Iron Deficiency Anemia and Pernicious Anemia.
Pernicious anemia (also known as Biermer’s disease) is an autoimmune atrophic gastritis, predominantly of the fundus, and is responsible for a deficiency in vitamin B12 (cobalamin) due to its malabsorption. Its prevalence is 0.1% in the general population and 1.9% in subjects over the age of 60 years. Pernicious anemia represents 20%–50% of the causes of vitamin B12 deficiency in adults. Given its polymorphism and broad spectrum of clinical manifestations, pernicious anemia is a great pretender. Its diagnosis must therefore be evoked and considered in the presence of neurological and hematological manifestations of undetermined origin. Biologically, it is characterized by the presence of anti-intrinsic factor antibodies. Treatment is based on the administration of parenteral vitamin B12, although other routes of administration (eg, oral) are currently under study. In the present update, these various aspects are discussed with special emphasis on data of interest to the clinician. NURS 6051 wk 7: Iron Deficiency Anemia and Pernicious Anemia
A 52-year-old male was initially presented in an ambulatory clinic complaining of fatigue and weakness for 2 weeks. The patient also complained of frequent epistaxis secondary to nose picking for 1 month. His fatigue was accompanied by dyspnea on exertion and lightheadedness which have increased in frequency in the last 4-5 days prior to the presentation. He denied similar symptoms in the past. He reported poor appetite but no weight loss or strange craving. Other than the symptoms reported previously, the review of symptoms was negative, including neurological complaints. Complete blood count (CBC) was taken in the clinic and he was found to have hemoglobin (Hb) of 6.2 g/dL. The patient was subsequently admitted to the hospital for further workup. NURS 6051 wk 7: Iron Deficiency Anemia and Pernicious Anemia
Further history revealed recent upper respiratory tract infection 1 month prior to the admission. The patient’s symptoms at that time consisted of sore throat, runny nose, and low grade fever. The symptoms resolved on thier own after 5 days. There was no rash or joint pain related to the recent upper respiratory tract infection. He denied any history of bleeding disorder or any past medical history including blood transfusion. The only medication reported was Metamucil to relieve occasional constipation.
The patient was originally from Mexico. He has been living in the United Stated for the last 14 years and has not recently visited his home country. He is married and has 2 children, age 16 and 14 years, which are healthy. The patient reported that his sister and his niece may have had history of anemia but he does not know the diagnosis. He denied any history of tobacco or drug use. He admitted to drink alcohol about 6 beers per week. He works in a pastry shop as a box assembler.NURS 6051 wk 7: Iron Deficiency Anemia and Pernicious Anemia
On admission, the patient was alert, oriented, and not in any distress. Physically, he looked thin and pale. Jaundice was also noted. His vital signs were blood pressure 107/59 mmHg, pulse 76/min, temperature 98.9 F, respiratory rate 18 min, oxygen saturation 100% on room air, height 165 cm, and weight 56 kg. His cardiopulmonary examination was normal. There was no lymphadenopathy. His abdomen was soft and nontender, with no organomegaly. There was no apparent rash, skin lesion, or joint swelling. Neurological exam was unremarkable. Rectal examination revealed normal prostate and no mass palpable. Brown stool was observed and bedside hemoccult test was negative.
Repeat CBC revealed Hb of 5.9 g/dL and hematocrit (Hct) of 18.6% with normal white blood cell (WBC) and platelet count. Red cell indices were normal except for red blood cell distribution width (RDW) which was abnormally high. Review of peripheral blood smear (Figure 1) showed marked anisocytosis and poikilocytosis. Microcytosis was predominant with few large cells noted as well as tear drop cells and elliptocytes. Multiple fragmented red blood cells were also noted. WBC appeared normal. Platelet appeared low with occasional clumping. Complete metabolic panel showed elevated total bilirubin of 3.7 mg/dL with predominant indirect bilirubin level. Other values were normal. Reticulocyte count was 2.4%, but reticulocyte index was 0.4. NURS 6051 wk 7: Iron Deficiency Anemia and Pernicious Anemia