Anaemia — SAQ

Stem

A 28-year-old vegetarian woman presents to the outpatient department with a 4-month history of progressive fatigue, exertional dyspnoea, and palpitations. She craves ice and chews several cups daily. Menses are regular but heavy (soaking 10 to 12 pads per cycle with clots). On examination she is pale, with a hyperdynamic precordium and a soft ejection systolic murmur at the pulmonary area. Nail beds show koilonychia and she has angular cheilitis. Investigations: Hb 72 g/L, MCV 68 fL, MCH 21 pg, reticulocytes 1.2%, ferritin 8 micrograms/L, serum iron 4 micromol/L, TIBC 92 micromol/L, transferrin saturation 4%. Peripheral film: microcytic hypochromic red cells with pencil cells. [1]

Questions

a) What is the diagnosis, and which two features of the history/examination support it most specifically? (2 marks) Iron deficiency anaemia (microcytic, hypochromic). Highly specific features: pagophagia (ice pica — classically associated with iron deficiency) and koilonychia (spoon nails); supported by menorrhagia, angular cheilitis, low ferritin/high TIBC.

b) Interpret the laboratory results and explain the underlying pathophysiology. (3 marks) Microcytic (MCV under 80) hypochromic anaemia with low reticulocytes (underproduction). Iron studies show the classic iron-deficiency pattern: low ferritin (depleted stores — under 30 is diagnostic), low serum iron, high TIBC/transferrin (liver synthesises transferrin in response to iron lack), and low transferrin saturation (under 20%). The marrow cannot deliver iron to developing erythroblasts → impaired haem synthesis → reduced MCH and MCV. Reticulocytes are low because erythropoiesis is iron-limited (underproduction). Hepcidin is suppressed (low iron stores), allowing maximal dietary absorption via ferroportin — but stores are still inadequate to meet the demand from ongoing menorrhagia. [1]

c) Outline the complete management plan, with specific drug, dose, route and duration. (3 marks)

• Oral ferrous sulphate 200 mg three times daily (elemental iron ~65 mg per tablet) for 3 to 6 months after haemoglobin normalises (to replenish stores). Take on an empty stomach with vitamin C; avoid within 2 hours of calcium, antacids, tea, coffee, dairy.
• Treat the cause: gynaecological referral for menorrhagia (e.g. tranexamic acid 1 g TDS during menses, levonorgestrel IUS, combined oral contraceptive).
• Dietary advice: iron-rich foods (red meat, legumes, leafy greens) with vitamin C.
• Expected response: reticulocytosis at 7 to 10 days; Hb rise of 10 to 20 g/L per fortnight; normalisation in 6 to 8 weeks.
• If oral fails/intolerant: IV ferric carboxymaltose 1000 mg.
• Resuscitation: transfusion is NOT indicated here (no symptoms of acute instability; chronic anaemia well compensated) — treat with iron. [1]

d) List two important complications of this condition if left untreated, and two of its potential adverse effects of treatment. (2 marks) Untreated: high-output cardiac failure; impaired cognitive/work performance; (in pregnancy — preterm delivery, low birth weight). Treatment adverse effects (oral iron): constipation, nausea, abdominal pain, dark stools; (IV iron) — hypersensitivity reaction, hypophosphataemia (ferric carboxymaltose), skin staining. [1]

References

1. [1]Pavord S, Myers B, Robinson S, Allard S, Strong J, Oppenheimer C; British Committee for Standards in Haematology. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol, 2012.PMID 22512001