Case based learning -IRON

Dr.L.Karpagavel
 Case history 1
• A 6 year old boy comes to the OPD with complains of loss of
appetite, early fatigue and lethargy. Mother complained that
the boy gets tired very soon while playing and suffer
headache frequently. On examination nails were flat and
brittle and pallor of face was seen.

• Provisional diagnosis : Anemia

 How will you proceed in a
suspected case of anemia
• Medical History
• Family history with socioeconomic status
• Perform physical exam
• DO the following tests
Complete blood count (CBC)
Peripheral Smear Study
serum iron
TIBC
Serum Ferritin
B12 levels
Places to look in for pallor(anemia)
during physical examination
 WHAT IS ANEMIA ?
• Anemia is a condition in which there is lack of healthy
red blood cells to carry adequate oxygen to body's
tissues.

• Iron deficiency anemia was suspected in this patient

and certain blood investigations were done
 Lab investigations
• Hemoglobin – 9 gm/dl 11-13g/dl
• Serum iron- 41 ug/dl Normal 50 -200 ug/dl
• Serum ferritin – 40 ug/dl Normal 50 -200 ug/dl
• Total iron binding capacity – 470 ug/dl Normal 250 - 450ug/dl
• Mean Corpuscular Volume – 65mm3/ml Normal– 80 -95 mm3/ml

PERIPHERAL SMEAR STUDY

Microcytic
Hypochromic picture
 What is iron ?

Iron belongs to the class of micro minerals

 MACRO MINERALS vs. MICRO
MINERALS
• MAJOR ELEMENTS or MACRO MINERALS - If
the daily requirement of a mineral is more than
100mg/dl
• MINOR ELEMENTS or TRACE ELEMENTS or
MICRO MINERALS - If the daily requirement of
a mineral is less than 100mg/dl
Macro mineral Trace elements

Calcium Iron

Magnesium Iodine

Phosphorous Copper

Sodium Zinc

Potassium Selenium
 Biomedical Importance of iron
• component of heme in hemoglobin and myoglobin-
transport of oxygen.

• Present in cytochrome a, b, c – cellular respiration &

ATP synthesis

• Component of cytochrome P-450 - Detoxification

• Iron deficiency anemia-very common disorder

 Distribution

• Normal adult:
Total body iron: 3-5gm.
75% in blood-Hemoglobin & Myoglobin
25% in Bone Marrow, Liver, Reticuloendothelial system
 Case Discussion-symptom
analysis
• Brittle & flat nails – Adequate oxygenation is required for the
growth of healthy nails

• Headache -Brain cells get less oxygen than usual

• Early tiredness & fatigue - due to inability of RBC to supply

sufficient oxygen to tissues
SYMPTOMS
 Where is iron absorbed ?
• Duodenum
 ABSORPTION
• Dietary iron in ferric
form bound to proteins
• Gastric HCl releases
ferric form
• Reduced to ferrous
with the help of ferric
reductase in the
enterocytes.
• Vitamin C and
Glutathione help in the
processes
• Ferrous form of iron is
only absorbed.
• Absorbed in the
DUODENUM
• Divalent metal
transporter helps
 ABSORPTION & TRANSPORT
• Converted to ferric form by
ferroxidase

• Ferric form combines with

apoferritin to form ferritin

• Ferritin – storage form and

temporarily stored

• Reduced & converted to

ferrous which crosses the
membrane

• In the plasma it is converted

again to ferric form by
ceruloplasmin

• Ferric combines transferrin –

transport form
FACTORS AFFECTING ABSORPTION OF IRON

• Increase Decrease

Vitamin C Phytates,Oxalates
Gastric HCl ,Cysteine Copper, Calcium, Phosphorous
 What is Mucosal Block Theory

• Iron Homeostasis is maintained at the level of Absorption

and Not by Excretion.

• ↓ Iron stores - ↑ Absorption of iron at the level of

intestinal mucosal cells.

• N or ↑ Iron stores - ↓ Absorption of iron at the level of

intestinal mucosal cells.
 Lab investigations -Analysis
• Hemoglobin – 9 gm/dl - Decreased
• Serum iron- 41 ug/dl Normal 50 -200 ug/dl - Decreased
• Serum ferritin – 40 ug/dl Normal 50 -200 ug/dl - Decreased
• Total iron binding capacity – 470 ug/dl Normal 250 - 450ug/dl
blood's ability to attach itself to iron and transport it around the body increased
• Mean Corpuscular Volume – 75mm3/ml Normal– 80 -95 mm3/ml
-
Decreased

PERIPHERAL SMEAR STUDY

Microcytic
Hypochromic picture
Lab investigations –Analysis contd
• Hemoglobin is less – Iron is essential
• Serum iron – Low
• Serum ferritin - Low
• TIBC is increased
• Peripheral Smear Study
Microcytic- Disruption of iron supply leads to impairment
in heme synthesis.
Hypochromic - Decrease of pigment hemoglobin
 What is ferritin

