Anemia due to Iron Deficiency and Chronic Disease

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 58-year-old African American male (AAM) was admitted from a nursing home (NH) with a chief complaint (CC) of being lethargic and not acting appropriately. The patient stated that his legs hurt, and they had been hurting for a long time.

Past medical history (PMH)

Diabetes mellitus type II (DM), hypertension (HTN), venous stasis ulcers, anemia, hepatitis C, peripheral vascular disease (PVD), congestive heart failure (CH).

Past surgical history (PSH)

Bilateral lower extremity (B) LE) stasis ulcers status post (S/P) debridement and multiple failed skin grafts 2 years ago, a right hallux amputation.

Medications

Tylenol (acetaminophen), Ambien (zolpidem), hydrocodone, FeSO4, clonidine, amitriptyline, Oxycontin (oxycodone), Lantus (insulin glargine), Lasix (furosemide), metformin, Actos (pioglitazone), metoprolol.

Social history (SH)

Remote history of heroin and cocaine abuse, former smoker and drinker.

Physical examination

VS 38-126-24-137/81.
Chest: CTA (B).
CVS: tachycardic but regular with no murmurs.
Abdomen: Soft, NT, ND, +BS.
Extremities: severe venous stasis ulcers of the lower extremities (B).
Neuro: AAO x 2. No focal neurological deficits apart from diminished sensation on (B) LE.


A diabetic patient with (B) infected stasis ulcers.

What laboratory workup would you order?

CBCD, CMP, UA.
Wound culture, BC x 2.
X-rays.

CBC in iron deficiency anemia (IDA) (left, click to enlarge the image); CMP, hypogycemia was corrected; CBCD, iron profile and prealbumin.

Iron and iron saturation were low but the ferritin was high and the TIBC was low. What was the reason?

A combination of iron deficiency anemia and anemia of chronic disease.

BUN was 51 mg/dL and creatinine 2.5 mg/dL. Hemoglobin was Hgb 8.8 mg/dL.

What questions would you ask? What are his baseline laboratory values?

A review of his previous medical records showed a BUN of 14 mg/dL and creatinine of 1.3 mg/dL seven months ago.

WBC was 17.1/mm3, hemoglobin 8.8 mg/dL, hematocrit 26.7, and hypochromic, microcytic peripheral smear. The differential count showed 69% neutrophils and 11% bands.

The patient most likely had an infection, and was volume depleted which could explain the rise in the BUN/Cr. His mucosal membranes were dry.

What happened?

The patient was admitted to a telemetry unit. Zosyn (piperacillin and tazobactam) and IV fluids were given.

His hemoglobin decreased to 7.6 mg/dL on the day after admission.

What do you think is the reason for the "drop" in hemoglobin?

Mainly hemodilution -- see the input and output summary over the last 24 hours (I/O) below. The patient was with a 3-L positive balance.


I/O showed that the patient was 3 liters positive.

The patient was transfused 2 units (U) pack red blood cells (PRBC), and iron profile and ferritin were ordered as add-on tests.

The iron profile showed severe iron deficiency bu why ferritin was high?

The patient had wound infection and this could be the reason for the high ferritin and platelets. TIBC was low because he also had anemia of chronic disease.

Note how the BUN and Cr returned to baseline values with the volume replacement with IV fluids (see the laboratory results above).

What is the cause of iron deficiency anemia? Is he bleeding?

The patient was hemodynamically stable -- stable vitals signs (VSS) and without orthostatic changes. The rectal exam showed brown stool, negative for occult blood and the H/H was stable. The admitting team decided that the patient's anemia was unlikely to be secondary to acute GI bleeding.

There are several causes for iron deficiency anemia that can be remembered by the mnemonic NIMBLE:

Need -- increased need as in pregnancy, children during stages of rapid growth, etc.
Intake is low, e.g. in malnutrition
Malabsorption
Blood
Loss, e.g. GI bleeding
Excessive donation, e.g. in blood donors

What happened to this patient?

His prealbumin was very low - 9.2. The most likely reason for iron deficiency anemia was malnutriton due to poor PO intake.

