Case Discussion R1 吳宗祐 VS 鄭兆能 2017/04/26

Patient Profile Name: 蘇X箖 Chart number: 181590xx Age: 10-month-old Gender: Female Date of admission: 2017/04/17~04/22 Informant: Parents and medical records

Chief Complaints Pale skin for 2-3 months

Present Illness Pale skin color for 2-3 months No peripheral cyanosis No dyspnea on exertion No exercise intolerance Mild dry cough and decreased activity/appetite/urine output since 3 days ago 180  60cc/meal Q4H No fever, no rhinorrhea, no diarrhea, no skin rash Stool color: dark brown Went to LMD  refer to NCKUH for pale skin

Past History Birth Hx: Feeding: G1P1, GA 38wks, C/S due to maternal PIH Uneventful perinatal hx BBW: 3000g Prenatal screen (echo, amniocentesis, lab): normal Newborn screen: normal Thalassemia family history: denied (both sides) Feeding: Breast milk until 2 months old Formula milk (S-26) 180ml/meal Supple food(+) 以水果為主

Past History Medical Hx: Allergic Hx: Nil Vaccination: Scabies, topical agents for scabies treatment for 4 months (contact: aunt who admitted to E-Da hospital) Allergic Hx: Nil Vaccination: As scheduled Rota(+), additional PCV(-) Growth and development: BL: 76.5 cm = 85-97th percentile BW: 8 kg = 15-50th percentile Developmental milestone: crawl(+), sit(+), standing with assistance(+)

PE Vital Signs: T: 37.3°C(04/17 23:00) P: 163/min(04/17 23:00) R: 30/min(04/17 23:00) BP: 107/62mmHg(04/17 23:00) General: fatigue(+,3 days), anorexia(+,3 days) HEENT: conjunctiva: Pale, sclera: anicteric, lips: pale Throat: not injected, Tonsil: no swelling, no pus Neck: supple, no JVE, no LAP Chest: symmetric expansion, bilateral clear breath sounds, crackle(-), wheezing(-) Heart: regular heart beat, murmur(-), gallop(?) Abdomen: flat and soft, normoactive bowel sound, tenderness(-), muscle guarding(-), hepatosplenomegaly(-) Extremities: warm, pitting edema(-), nail beds: pale Skin: no edema, petechiae or ecchymosis

Initial Lab

D/D for Pallor in Children Anemia Decreased RBC or Hb production Increased RBC destruction Blood loss Trauma GI loss: Meckel’s diverticulum, Peptic ulcer Idiopathic pulmonary hemosiderosis Non-hematologic Respiratory failure Shock Hypoglycemia Pheochromocytoma Skin edema

Anemia Decreased production Increased destruction Iron deficiency Folic acid, Vitamin B12 deficiency Fanconi's anemia Aplastic anemia Malignancy* Thalassemias Lead poisoning Anemia of chronic disease Increased destruction Hereditary spherocytosis G6PD deficiency Sickle cell syndromes* Autoimmune hemolytic anemia* Isoimmune hemolytic anemia* Disseminated intravascular coagulation* Hemolytic uremic syndrome* Thrombotic thrombocytopenic Purpura* Cavernous hemangioma (Kasabach Merritt syndrome)

Microcytic Normocytic Macrocytic Anemia without abnormality of other cell lines Microcytic Iron Deficiency Thalassemia Sideroblastic anemia Anemia of chronic disease Normocytic Low or normal Reticulocyte count Infection Drugs Lead poisoning Acute blood loss High Reticulocyte count Hemorrhage Hemolytic anemia Membranopathy Enzymopathy Hemoglobinopathy Macrocytic VitB12/Folate deficiency Sickle cell disease

Initial Lab Corrected reticulocyte percentage = Reti x Hct / normal Hct = 8.95 x 10.1 / 37 = 2.4 Reticulocyte Production Index = 0.98 (<2) Hypoproliferation of Reticulocytes

Initial Lab

Treatment course Abd echo: normal F/u Lab: improved Stool OB(+) Meckel diverticulum scan: negative F/u Lab: improved MBD Start Iron supplement since afternoon

Lab

Lab

Lab Date 04/17 04/19 04/22 RBC (10^6/μL) 1.28 1.26 1.57 Hb (g/dL) 2.9 3.1 3.9 Hct (%) 10.1 10.0 13.5 MCV (pg) 78.3 79.3 86 Reti (%) 8.95 11.02 16.86

Final Diagnosis Severe iron-deficiency anemia, gastro- intestinal bleeding related

Discussion – Iron Deficiency Anemia A reduction of the hemoglobin concentration or red blood cell (RBC) volume below the range of values occurring in healthy persons.

Iron-Deficiency Anemia The most widespread and common nutritional disorder in the world. 30% of the global population, most live in developing countries. Daily needs: 1mg of iron during the fist 15 years of life  dietary intake 8-10mg iron per day Breastfed infants absorb 2-3 times more efficiently than cow’s milk In term infants, anemia caused solely by inadequate dietary iron usually occurs at 9-24 month of age Chronic IDA from occult bleeding may be caused by a lesion of the GI tract, such as peptic ulcer, Meckel diverticulum, polyp, hemangioma, or inflammatory bowel disease.

Clinical Manifestation Mostly asymptomatic Severe anemia (Hb<5) Irritability, anorexia, and lethargy develop Systolic flow murmurs, tachycardia High output cardiac failure ID/IDA has non-hematologic systemic effects Associated with impaired neurocognitive function in infancy. Associated with later cognitive defects. Increased risk of seizures, strokes, breathholding spells in children, and exacerbations of restless leg syndrome in adults.

Lab Findings Microcytic anemia High red cell distribution width (RDW) Reduced RBC, normal WBC, normal or elevated Plt Reduced serum ferritin, reduced serum iron Increased total iron-binding capacity (TIBC) Un-elevated CRP

Treatment Oral administration of simple ferrous salts Adolescents sometimes have GI complaints May increase the virulence of malaria and certain GNB, particularly in developing countries. Iron overdose is associated with Yersinia infection Dietary counseling is usually necessary. Excessive intake of milk(cow’s milk), should be limited. Blood transfusion is rarely necessary

Treatment

Take home message PE 很重要 PE 很重要 PE 很重要 How to approach a pale children Hematologic v.s. non-hematologic cause How to approach anemia Decrease production v.s. increased destruction Microcytic v.s. normocytic v.s. macrocytic Reticulocyte counts/reticulocyte production index Iron deficiency anemia

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