Medicine - A 60-year-old lady with history of 8 transfusions in the past two years.......................

Medicine

1. A 60-year-old lady with history of 8 transfusions in the past two years presents with Hb = 6g/dL , RBC count = 2.3 mn/dL, Platelets – 3.3 lakhs/dL, MCV–60, Total count 5600/dL. Normochromic and hypochromic microcytic cells. Which of the following is not necessary?
A. Urine hemosiderine
B. Pulmonary hemosiderine
C. Bone marrow examination
D. GI endoscopy

Answer: B. Pulmonary hemosiderine

Explanation

Anemia with low RBC count,low MCV and hypochromia points towards a diagnosis of iron deficiency anemia and absent iron stores on bone marrrow examination is the gold standard test for the same. Despite blood transfusions (which are a source of iron), if the patient continues to have iron deficient state, then it points towards chronic blood loss as a cause of the iron deficiency.Chronic blood loss can occur from the GIT (for which a GI endoscopy is warranted) or in the urine (in patients with intravascular hemolysis and hemosiderinuria).Intravascular hemolysis classically occurs in PNH (paroxysmal nocturnal hemoglobinuria) where hemosiderinuria leads to chronic iron deficiency with low MCV and hypochromic cells on peripheral smear.This is in contrast to auto-immune hemolytic anemia where the hemolysis is predominantly extravascular and there is no loss of hemosiderin in the urine or development of iron deficiency.

A rare cause of recurrent IDA may also be idiopathic pulmonary hemosiderosis where the patient has recurrent episodes of pulmonary hemorrhage and hemosiderin is lost in the sputum.This can be picked up on looking for hemosiderin in the sputum or BAL specimen but such patients will give a typical history of recurrent episodes of dyspnea and cough with chest x-ray showing diffuse alveolar infiltrates.In the absence of these features in the above patient routine evaluation for pulmonary hemosiderin is not indicated in all patients with recurrent IDA.