major the com-
pensatory mechanism is overtaxed and iron loading results.
Thalassemia of intermediate grades of severity may result in inter-
mediate faults in the control of iron absorption; evidence on this point is
Annals New York Academy of Sciences
lacking. In considering the possibility of iron loading in thalassemia minor
one must exclude such diseases as hereditary hypochromic iron-loading
anemia which resembles thalassemia minor. One must also classify
correctly those cases which a r e thalassemia minor in name only.
In three cases of thalassemia minor it appeared that absorption of
iron from a single orally administered dose was somewhat increased above
normal. There did not appear to be any excessive accumulation of storage
iron in these subjects. The plasma iron-binding capacity was not saturated,
and removal of storage iron from one of the subjects by means of repeated
phlebotomy demonstrated the total load of body iron to be of normal size.
I t is suggested that in thalassemia minor the increased iron absorption
is balanced by increased excretion, thereby preventing the iron accumula-
tion and siderosis which occur in thalassemia major.
The information provided in this preliminary report is meager as is
the amount of good information on iron balance in the literature of thalas-
semia. The problem of iron balance in thalassemia minor, and thalassemia
major as well, needs more work.

Ref ewnces
1. LARIZZA, G. MATIOLI,E. SULIS& G. ARESV.1958. Contributo
alla conoscenza dell anemia talassemica. (Ricerche condotte con Iausilio
del Fe).Haeniatologica 43: 517.
2. BOWDLER, A. J. & E. R. HZIEHNS.1963. Thalassaemia minor complicated
by excessive iron storage. Brit. J. Haemat. 9: 13.
3. CALLENDER, S. T., B. J. MALLETT& M. D. SMITH. 1957. Absorption of hemo-
globin iron. Brit. J. Haemat. 3: 186.
& C. H. SMITH. 1962. Studies on congenital hemolytic syndromes. IV.
Gastrointestinal absorption of iron. Blood 19: 359.
5. VAN HOEK, R. & M. E. CONRAD.1961. Iron absorption. Measurement of
ingested iron! by a human whole-body liquid scintillation counter. J. Clin.
Invest. 40: 1153.
6. CROSBY,W. H., M. E. CONRAD & M. S. WHEBY. 1963. The control of iron
balance by the intestinal mucosa. Blood 22: 429.
7. COOLEY,T. B., E. R. WITWER& P. LEE. 1927. Anemia in children with
splenomegaly and peculiar changes in bones. Report of cases. Am. J. Dis.
Child. 34: 347.
8. WHIPPLE, G. H. & W. L. BRADFORD.1932. Racial o r familial anemia of
children associated with fundamental disturbances of bone and pigment
metabolism (Cooley-von Jaksch). Am. J. Dis. Child. 44: 336.
9. PANIZON, F. & C. VULLO. 1952. Sulla envoluzione della siderosi e fibrosi
epatica nella malattia di Cooley. Studio bioptico su 20 casi. Acta Paediat.
Lat. 10: 71.
10. ELLIS,J. T., I. SCHULMAN & C. H. SMITII. 1954. Generalized siderosis with
fibrosis of liver and pancreas in Cooleys (Mediterranean) anemia. Am.
J. Path. 30: 287.
11. WITZLEBEN,C. L. & J. P. WYATT.1961. The effect of long suivival on the
pathology of thalassaemia major. J. Path. Bact. 82: 1.
Crosby & Conrad: Iron Balance 623
12. BANNERMAN, R. M. & S. T. CALLENDER.1961.Iron absorption in thalassemia.
In Proc. VIIIth Cong. European SOC.Haemat. 11. Vienna. : 304. Ed. S.
Karger. Basel, Switzerland.
13. CROSBY,W. H. 1963. The control of iron balance by the intestinal mucosa.
Blood 22: 441.
14. CROSBY,W. H. & M. E. CONRAD.1960. Hereditary spherocytosis: Observa-
tions on hemolytic mechanisms and iron metabolism. Blood 15: 662.
15. WILLIAMS,R., P.J. SCHEUER & S. SHERLOCK. 1962. The inheritance of idio-
pathic hemochromatosis. A clinical and liver biopsy study of 16 families.
Quart. J. Med. 31 : 249.
16. CROSBY,W.H. & T. W. SHEEHY.1960. Hypochromic iron-loading anemia:
Studies of iron and hemoglobin metabolism by means of vigorous
phlebotomy. Brit. J. Haemat. 6: 56.
17. ETIENNE-MARTIN, P.,C. KLEPPINC& J. BINET. 1959. Hemochromatose a u
cours d'une thalassemie mineure. Arch. Mal. Appar. Dig. 48: 844.