1. Pediatric Case Conference R3 楊佳融

2. Patient ’ s Profile 1-year-2-month old boy 1-year-2-month old boy BW: 13 kg BW: 13 kg T/P/R: // BP:? E4V5M6 T/P/R: // BP:? E4V5M6 檢傷主訴 : 發燒 檢傷主訴 : 發燒 Chief complaint: Chief complaint: intermittent fever up to 38+ degree for 3 days intermittent fever up to 38+ degree for 3 days

3. Present illness intermittent fever up to 38+ degree for 3 days intermittent fever up to 38+ degree for 3 days Cough, stuffy nose, watery rhinorrhea for 2 weeks Cough, stuffy nose, watery rhinorrhea for 2 weeks Decreased appetite and fair activity while afebrile Decreased appetite and fair activity while afebrile No vomiting, no diarrhea, no abdominal pain No vomiting, no diarrhea, no abdominal pain No dysuria, no chest pain, no SOB, no skin rash No dysuria, no chest pain, no SOB, no skin rash No jerk, no unstable gait No jerk, no unstable gait Transfer from LMD due to leukocytosis and microcytic anemia Transfer from LMD due to leukocytosis and microcytic anemia

4. Past history G2P2, GA 39+ weeks, NSD, BBW 3640 gm G2P2, GA 39+ weeks, NSD, BBW 3640 gm Newborn screen: no specific finding Newborn screen: no specific finding Admission or operation : nil Admission or operation : nil Denied systemic illness Denied systemic illness

5. Physical Examination PAT: PAT: appearance: fair-looking appearance: fair-looking breathing: good breathing: good circulation: good circulation: good Neck: LAP (-), supple, no stiffness Neck: LAP (-), supple, no stiffness HEENT: HEENT: Conjunctiva: mild pale Sclera: not icteric Conjunctiva: mild pale Sclera: not icteric Eardrum: no injected Oral ulcer: no ulcer Eardrum: no injected Oral ulcer: no ulcer Thorat: injected Thorat: injected Tonsil: bil. Enlarged, exduate Tonsil: bil. Enlarged, exduate

6. Physical Examination Heart: regular heart beat without murmur Heart: regular heart beat without murmur Breath sound: clear, no rales Breath sound: clear, no rales no subcostal retraction no subcostal retraction Abdomen: soft and flat, no tenderness Abdomen: soft and flat, no tenderness normoactive bowel sound normoactive bowel sound liver spam: 3 cm below RCM liver spam: 3 cm below RCM Extremity: free, no skin rash Extremity: free, no skin rash

7. Initial Impression Fever favor acute tonsillitis Fever favor acute tonsillitis Microcytic anemia Microcytic anemia

8. Initial order Check CBC/DC, BUN, AST, CRP,LDH, Check CBC/DC, BUN, AST, CRP,LDH, B/C X 1, U/A, Reticulocyte B/C X 1, U/A, Reticulocyte EBV- IGM, EBV- IGG EBV- IGM, EBV- IGG CXR CXR Admitted to PED Admitted to PED

9. CXR

10. Laboratory Data WBC: 15400 /μL Hb: 7.4 g/dL Atypical-Lympho: 1.5 % MCV: 57.3 Fl Segment: 29.5% MCH: 15.1 pg/Cell Lymphocyte: 58.5% MCHC: 26.4 g/dL Monocyte: 10.0% RDW: 19.8 % Eosinophil: 0.5 % Platelet: 506 K/μL Reticulocyte: 2.9 %RBC BUN: 5 mg/Dl U/A : negative AST: 42 U/L Ferritin: 6.7 ng/ml CRP: 0.83 mg/L LDH: 94 U/L

11. Discussion

12. Physiologic etiologies for anemia Disorders resulting in an inability to adequately produce red blood cells (ie, bone marrow depression). Disorders resulting in an inability to adequately produce red blood cells (ie, bone marrow depression). Disorders resulting in rapid RBC destruction (hemolysis) or RBC losses from the body (bleeding). Disorders resulting in rapid RBC destruction (hemolysis) or RBC losses from the body (bleeding).

13. LABORATORY EXAMINATION The laboratory examination should begin with a complete blood count including red blood cell indices, a reticulocyte count, and a review of the peripheral blood smear. The laboratory examination should begin with a complete blood count including red blood cell indices, a reticulocyte count, and a review of the peripheral blood smear.

15. Blood smear Blood smear— A review of the peripheral smear is an essential part of any anemia evaluation. Blood smear— A review of the peripheral smear is an essential part of any anemia evaluation.

