Question

Julie is a white, 35 year old mother of two who went to see her gynecologist after feeling increasingly fatigued over the last 3 months or so. She has had trouble keeping up with the activities of her young children and working full-time. She does not take any medications, but did recently start a multivitamin in hopes it would increase her energy. Her weight has been stable, she has had no changes in her diet or sleep habits, except for recently she started eating ice. Her past medical history and family history are negative. She does not smoke, drink or do any illicit drugs. On physical test she was found to have pale conjunctiva, spooning of her nails, and her stools were negative for occult blood. Her doctor ordered a CBC which showed a hemoglobin of 8.2 g/dL, hematocrit of 26%, RBC count of 3.5 million/uL, MCV 74.2fL, WBC count of 6,400/uL. Based off of these results her doctor diagnosed Julie with anemia.

Please respond to each of the following in your reply:

1. What is the significance of Julie eating ice?
2. What type of anemia does Julie most likely have, why do you think this?
3. Based off of the type of anemia that you think Julie has, what additional tests would you like to see ordered?
4. What would be an appropriate treatment for Julie?

Answer 1

Patient is female and is mother also. Her clinical features and laboratory tests results are suggesting towards anemia known as Iron Deficiency Anemia. It is most common type of anemia worldwide. It is very common in reproductive age females because of increased loss of iron during menstruation and inadequate fulfilment of increased requirement of iron.

1) Ice eating is a symptom suggesting of PICA. Pica is eating or chewing certain substances that have no nutritional value like ice, soil, etc. Pica is a feature suggesting of iron deficiency anaemia.

2) Julie may have most probably Iron deficiency anaemia because it is very prevalent in her age group and also she has features like spooning of nails, pallor in conjunctiva, and absence of blood in the stools. Haemoglobin is low, RBC count is low, MCV (Mean corpuscular volume) is also low (Normal- 82-96 fL) indicating Hypochromic anemia, most commonly seen in Iron deficiency anaemia. She also has fatigue.

3) Additional investigations required:

• Serum ferritin (decreased)
• Total Iron Binding capacity (increased)
• Transferrin saturation (decreased)

4) Treatment is tablet Ferrous sulfate 200mg. (It contains 60mg iron and out of which 10% 6mg is absorbed). Other options are Ferrous fumarate. These tablets are to be taken empty stomach. Aim of the treatment is not only correction of anemia, but also the repletion of iron stores in the body. The total duration of treatment is 8-12 weeks. If no response or no compliance of patient occurs, then IV iron has to be given.