Posted: February 9th, 2023

A 72-year-old man developed chest pain

Iron-Deficiency Anemia
Case Study
A 72-year-old man developed chest pain whenever he was physically active. The pain ceased on
stopping his activity. He has no history of heart or lung disease. His physical examination was
normal except for notable pallor.
Studies Result
Electrocardiogram (EKG), p. 485 Ischemia noted in anterior leads
Chest x-ray study, p. 956 No active disease
Complete blood count (CBC), p.
156
Red blood cell (RBC) count, p.
396
2.1 million/mm (normal: 4.7–6.1 million/mm)
RBC indices, p. 399
Mean corpuscular volume
(MCV)
72 mm3
(normal: 80–95 mm3
)
Mean corpuscular hemoglobin
(MCH)
22 pg (normal: 27–31 pg)
Mean corpuscular hemoglobin
concentration (MCHC)
21 pg (normal: 27–31 pg)
Red blood cell distribution width
(RDW)
9% (normal: 11%–14.5%)
Hemoglobin (Hgb), p. 251 5.4 g/dL (normal: 14–18 g/dL)
Hematocrit (Hct), p. 248 18% (normal: 42%–52%)
White blood cell (WBC) count, p.
466
7800/mm3
(normal: 4,500–10,000/mcL)
WBC differential count, p. 466 Normal differential
Platelet count (thrombocyte
count), p. 362
Within normal limits (WNL) (normal: 150,000–
400,000/mm3
)
Half-life of RBC 26–30 days (normal)
Liver/spleen ratio, p. 750 1:1 (normal)
Spleen/pericardium ratio <2:1 (normal)
Reticulocyte count, p. 407 3.0% (normal: 0.5%–2.0%)
Haptoglobin, p. 245 122 mg/dL (normal: 100–150 mg/dL)
Blood typing, p. 114 O+
Iron level studies, p. 287
Iron 42 (normal: 65–175 mcg/dL)
Total iron-binding capacity
(TIBC)
500 (normal: 250–420 mcg/dL)
Transferrin (siderophilin) 200 mg/dL (normal: 215–365 mg/dL)
Transferrin saturation 15% (normal: 20%–50%)
Case Studies
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Ferritin, p. 211 8 ng/mL (normal: 12–300 ng/mL)
Vitamin B12, p. 460 140 pg/mL (normal: 100–700 pg/mL)
Folic acid, p. 218 12 mg/mL (normal: 5–20 mg/mL or 14–34 mmol/L)
Diagnostic Analysis
The patient was found to be significantly anemic. His angina was related to his anemia. His
normal RBC survival studies and normal haptoglobin eliminated the possibility of hemolysis..
His RBCs were small and hypochromic. His iron studies were compatible with iron deficiency.
His marrow was inadequate for the degree of anemia because his iron level was reduced.
On transfusion of O-positive blood, his angina disappeared. While receiving his third unit of
packed RBCs, he developed an elevated temperature to 38.5°C, muscle aches, and back pain.
The transfusion was stopped, and the following studies were performed:
Studies Results
Hgb, p. 251 7.6 g/dL
Hct, p. 248 24%
Direct Coombs test, p. 157 Positive; agglutination (normal: negative)
Platelet count, p. 362 85,000/mm3
Platelet antibody, p. 360 Positive (normal: negative)
Haptoglobin, p. 245 78 mg/dL
Diagnostic Analysis
The patient was experiencing a blood transfusion incompatibility reaction. His direct Coombs
test and haptoglobin studies indicated some hemolysis because of the reaction. His platelet count
dropped because of antiplatelet antibodies, probably the same ABO antibodies that caused the
RBC reaction.
He was given iron orally over the next 3 weeks, and his Hgb level improved. A rectal
examination indicated that his stool was positive for occult blood. Colonoscopy indicated a rightside colon cancer, which was removed 4 weeks after his initial presentation. He tolerated the
surgery well.
Critical Thinking Questions
1. What was the cause of this patient’s iron-deficiency anemia?
2. Explain the relationship between anemia and angina.
3. Would your recommend B12 and Folic Acid to this patient? Explain your rationale for
the answer
4. What other questions would you ask to this patient and what would be your rationale for
them?
—>
The patient in this case study is a 72-year-old man who developed chest pain during physical activity. The results of his initial studies, including an electrocardiogram (EKG) and chest x-ray, were normal. However, his complete blood count (CBC) showed that he was significantly anemic, with a red blood cell (RBC) count of 2.1 million/mm (normal range: 4.7-6.1 million/mm), a hemoglobin (Hgb) level of 5.4 g/dL (normal range: 14-18 g/dL), and a hematocrit (Hct) level of 18% (normal range: 42-52%).
Further studies on his RBCs revealed that they were small and hypochromic, which is consistent with iron-deficiency anemia. His iron level was 42 (normal range: 65-175 mcg/dL), his total iron-binding capacity (TIBC) was 500 (normal range: 250-420 mcg/dL), and his transferrin saturation was 15% (normal range: 20-50%). Additionally, his ferritin level was 8 ng/mL (normal range: 12-300 ng/mL), which is low and also consistent with iron-deficiency anemia.
The patient was given a transfusion of O-positive blood, and his angina disappeared. However, during the third unit of packed RBCs, he developed a fever, muscle aches, and back pain, indicating a blood transfusion incompatibility reaction. His direct Coombs test and haptoglobin studies showed evidence of hemolysis due to the reaction, and his platelet count dropped because of antiplatelet antibodies.
The patient was given iron orally over the next 3 weeks to treat his iron-deficiency anemia and prevent further complications. The case study highlights the importance of a thorough diagnostic process and the role of laboratory tests in identifying and managing anemia. Additionally, it highlights the potential complications that can arise from blood transfusions, and the importance of proper blood typing and compatibility testing.