The patient received 2 U PRBC. A blood conservation protocol was started with iron and Epogen (epoetin alfa). A nutrition consult was called.

Final diagnosis

Iron deficiency anemia (IDA) secondary to malnutrition. Anemia of chronic disease.

What did we learn from this case?

The most dangerous cause of iron deficiency anemia is GI bleeding and it needs to be ruled out first.

Consider poor PO intake in the differential diagnosis of iron deficiency anemia, especially in the debilitated patients with multiple comorbidies.

A decrease in the hemoglobin can be due to hemodilution. This is especially true in hypovolemic patients with preexisting anemia. The rule of thumb is that one liter of IVF can decrease the hemoglobin by as much as one gram/dL.

Use the blood conservation protocol early. Giving blood has the disadvantages of being expensive and exposing patients to infections.

References

Iron Deficiency Anemia. Marcel E Conrad. eMedicine, 2006.
Iron Deficiency Anemia. American Academy of Family Physicians, 2007.
Normocytic Anemia. American Academy of Family Physicians, 2000.
Anemia in the Elderly. American Academy of Family Physicians, 2000.
Anemia, Chronic. Fredrick Melik Abrahamian et al. eMedicine, 2008.

Published: 06/01/2004
Updated: 02/01/2009

13 comments:

  1. Abbreviations used:

    2 U PRBC = 2 units of PRBC (Packed Red Cell Blood)

    AAO = ?

    (B) = Both / Bilaterally
    BC = blood culture
    BS = Bowel sound
    BUN = Blood Urea Nitrogen

    CBC = complete blood count CBC
    CBCD = complete blood count (CBC) plus diff (D)
    CC = complaints?
    CMP = Comprehensive Metabolic Panel
    CRI = Chronic Renal Insufficiency
    CTA = ?

    DM = Diabetes Mellitus

    HTN = Hypertension

    IDA = Iron deficiency Anaemia
    IVF = Intravenous fluid

    LE = lower extremities

    ND = ?
    NT = None Tender

    PRBC = Packed Red Cell Blood

    UA = Urine analysis

    VS = Vital signs (Temperature, Pulse, Respiratory rate, Blood pressure)
    VSS = Vital Signs Stable

    WBC = White Blood Cells

    Zosyn = trade name for Penicillin

    http://www.alnuke.com

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  2. CTA (B) = clear to auscultation bilaterally

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  3. Asyik:

    Zosyn is a trade name for the combination of piperacillin and tazobactam, it is not just plain old penicillin.

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  4. AAO: Alert, active,oriented? It related to cognition/memory. 2 (range 0-3?).
    A.Jácome, MD

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  5. ND = non-distended

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  6. Instead of AAO, a lot of hospitals will use AOxN where N ranges from 0-3 for awareness of person, place and time. When giving a number other than o or 3, it is helpful to indicate in the record what the deficit is (not so relevant to this case, but from a continuity of care perspective you might want to know if the deficit you see today is the same one the patient had last week before you came on service).

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  7. would you please check the blood haemoglobin level?

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  8. Hemoglobin level was already checked. Please see the labs above.

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  9. This is missing a lab page -- ie TIBC is low ( not shown ) . Can you please add it. Thanks

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  10. There is no "missing lab page."

    TIBC is low (shown) because there is a combination of Iron deficiency anemia (IDA) and Anemia of chronic disease.

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  11. there is a missig lab test -->reiculocytes count

    retic count is very important for the initial classification of anemia in any pt.... it must be done immediately after CBC (or as pat of it)

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  12. I think reticulocyte counte is not helpful in this case
    as it will be with hemolysis or acute bleeding.

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  13. You can't say a patient is malnourished just because they have a low pre-albumin (PAB). PAB was believed to be a short-term indicator of nutritional status; it was thought to give an idea about the previous (appx) 3-4 days. You really can't say someone is malnourished with poor intake of 3-4 days. However, most nutrition specialists don't believe PAB really reflects nutrition status - it reflects infection or inflammation. PAB is a negative acute phase reactant and so decreases with infection. The patient had an infection. Additionally, the case gave no info about weight, weight loss, or % DBW - so how can you say this patient is malnourished?

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