Case 4. Pallor of skin (Severe iron deficiency anemia)
Author: Natalia Bogutska
Case outline
You are doctor intern in the office of a general practitioner of
family medicine on an independent reception of patients. A 33 year old
Olena Hayduk without a preliminary record came to your reception because
she was advised to be consulted due to her lab tests. The pediatrician
advised her to contact her family doctor without delay. A woman gives
you a piece of paper with the blood test result printed on the automatic
blood analyzer.
You assess the CBC analysis.
From the anamnesis:
Patient reports that she has three children, the elderly boy has
recently undergone an operation to replace the aortic valve, he is
constantly receiving warfarin, the rest of the children are healthy, all
are vaccinated. She was married, she has never been ill and has never
been hospitalized before, except for the appendectomy that was about 20
years ago. Allergies have never happened. No medication are used by her,
except for zolmigren for headache and aspirin because of menalgia
occasionally. She is vegetarian for 5 years. Does not smoke, alcohol
consumes occasionally, several times a year, does not use narcotic
drugs. Two weeks ago she was treated with a dentist - he made several
dental fillings. The patient's parents are alive, the father is ill with
type II diabetes, there are no other significant illnesses in the
family.
Examination:
Objectively (lying): a white woman 33 years old, with asthenic body
building, weight 52 kg, height 169 cm, T axillary 35,8°C, RR 28 per min,
HR 112 per min, blood pressure 100/55 mm Hg, skin is dry, skin and
mucous membranes are very pale. Treated dental caries, tonsils are not
enlarged, single submandibular lymph node is painless and enlarged up to
1 cm, apical heart impulse displaced to the left, tones of the heart
are slightly weakened, at the apex - aortic systolic murmur of the II
degree, vesicular breathing, the liver is not palpable, the skin is
swollen on the lower limbs up to ankles. Abdomen is soft, sensitive to
palpation in the epigastrium. Neurologically - without pathological
changes. Menstrual discharge for 7th day.
You report your findings to the patient, but she calms you: changes
in her heart have been found on the ultrasound of the heart during
pregnancy, these changes are the same as her eldest son’s, but she has
been repeatedly examined and told that she does not need treatment. Due
to medical documentation, the last time she was examined by doctor two
years ago, she was diagnosed having the bicuspid aortic valve.
Suddenly a woman begins to cry and apologize for this: a month ago
her husband-soldier was killed in the combat zone, she is very
"nervous", she does not sleep at night almost at all, she can fall
asleep only sitting, she's afraid of who her children will remain with
if she gets any sickness, so she decided to check her health status.
This is a clinical case of the management of severe chronic iron deficiency anemia of mixed genesis in a patient with
premenopausal menorrhagia and the upper gastrointestinal bleeding as
well as heart failure due to volume overload (cardiogenic pulmonary
edema) during infusion of crystalloids and packed red blood cells.
The clinical case of the management of severe chronic iron deficiency
anemia of mixed genesis in a young patient Hayduk Olena (who has 3
children) with premenopausal menorrhagia is offered for students’
consideration. In addition, bleeding from the upper gastrointestinal
tract is present in this patient. Also, heart failure (cardiogenic
pulmonary edema) develops and progresses due to volume overload (i/v
infusion of crystalloids and packed RBC with regard to bleeding).
At first, students should pay attention to the expressed anemic
syndrome according to clinical signs (it should be assessed that this is
a severe anemic syndrome), as well students should carry out
age-specific and gender dependent analysis of the possible causes of the
development of this anemic syndrome. Students should be aware that the
patient's complete blood count test does not belong to her (a system error
is an error in handing out analyzes to patients), and the degree of
anemia is not clinically relevant to the analysis. Anamnestic data,
anemic syndrome, detected heart murmur should encourage students to make
the most appropriate choice - to set up an complete blood test, an ECG,
and continue to collect anamnesis. If students are concentrated on the
psychological state of the patient, which is exacerbated by a severe
anemic syndrome, or on an existing diagnosis of the bicuspid aortic
valve, then they can choose false steps with a loss of time. The choice
of the immediate appointment of amoxicillin orally due to the risk of
bacterial endocarditis (fixation, inadequate skills, choice of a more probable diagnosis – playing odds) is incorrect, since neither clinical nor anamnestic data are in favor of a probable bacterial endocarditis.
Choice 1. Complete blood test, an ECG, and continue to collect anamnesis (E) /
oral ferrotherapy and direct the patient to psychological support
social group (G) / ultrasound of the heart and counseling a psychiatrist
(P)/ sedative herbage, a re-examination with a doctor-curator and a
consultation of a cardiologist (P) / amoxicillin due to the risk of
bacterial endocarditis (P).
Under the condition of not proper choices time will be lost, bleeding
may resume and the possibility of a detailed history collection will be
lost in order to determine the probable causes of anemic syndrome.
Later on the patient presents additional cause of anemia (except
menorrhagia and vegetarianism), - severe gastrointestinal bleeding,
which, in addition to the pre-existing severe anemic syndrome,
determines the need to direct the patient to a hospital for immediate
transfusion of packed RBC and further examination. Any delay is
unacceptable.
