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.
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.
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.
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.
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
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.
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.
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.