History

What history would you like to ask?

To address the last question, let’s consider the differential diagnosis of microcytosis. Which of the following are potential causes?

a
Vitamin B12 deficiency
b
Iron deficiency
c
Inflammation
d
Hypothyroidism
e
Thalassemia

The differential diagnosis for microcytosis includes:

  • Iron deficiency
  • Thalassemia
  • Inflammation
  • Rarer conditions such as:
    • Fragmentation syndrome (i.e., microangiopathic hemolytic anemia)
    • Certain congenital anemias
    • Hyperthyroidism

Anemia of any cause can can lead to symptoms of fatigue, shortness of breath, chest pain, and headaches. Let’s consider symptoms associated with each of the various causes of microcytosis:

  • Iron deficiency:
    • Pica
    • Restless legs
    • Sore tongue
    • Alopecia
    • Brittle nails
    • Dysphagia
  • Thalassemia:
    • Thalassemia minor is generally not associated with symptoms.
    • Thalassemia major may be associated with:
      • Jaundice
      • Growth retardation
      • Craniofacial changes, for example bossing of skull
      • Failure of sexual maturation
      • History of transfusion dependence
      • History of iron overload
  • Inflammation:
    • History and/or symptoms of:
      • Rheumatological condition
        • Raynaud’s
        • Arthralgia
        • Myalgia
        • Morning stiffness
        • Dry eyes
        • Dry mouth
        • Skin rash
        • Mouth ulcers
        • Headache
      • Inflammatory bowel disease:
        • Chronic diarrhea
        • Abdominal pain
        • Nausea and vomiting
        • Weight loss
        • Skin lesions
        • Ocular inflammation such as uveitis
        • Mouth ulcers
      • Malignancy:
        • Weight loss
        • Fevers
        • Night sweats
        • Symptoms referable to organ(s) involved
      • Chronic infection:
        • Fever
        • Symptoms referable to site(s) involved, for example chronic respiratory infections associated with:
          • Shortness of breath.
          • Fatigue
          • Mucus production
          • Fever
          • Sore throat
          • Postnasal drip or nasal discharge

Now you armed with a series of questions to ask the patient!

Before you interview the patient, which of the following can we exclude as a sole cause of the microcytosis?

a
Iron deficiency
b
Thalassemia
c
Iron deficiency + thalassemia
d
Inflammation
While 10-20% of cases of anemia of inflammation are associated with microcytosis, the mean cell volume (MCV) is not this low.
e
Fragmentation syndrome (thrombotic thrombocytopenia purpura)
Conditions such as thrombotic thrombocytopenia purpura (TTP) may lead to microcytosis from schisoctyosis, but the mean cell volume (MCV) is not this low.

That leaves iron deficiency and/or thalassemia as the likeliest cause of the patient’s microcytosis.

You obtain a history (next slide).

This is a 60 year-old man referred to you for evaluation of microcytic anemia. He was recently admitted to the hospital with chest pain. He had coronary angiography that showed a significant proximal left anterior descending artery (LAD) lesion. He underwent bypass surgery with an internal mammary graft to the LAD. His course was uncomplicated and he was discharged home. Since discharge, he has developed increasing fatigue, shortness of breath on exertion, palpitations and postural lightheadedness. He was found to be anemic and was started on ferrous gluconate 325 mg daily. however, he developed epigastric discomfort and constipation. so he stopped the medication. He denies symptoms of pica, restless legs, alopecia or sore tongue. He denies a past history of anemia. Apart from his coronary artery disease, he has no other active medical problems. There is no family history of thalassemia or other hematological disorders. His medications include atorvastatin, metoprolol and aspirin. He is allergic to sulfonamides.

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