Choice 2. Direct the patient to a hospital for
immediate transfusion of packed RBC (E) / coagulogram, blood iron and
consult a gynecologist to treat menorrhages (G) / ultrasound of the
heart and psychiatrist’s consultation to exclude neurogenic anorexia or
depression (P) / stop taking aspirin, iron replacement therapy and a
blood test with reticulocytes in 10 days (P)
As the patient in the process of management presents her
gastrointestinal bleeding which is likely to originate from the upper
gastrointestinal tract, while directing the patient to the hospital for
transfusion of packed RBC, and following the examination, it is worth to
catheter the veins, provide oxygen therapy, bolus infusion of
crystalloid fluids with strict monitoring, omeprazole 80 mg i/v bolus.
Less valid options are (1), since neither vit. K1 (kanavit) nor the
tranexam are not appropriate in these conditions. Hospitalization of the
patient to a remote hospital is a fatal mistake, since relapse of
bleeding is probable, the time is lost, and in the road it is impossible
to ensure either the conduct of blood substitutes due to severe
bleeding, or invasive methods of hemostasis of the ulcer bleeding, etc.
Choice 3. Catheter the veins, oxygen therapy, bolus
infusion of crystalloid fluids with strict monitoring, omeprazole 80 mg
i/v bolus (E) / catheterization of the peripheral vein, i/v epinephrine,
infusion of crystalloid with dopamine, i/v omeprazole 80 mg and vit. K1
(kanavit) 10 mg (G) / catheterization of several peripheral veins,
oxygen therapy, infusion of crystalloid bolus, tranexam 15 mg / kg once
i/v slowly (1 ml / min), vit. K1 (kanavit) 10 mg i/v (G) /
Hospitalization of the patient to a remote hospital (P).
Depending on the correctness of the selected preliminary steps, then
manifestations of congestive heart failure or pulmonary edema of
cardiogenic origin develop due to volume overload in the intensive care
unit with the rapid introduction of crystalloids, and then packed RBC,
in patients with pre-existing hypoxic cardiopathy on the background of
severe iron deficiency anemia. In this regard, the correct tactic is to
introduce oxygen therapy, lazix and depending on the effect – quick or
slow prolonged infusion of packed RBC after a biological compatibility
testing. The less true choice is to continue infusion of the second dose
of packed RBC after a biological compatibility testing on the
background of oxygenation through the mask and i/v bolus introduction of
lazix without concomitant diuretic therapy. Wrong steps are will
increase cardiac decompensation.
Choice 4. Oxygen therapy, lazix and depending on the
effect – quick or slow prolonged infusion of packed RBC (E) / to
continue infusion of the second dose of packed RBC after a biological
compatibility testing on the background of oxygenation through the mask
and i/v bolus introduction of lazix without concomitant diuretic therapy
(G) / the continuation of packed RBC infusion without diuretics (P) /
dexamethasone i/v, ultrasound of the heart, a cardiologist's
consultation for the choice of further tactics or urgent
esophagogastroduodenophybroscopy (P)
In the future, taking into account the history (menorrhagia) and
gastrointestinal bleeding caused by taking nonsteroidal
anti-inflammatory drugs (aspirin), it is advisable for the patient to be
consulted by a gynecologist, to take oral ferrotherapy at a dose of
100-200 mg of elemental iron per day in 2-3 doses with control of CBC in
1 month, omeprazole 20 mg orally once daily for 6 weeks. Parenteral
administration of iron drugs is not feasible and may be accompanied by
additional risks of side effects.
Choice 5. Consultation of a gynecologist, oral
ferrotherapy at a dose of 100-200 mg of elemental iron per day in 2-3
doses with control of CBC in 1 month, omeprazole 20 mg orally once daily
for 6 weeks (E) / consultation of the gastroenterologist for the
exclusion of celiac disease, i/v ferrotherapy with the transition to
oral iron sulfate administration, refusal to use non-steroidal
anti-inflammatory drugs (G) / consultation of a psychiatrist and a
nutritionist, omeprazole 20 mg orally 1 time per day for 4 weeks,
parenteral - iron drugs (P).
In addition to the aforementioned mistakes, students may be guilty of
mistakes due to a lack of knowledge and skills in identifying certain
diseases (severe anemia) and complications (cardiogenic pulmonary
edema), possible neglect and fixation, giving preference to a more likely condition – playing odds
(after transfusion of packed RBC such more probable complication as
transfusion reaction may be suspected, and the lung edema may be
missed).
In the future, an intrauterine hormone system "Mirena" was assigned
for the treatment of menorrhagia in premenopausal Olena Hayduk. The
patient will have to take oral iron drugs for about 3 months in a
prophylactic dose after hemoglobin normalization; omeprazole should be
taken 20 mg orally once a day for 6 weeks for the healing of
gastrointestinal erosions after the use of aspirin.
Learning Objectives
- Epidemiology, causes, clinical picture, laboratory diagnosis and
management of iron deficiency anemia in the gender and age aspects
- Therapy of iron deficiency anemia with oral and parenteral
administration of iron preparations. Indications, contraindications,
dosage, complications.
- General principles of transfusion therapy. Indications for
transfusion of red blood cells in iron deficiency anemia. Complications.
Compatibility tests.
- Gastrointestinal bleeding. Causes, manifestations, diagnostics, differential diagnostics, tactics for urgent help.
- Menorrhagia. Algodysmenorrhea. Survey, diagnostics, tactics of conduct.
- Congestive heart failure with intact contractility of the heart.
Volume overload. Diagnostics, tactics of management, emergency care.
Errors covered:
- System error
- Fixation
- Playing the odds
