Posted: May 31st, 2023

The cause of this patient’s iron-deficiency anemia

Case Study
A 72-year-old man developed chest pain whenever he was physically active. The pain ceased on
stopping his activity. He has no history of heart or lung disease. His physical examination was
normal except for notable pallor.
Studies Result
Electrocardiogram (EKG), p. 485 Ischemia noted in anterior leads
Chest x-ray study, p. 956 No active disease
Complete blood count (CBC), p.
156
Red blood cell (RBC) count, p.
396
2.1 million/mm (normal: 4.7–6.1 million/mm)
RBC indices, p. 399
Mean corpuscular volume
(MCV)
72 mm3
(normal: 80–95 mm3
)
Mean corpuscular hemoglobin
(MCH)
22 pg (normal: 27–31 pg)
Mean corpuscular hemoglobin
concentration (MCHC)
21 pg (normal: 27–31 pg)
Red blood cell distribution width
(RDW)
9% (normal: 11%–14.5%)
Hemoglobin (Hgb), p. 251 5.4 g/dL (normal: 14–18 g/dL)
Hematocrit (Hct), p. 248 18% (normal: 42%–52%)
White blood cell (WBC) count, p.
466
7800/mm3
(normal: 4,500–10,000/mcL)
WBC differential count, p. 466 Normal differential
Platelet count (thrombocyte
count), p. 362
Within normal limits (WNL) (normal: 150,000–
400,000/mm3
)
Half-life of RBC 26–30 days (normal)
Liver/spleen ratio, p. 750 1:1 (normal)
Spleen/pericardium ratio <2:1 (normal)
Reticulocyte count, p. 407 3.0% (normal: 0.5%–2.0%)
Haptoglobin, p. 245 122 mg/dL (normal: 100–150 mg/dL)
Blood typing, p. 114 O+
Iron level studies, p. 287
Iron 42 (normal: 65–175 mcg/dL)
Total iron-binding capacity
(TIBC)
500 (normal: 250–420 mcg/dL)
Transferrin (siderophilin) 200 mg/dL (normal: 215–365 mg/dL)
Transferrin saturation 15% (normal: 20%–50%)
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2
Ferritin, p. 211 8 ng/mL (normal: 12–300 ng/mL)
Vitamin B12, p. 460 140 pg/mL (normal: 100–700 pg/mL)
Folic acid, p. 218 12 mg/mL (normal: 5–20 mg/mL or 14–34 mmol/L)
Diagnostic Analysis
The patient was found to be significantly anemic. His angina was related to his anemia. His
normal RBC survival studies and normal haptoglobin eliminated the possibility of hemolysis..
His RBCs were small and hypochromic. His iron studies were compatible with iron deficiency.
His marrow was inadequate for the degree of anemia because his iron level was reduced.
On transfusion of O-positive blood, his angina disappeared. While receiving his third unit of
packed RBCs, he developed an elevated temperature to 38.5°C, muscle aches, and back pain.
The transfusion was stopped, and the following studies were performed:
Studies Results
Hgb, p. 251 7.6 g/dL
Hct, p. 248 24%
Direct Coombs test, p. 157 Positive; agglutination (normal: negative)
Platelet count, p. 362 85,000/mm3
Platelet antibody, p. 360 Positive (normal: negative)
Haptoglobin, p. 245 78 mg/dL
Diagnostic Analysis
The patient was experiencing a blood transfusion incompatibility reaction. His direct Coombs
test and haptoglobin studies indicated some hemolysis because of the reaction. His platelet count
dropped because of antiplatelet antibodies, probably the same ABO antibodies that caused the
RBC reaction.
He was given iron orally over the next 3 weeks, and his Hgb level improved. A rectal
examination indicated that his stool was positive for occult blood. Colonoscopy indicated a rightside colon cancer, which was removed 4 weeks after his initial presentation. He tolerated the
surgery well.
Critical Thinking Questions
1. What was the cause of this patient’s iron-deficiency anemia?
2. Explain the relationship between anemia and angina.
3. Would your recommend B12 and Folic Acid to this patient? Explain your rationale for
the answer
4. What other questions would you ask to this patient and what would be your rationale for
them?

_________________________-
The cause of this patient’s iron-deficiency anemia is likely related to chronic blood loss, which is supported by the presence of occult blood in the stool. The patient’s low iron levels, reduced iron-binding capacity, and low ferritin levels indicate a deficiency of iron, an essential component for red blood cell production. The right-side colon cancer, discovered later, may have been the source of the chronic blood loss leading to iron deficiency.

Anemia, particularly severe anemia, can lead to a decreased oxygen-carrying capacity of the blood. This reduced oxygen supply to tissues and organs can result in various symptoms, including angina. Angina is chest pain or discomfort that occurs when the heart muscle doesn’t receive enough oxygen-rich blood. In this case, the patient’s anemia caused by iron deficiency resulted in reduced oxygen delivery to the heart muscle during physical activity, triggering chest pain. The pain ceased when the activity was stopped, allowing the heart to work under reduced oxygen demands.

Yes, it would be recommended to provide Vitamin B12 and Folic Acid supplementation to this patient. Although the primary cause of the anemia in this case is iron deficiency, it is important to assess for other underlying deficiencies that can contribute to anemia. The low levels of Vitamin B12 (140 pg/mL) and Folic Acid (12 mg/mL) suggest possible deficiencies. Supplementation of these vitamins can help correct any deficiencies and support red blood cell production. It is important to address any underlying nutritional deficiencies to optimize the patient’s overall health and prevent potential complications.

Additional questions to ask the patient may include:

Have you experienced any gastrointestinal symptoms such as abdominal pain, changes in bowel habits, or rectal bleeding?
Have you noticed any unexplained weight loss or fatigue?
Do you have a family history of colon cancer or any other relevant medical conditions?
Have you undergone any recent surgeries or medical procedures?
Are you taking any medications or have any known allergies?
These questions aim to gather more information about the patient’s symptoms, medical history, and potential risk factors. They can help in further assessing the extent of gastrointestinal involvement, identifying other possible causes of anemia, evaluating the patient’s overall health status, and guiding appropriate diagnostic and treatment measures.

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