IRON-DEFICIENCY ANAEMIA

Question 1

What type of anaemia? - micro/macro/normo

Answer 1

Microcytic

Question 2

What is the problem if untreated?

Answer 2

Lethargy. Makes you more susceptible to illness and infection as a lack of Fe in your body affects your immune system

Question 3

How common is it?

Answer 3

Very common – up to 14% menstruating women. Pre-menopausal women have higher incidence due to menstrual blood loss and pregnancy

Question 4

Aetiology

Answer 4

Blood loss eg menorrhagia or GI bleeding
Inherited bleeding disorders: haemophilia A&B, thrombocyotopenia
Poor diet in babies or children, those on special diets or in poverty
Malabsorption eg celiac disease
Hookworm (in the tropics)
Lack of dietary intake

Question 5

Risk factors

Answer 5

• Heavy menstruation
• Malignancy
• Pregnancy
• Rapid growth

Question 6

Symptoms

Answer 6

• Fatigue
• Headache
• SOB on exertion
• Palpitations
• Sore troat and taste disturbance
• Pruitis
• Hair loss
• Tinnitus
• Angina (with CHD, pre-exisiting)

Question 7

Signs

Answer 7

• Koilonychia (spoon shaped nails)
• Atrophic glossitis
• Anular cheilosis (ulceration at the side of the neck)
• Pallor
• Tachycardia
• Brittle nails
• Pale conjunctiva
• Brittle hair

Question 8

Signs in more severe cases

Answer 8

tachycardia, arrhythmias, flow murmurs, cardiac enlargement, ankle oedema and heart failure

Question 9

What is Paterson-Brown-Kelly syndrome?

Answer 9

A syndrome of dysphagia and glossitis may present in serious cases (Paterson-Brown-Kelly syndrome): a post-cricoid web of mucosa and submucosa.

Question 10

What are two types of investigations we need to do?

Answer 10

Blood Tests

Rule out underlying cause

Question 11

What investigations can we do to rule out the cause?

Answer 11

• Urine Test
• Upper +/- lower GI investigations eg Endoscopy or CT scan (esp male and post menop women)
• Screen for celiac disease

Question 12

What are you looking for in FBC?

Answer 12

o	small (microcytic, ↓MCV <80fl), 
o	pale (hypochromic, MCH <27pg) cells
o	poikilocytosis (variation in shape)
o	anisocytosis (variation in size)

Question 13

What blood tests?

Answer 13

FBC

Serum Ferritin

Question 14

What are you looking for in serum ferritin?

Answer 14

reflects amount of stored iron; normal = 30–300 mcg/L (11.6–144 nmol/L) in males and 15–200 ⎧g/L (5.8–96 nmol/L) in females; acute-phase inflamm marker so ↑ in presence of inflamm or malignant diseases (use serum iron/TIBC/serum ferritin/soluble transferrin together instead); if ↓ then pt is definitely deficient
o Should be measured to confirm iron deficiency
o Reflects amount of stored iron
However ferritin levels can be raised during inflammation or infection even if iron stores are low

Question 15

What other blood tests?

Answer 15

• ZPP
• Serum iron/ TIBC (total iron binding capacity): serum iron ↓ and TIBC ↑if iron deficient
• Serum soluble transferrin receptors: ↑ in deficiency; helps distinguish between iron deficiency and anaemia of chronic diseases
• Bone marrow

Question 16

What Hb values are you looking at?

Answer 16

Hb <13g/dL in men
Hb <12g/dL in women
Hb <11g/dL in pregnancy

Question 17

What are the treatments?

Answer 17

FERROUS SULPHATE
• Treat the cause – Oral Iron eg ferrous sulphate 200mg/8h PO and continue until Hb normal for 3/12
• Get patient to change diet to iron rich foods eg red meat, dark green veg, prunes etc
• Hb should rise 1g/dL per week
• Blood transfusions almot never needed unless pt is haemodynamically unwell

Question 18

What are the side effects of ferrous sulphate?

Answer 18

S/E: Constipation, black stools, diarrhoea, heartburn, nausea, abdo pain

Question 19

What are the differentials?

Answer 19

• Thalassaemia
• Sideroblastic anaemia
• Anaemia of chronic disease
• Lead poisoning
• Chronic fatigue, depression, heart failure, COPD, asthma, hypothyroidism, hyperthyroidism

Question 20

What is sideroblastic anaemia?

Answer 20

Inherited or acquired disorders characterised by refractory anaemias; ring sideroblasts in bone marrow is diagnostic (there is accumulation of iron in the mitochondria of erythroblasts owing to disordered haem synthesis forming a ring of iron granules around the nucleus that can be seen with Perls’ reaction); blood film of dimorphic (two types of RBC seen).

Question 21

What is anaemia of chronic disease?

Answer 21

Esp hospital pts, chronic infections (TB) or chronic inflamm disease (IBD, rheumatoid, SLE, polymyalgia rheumatic, cancers); ↓ release of iron from bone marrow, inadequate EPO response to anaemia, decreased RBC survival; mechanisms unclear; serum ferritin raised due to inflamm process. Pts do not respond to iron therapy; anaemia of renal disease responds to synthetic EP