Iron deficiency anemia

(Anemia of Chronic Blood Loss; Hypochromic-Microcytic Anemia; Chlorosis; Hypochromic Anemia of Pregnancy, Infancy and Childhood)

Chronic anemia characterized by small, pale RBCs and Fe depletion.

Etiology

Blood loss:

Uterine (menorrhagia, metrorrhagia).

Chronic gastrointestinal blood loss:

• esophageal varices;

• hiatus hernia;

• peptic ulcer;

• chronic aspirin ingestion;

• carcinoma of stomach, colon, caecum, rectum;

• ulcerative colitis;

• hemorrhoids;

• diverticulosis;

• hookworm infestation (anemia with eosinophilia).

Urine bladder and kidney:

• glomerulonephritis;

• carcinoma of kidney and urine bladder.

Increased requirements:

• prematurity (diminished iron stores);

• growth (infants and young children);

• females in reproductive age group: menstruation, pregnancy, lactation.

Impaired absorption:

• achlorhydria (especially in middle aged females);

• atrophic gastritis;

• gastrectomy;

• gastroenterostomy;

• tropical sprue or coeliac disease.

Inadequate intake:

• improper feeding in infants and young children;

• poverty;

• dietary fads;

• anorexia (nervosa, of pregnancy or malignancies).

Pathophysiology: The amounts of iron in organism are distributed between active iron pools (hemoglobin and tissue enzymes) and iron stores (ferritin and hemociderin). Iron deficiency develops when iron loss more than iron intake with food or when increased natural iron requirements or impaired iron absorption appears negative iron balance between iron intake and iron stores that causes decreased iron supply to the bone marrow and iron-deficient erythropoiesis. The several stages of iron deficiency are distinguished: iron-store depletion, iron-deficiency erythropoiesis, iron-deficiency anemia.

The pathogenesis of clinical features may be explained by decreased amount of iron resulted by insufficient tissue supply with oxygen. Reduction in oxygen carrying capacity leads to tissue hypoxia symptoms referable to systems with high oxygen requirements, such as skeletal musculature, cardiovascular system and central nervous system are particularly prominent. Specific action of iron deficiency on the activity of hem content enzymes leads to the trophic disturbance of tissue.

Clinical features

The clinical features include two syndromes: general anemic and specific one due to the iron lack.

Anemic syndrome. The patients complaint on fatigue, tiredness, faintness, easy fatigability, dyspnea, palpitation, heart pain, headache, giddiness, spots before the eyes, lack of concentration, drowsiness, numbness, coldness, tingling of hands and feets. Mild fever 37,2-38,2 °C is observed. Physical examination of the cardiovascular system reveals the displacement of the left relative cardiac border outside, diminished first sound, functional systolic murmurs over sound points with maximal intensity over pulmonary artery, systolic bruits over carotic arteries. ECG changes occur- ST-segment depression and flattening or inversion of T-wave. Amenorrhoea, menorrhagia in females and loss of libido in the males appear.

Cideropenic syndrome was first described by Basenstrom in 1930. The patient complains on the generalized muscular weakness, disorders of muscular sphincters and disorders of urination.

The colour of the skin is pallor with greenish tint. Pallor of the nail beds, mucous membranes of the mouth, conjunctivae, sclerae are revealed. The skin is dry with creak (chirp rattle) on the legs and hands leukoplakia. The nail beds became dry, fragile, with sketch, spoon-shaped named koilonychias. The hair became thin, fragile, and grey.

The gastrointestinal disorders are the specific symptoms and signs of iron deficiency anemia. The patients complain on the difficulties during swallowing solid food - Plummer-Vinson syndrome according to the atrophy of the postcricoid esophageal web. In chronic, severe iron deficiency the patients have specific features - pica chlorotica, which characterized by the eating of unusual items such as coal, earth, chalk, clay, starch, ice (pagophagia) and smell acetone, petroleum.

Nausea, regurgitation, pain and dulling at the epigastric region after meal, diarrhea, anorexia are the specific symptoms of the patients with iron deficiency anemia. The clinical signs of anemia- glossitis with redness and papillae atrophy, angular stomatitis, inflammation of the gum, cheilosis.

During the endoscopic investigations and biopsy the atrophy esophagitis and gastritis are detected. Sometimes may be splenomegaly.

Additional methods of examination

Clinical blood analysis:

• hemoglobin concentration is decreased;

• red blood cells count decreased normal or slightly decreased;

• mean cell volume (MCV) < 76 fl;

- mean cell hemoglobin (MCH) < 27 pg;

• mean cell hemoglobin concentration (MCHC) < 30 gm%;

• color index < 0,8;

• anisocytosis, microcytic red cells;

• poikilocytosis, pencil shaped cells and target cells;

• hypoehromia, ring or pessary cells;

• few polychromatophils;

• reticulocyte count is variable;

• red blood cells osmotic fragility is slightly decreased;

• hematocrit low.

Bone marrow:

• micronormoblaslic erythroid hyperplasia;

• predominantly intermediate normoblasts;

• cytoplasm decreased and shows differential staining;

• bone marrow iron is reduced or absent.

Biochemical blood analysis:

• serum iron level is reduced;

• total iron binding capacity is increased;

- unsaturated iron binding capacity is also raised; percentage saturation reduced.