• Storage form of iron

• Formed when Apoferritin combines with ferric form.
• It is seen in intestinal cells, liver, spleen and bone
marrow.
• It is an index of iron status in the body.
 Excretion

• One way element (very little is excreted)

• Not excreted in urine.
• Feces, Menstrual blood, Skin
• Faeces contain unabsorbed iron as well as iron
trapped in the intestinal cells, which are then
desquamated.
Iron deficiency Anaemia
 IRON DEFICIENCY ANEMIA
• Commonest of all nutritional diseases.
• Maternal Anemia cause for perinatal mortality

Causes:
• Nutritional deficiency - India
• Impaired absorption
• Hookworm infection
• Chronic blood loss
 CAUSES OF IRON DEFICIENCY
1.Nutritional deficiency of iron –common in India.
2.Lack of absorption: Subtotal gastrectomy and hypochlorhydria.
3.Hookworm infection: One hookworm will cause the loss of about
0.3 mL of blood per day.
4.Repeated pregnancies: About 1 g of iron is lost from the mother
during one delivery.
5.Chronic blood loss: Hemorrhoids (piles), peptic ulcer, menorrhagia.
6.Nephrosis: Haptoglobin, hemopexin and transferrin are lost in urine,
along with loss of iron.
7.Lead poisoning: Iron absorption and hemoglobin synthesis are
reduced.
 Cause for iron deficiency in this
patient
• Main cause of iron deficiency in India is dietary deficiency
superimposed by high phytate content in Indian diet Impairs
absorption of iron

• In addition worm infection is important in Indian children

 IRON DEFICIENCY ANEMIA
•It is the most common nutritional deficiency disease. About 30%
of world population is anemic. About 85% of pregnant women suffer from
anemia.
•Maternal anemia contributes to increase in perinatal mortality.
•Iron deficiency is characterized by microcytic hypochromic anemia.
Anemia is diagnosed when hemoglobin level is <10 g/dL and/or ferritin
level is below 12 μg/dL.
Clinical Manifestations
•When the level is lower than 10 g, body cells lack oxygen and patient
becomes uninterested in surroundings (apathy).
•Lack of cellular respiration &ATP – Metabolic process slow
•Cognitive dysfunction –impaired memory & Attention, poor scholastic
performance.
•Very chronic iron deficiency anemia will lead to impaired attention,
irritability, lowered memory and poor scholastic performance.
•Chronic iron deficiency is manifested as koilonychia or “spoon nail”
 What are the risk factors of iron
deficiency anemia
• Being a female
• being a vegetarian
• donating blood frequently
• being 65 or older
 Why iron is not absorbred
• Conditions like celiac disease, ulcerative colitis,
or Crohn's disease can make it harder for your
intestines to absorb iron. Surgery such as
gastric bypass that removes part of your
intestines, and medicines used to lower stomach
acid can also affect your body's ability to absorb
iron.
 What type of diet modifications
• healthy diet rich in iron and vitamins.
• Examples of iron-rich foods include:
• red meat
• seafood
• poultry
• beans
• leafy greens like spinach
• iron-fortified cereals, pasta, and bread
• Vitamin C helps with iron absorption. Try to
combine foods or beverages high in vitamin C with
your iron.
 Treatment of Iron Deficiency
• Deworm the patient
• Oral iron supplementation + folic Acid
Usually given along with Vitamin C and Vitamin E
•Oral iron supplementation is the treatment of choice.
•Iron tablets are usually given along with vitamin C, to convert it
into ferrous form, for easy absorption and Vitamin E to prevent
free radical formation.
•Administration of iron-zinc combinations are beneficial to correct
deficiency of both.
•There are different pharmaceutical preparations. Ferrous sulfate
is the first choice, as it is easily absorbed and has maximum
bioavailability. If that is not tolerated, ferrous fumarate or ferrous
gluconate may be tried. If that is also not tolerated, then iron
polymaltose or iron bisglycinate may be tried.
Can iron tablets cause constipation
• Yes
• The body will only absorb so much of any
mineral at a time. Even with highly absorbable
forms of iron such as ferrous diglycinate, a large
dose will cause some iron to remain in the gut
and contribute to constipation
• If you have constipation from iron, one
excellent solution is to prescribe a liquid form
of iron supplement
 Can iron tablets cause black stool
• Yes
• Unabsorbed iron
 Can you take iron tablets and
antacids & milk
• Do not take antacids or drink milk or caffeine
drinks (such as coffee, tea, or cola) at the same
time or within 2 hours of the time that you
take your iron pills.
THANK YOU