Microcytic Anemia

Richard Zanetti; Brian Feldman; Timothy Porea

doi:10.1542/pir.2019-0295

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Richard Zanetti, MD, MPH*
Brian Feldman, MD, MPH^†
Timothy Porea, MD, MPH^‡

^*Walter Reed National Military Medical Center, Bethesda, MD
^†Naval Medical Center Portsmouth, Portsmouth, VA
^‡Texas Children’s Hospital and Baylor College of Medicine, Houston, TX

AUTHOR DISCLOSURE
Dr Porea holds stock in Walgreens and Merck. Drs Zanetti and Feldman have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentations

Herein we present 3 different patient presentations with a common diagnosis.

Case 1: A 9-year-old boy with a normal diet presents for evaluation of fatigue. During review of systems, intermittent loose stools without hematochezia are reported. Screening laboratory values are obtained and reveal microcytic anemia (red blood cell [RBC] count, 4.6×10⁶/μL [4.6×10¹²/L]; hemoglobin level, 9.6 g/dL [96 g/L]; mean cell volume [MCV], 66 fL; and RBC distribution width [RDW], 14.7%) and a low serum iron level (<9 μg/dL [1.61 μmol/L]). He is given a presumptive diagnosis of iron deficiency and is started on replacement therapy. Four weeks later, repeated laboratory tests show only mild improvement (RBC count, 4.91×10⁶/μL [4.91×10¹²/L]; hemoglobin level, 10.3 g/dL [103 g/L]; MCV, 66 fL; RDW, 15.6%; ferritin level, 19 ng/mL). Additional laboratory values at this time reveal an elevated erythrocyte sedimentation rate (ESR) (32 mm/hr) and a decreased albumin level (2.6 g/dL [26 g/L]).
Case 2: A 14-year-old boy with a regular diet is found to have microcytic anemia (RBC count, 4.5×10⁶/μL [4.5×10¹²/L]; hemoglobin level, 8.7 g/dL [87 g/L]; MCV, 60 fL; RDW, 15.6%) during evaluation for an acute febrile respiratory illness. At presentation he also reports a history of fatigue and 4 to 8 bowel movements per day with occasional episodes of hematochezia that predated his febrile illness. Further evaluation demonstrates occult blood in his stool on 3 separate samples, as well as a low albumin level (2.2 g/dL [22 g/L]) and an elevated ESR (55 mm/hr). …