Iron Deficiency Anemia-A case analysis
28 year old female presents with brain fog, poor brain endurance and mood instability that is worse around her menstrual cycle. History reveals onset of menses at age 12 with heavy, prolonged but consistent cycles. During her high school years she missed school for a few days every month due to pain and fatigue.
Labs show the following:
- RBC: Lab low
- Hemoglobin: Lab low
- Hematocrit: Low normal
- MCV: Lab low
- Serum Iron: Normal
- Serum Ferritin: Lab low
- TIBC: Elevated
- Serum B12: Low normal
Based on the information you have, what is your assessment of this client?
Based on the low RBC count, hemoglobin and borderline low hematocrit, this patient is either clinically anemic or trending toward anemia. If the values are below reference, then she can be called anemic, but if they are below optimal/functional range, the patient could be “shifting” to an anemic state. Since the patient is demonstrating a low RBC marker with low ferritin and microcytic marker (low MVC) as well as hypochromic marker (low hemoglobin), it appears that this could be iron deficiency anemia (IDA) and not anemia of chronic disease (ACD). Other indications of IDA include the elevated TIBC, which is often seen in IDA (Kahn Academy, 2014).
It may seem contradictory that her serum iron levels are normal on the lab. However, during the development of iron deficiency, an elevation of TIBC occurs before the decrease of serum iron, which an indicate a compensatory mechanism to mobilize all traces of tissue iron to maintain normal erythropoiesis (Ballas, 1979). She could be in the early stages of iron deficiency.
Are there any other essential labs you would ask to have ordered?
I would request a full work up with this patient that includes obtaining a detailed history as well as running additional labs. Within the full evaluation, I would want to use the patient’s age, gender, and symptoms to create a clinical picture of the patient. Are there any signs of GI issues, IBD or bleeding that could indicate iron wasting? Other symptoms I would look for are pallor, fatigue, brain fog, memory problems, muscles weakness, unsteady gait, numbness, tingling, depression, migraines/headaches and low blood pressure, shortness of breath, peripheral neuropathy. Also, is she overweight? Hepcidin expression is increased in chronic inflammation and obesity, and that can contribute to decreased iron absorption (Hurrell and Egli, 2018).
I would also like for this woman to run a full functional blood chemistry panel if she hasn’t already. What is her platelet count? Often times platelet counts are elevated in patients with IDA, but in some cases, thrombocytopenia is also reported (Ibrahim et al., 2012). “In patients with menorrhagia, inadequate contraction of spiral arterioles in the endometrium leads to qualitative and quantitative platelet dysfunction causing prolonged period of heavy menstrual flow (Ibrahim et al., 2012). In fact, it should be noted that in patients with menorrhagia, inadequate contraction of spiral arterioles in the endometrium leads to qualitative and quantitative platelet dysfunction that can also prolong heavy menstrual flow. “They found iron deficiency anemia in women caused arachidonic acid induced platelet dysfunction through iron-containing enzymes may give rise to increased menstrual blood loss, which can be reversed through iron repletion” (Ibrahim et al., 2012). Within the patient work up, I would have to identify what may have triggered the iron depletion, whether it was through blood loss or an iron or deficient diet. It is essentially a chicken or egg scenario of which came first: the blood loss leading to iron deficiency, or the iron deficiency leading to blood loss.
Additional testing would include evaluating the B12 deficiency if she presents clinical symptoms of B12 deficiency. These include serum MMA, homocysteine, and B12 Unsaturated Binding Capacity. However, according to Berg & Shaw (2013), B12 testing is not needed unless there is a clinical indication such as macrocytosis or neurological signs of B12 deficiency. Since her MCV is low and not high, she is not demonstrating the most obvious clinical evidence of macrocytosis, which can often precede the anemia. However, neurological manifestations can also occur when both MCV and iron levels are normal. However, since most of her symptoms occur around menstruation, a B12 evaluation may not be necessary at the moment and it could be explored in the future if symptoms do not resolve.
What else would you like to know about this client?
I would like to see a detailed diet record to determine if she is missing iron in her diet. Is she a vegetarian? Also, what is the state of her gut? Could she have an inflammatory gut disease that is leading to malabsorption? Is she consuming fiber? Nondigestible carbohydrates that are present in plant foods can resist digestion in the small intestine, but are fermented to SCFA’s in the colon can increase colonic iron absorption (Hurrell and Egli, 2018).
Any chance she can be pregnant?
Has she had a time in her life where she loss significant blood?
What would be your initial recommendations?
Using her food journal, I would modify her diet to include more natural sources of bioavailable iron. These include foods that contain heme iron from meat since it is more bioavailable. Adding in foods that include the heme from of iron can enhance absorption of plant foods that contain sources of nonheme iron. For example, according to (Hurrell and Egli, 2018), the addition of beef, chicken or fish can increase nonheme absorption 2-3 fold. Also, she should reduce her intake of foods that can inhibit the absorption of iron. These include phytates (grains, nuts and legumes), polyphenols (legumes, tea, coffee, wine), calcium containing foods, and some proteins such as milk proteins, egg proteins, and albumin. The 2 major bovine milk protein fractions, casein and whey, and egg white were shown to inhibit iron absorption in humans (Hurrell and Egli, 2018). I would also include sources of ascorbic acid in her diet to enhance iron absorption. “The enhancing effect is largely due to its ability to reduce ferric to ferrous iron by is also due to its potential to chelate iron (Hurrell and Egli, 2018). Since sometimes the polyphenols of the fruits and vegetables can cancel out the iron absorption effect, it may be best to supplement with ascorbic acid. After about 60-90 days of dietary interventions, I would recommend retesting the levels. If she is still showing IDA, then I would explore hypochlorhydria and considering supplementing with iron bis-glycinate and HCL.
Atili, A. (2018). Phytic Acid 101: Everything You Need to Know. Retrieved (2018, Sept 160 from https://www.healthline.com/nutrition/phytic-acid-101
Berg, R. L., & Shaw, G. R. (2013). Laboratory evaluation for vitamin B12 deficiency: the case for cascade testing. Clin Med Res, 11(1), 7-15. doi:10.3121/cmr.2012.1112
Ballas, S. K. (1979). Normal serum iron and elevated total iron-binding capacity in iron-deficiency states. Am J Clin Pathol, 71(4), 401-403.
Ibrahim, R., Khan, A., Raza, S., Kafeel, M., Dabas, R., Haynes, E., . . . Zaman, M. (2012). Triad of iron deficiency anemia, severe thrombocytopenia and menorrhagia-a case report and literature review. Clin Med Insights Case Rep, 5, 23-27. doi:10.4137/CCRep.S9329
Hurrell R., Egli, I. (2018). Iron bioavailability and dietary reference values. Am J Clin Nutr (suppl), 1461-7
Kahn Academy (2014). Chronic disease vs. iron deficiency anemia. Retrieved (2015, Sept 15) from https://www.youtube.com/watch?v=tVNRn4srPUI&feature=youtu.be