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What was the cause of this patient’s iron-deficiency anemia? Iron-Deficiency Anemia Case Studies 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%) 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 B12 and folate levels eliminated the possibility of vitamin deficiencies. 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 right-side colon cancer, which was removed 4 weeks after his initial presentation. He tolerated the surgery well.
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