16. Red cell distribution width (RDW)) a quantitative measure of the variability of RBC sizes in the sample (anisocytosis). a quantitative measure of the variability of RBC sizes in the sample (anisocytosis). Patients with a RDW greater than 20 are more likely to have iron deficiency, whereas patients with normal RDW values are more likely to have thalassemia or the anemia of chronic disease Patients with a RDW greater than 20 are more likely to have iron deficiency, whereas patients with normal RDW values are more likely to have thalassemia or the anemia of chronic disease

17. Reticulocyte count an indication of bone marrow erythropoietic activity. an indication of bone marrow erythropoietic activity. An increased reticulocyte count generally is seen as a normal bone marrow response to ongoing hemolysis or nonchronic blood loss. An increased reticulocyte count generally is seen as a normal bone marrow response to ongoing hemolysis or nonchronic blood loss. On the other hand, anemia with a low reticulocyte count indicates a suboptimal bone marrow response On the other hand, anemia with a low reticulocyte count indicates a suboptimal bone marrow response

18. DDx of microcytic anemia TEST Iron deficiency anemia Alpha/beta thalassemia Anemia of chronic disease Hbdecreaseddecreaseddecreased MCVdecreaseddecreased Normal- decreased RDWincreasednormal Normal- increased Erythrocyte protoporphyrin increasednormalincreased Total iron-binding capacity increasednormaldecreased Transferrin saturation decreasednormaldecreased Serum ferritin decreasednormalincreased Transferrin receptor increasednormalincreased

19. Iron deficiency anemia in infants and children, 30 percent of daily iron needs must come from diet because of the growth spurt and increase in body (muscle) mass. in infants and children, 30 percent of daily iron needs must come from diet because of the growth spurt and increase in body (muscle) mass. 9 % of children age 12 to 36 months in the United States had iron deficiency and that 3 % had IDA. 9 % of children age 12 to 36 months in the United States had iron deficiency and that 3 % had IDA. The most common presentation of IDA is an otherwise asymptomatic The most common presentation of IDA is an otherwise asymptomatic

20. Iron deficiency anemia Common factors leading to an imbalance in iron metabolism include: Common factors leading to an imbalance in iron metabolism include: Insufficient iron intake Insufficient iron intake Decreased absorption due to poor dietary sources of iron Decreased absorption due to poor dietary sources of iron Early introduction of whole cow's milk Early introduction of whole cow's milk Occult blood loss secondary to cow's milk intolerance Occult blood loss secondary to cow's milk intolerance Medications (eg, aspirin, nonsteroidal antiinflammatory drugs) Medications (eg, aspirin, nonsteroidal antiinflammatory drugs) Malabsorption states Malabsorption states

21. Iron deficiency anemia DIAGNOSIS: DIAGNOSIS: For infants presenting with a mild microcytic anemia and a presumptive diagnosis of IDA, the most cost effective strategy is a therapeutic trial of iron For infants presenting with a mild microcytic anemia and a presumptive diagnosis of IDA, the most cost effective strategy is a therapeutic trial of iron Ferrous sulfate (3 mg/kg of elemental iron, once or twice daily between meals for four weeks) should produce a rise of greater than 1 gm/dL in patients with iron deficiency. Ferrous sulfate (3 mg/kg of elemental iron, once or twice daily between meals for four weeks) should produce a rise of greater than 1 gm/dL in patients with iron deficiency.

22. Iron deficiency anemia DIAGNOSIS: DIAGNOSIS: elevated red cell distribution width (RDW) is the earliest hematologic manifestation of iron deficiency elevated red cell distribution width (RDW) is the earliest hematologic manifestation of iron deficiency iron deficiency in infants and young children usually is identified by a serum ferritin concentration of less than 12 ng/mL and IDA by a hemoglobin concentration below 11.0 g/dL combined with a low serum ferritin. iron deficiency in infants and young children usually is identified by a serum ferritin concentration of less than 12 ng/mL and IDA by a hemoglobin concentration below 11.0 g/dL combined with a low serum ferritin.

23. Iron deficiency anemia DIAGNOSIS: DIAGNOSIS: A more complete evaluation for IDA is indicated at presentation in children with complicated medical histories, which would include serum iron, ferritin, total iron-binding capacity, and transferrin saturation A more complete evaluation for IDA is indicated at presentation in children with complicated medical histories, which would include serum iron, ferritin, total iron-binding capacity, and transferrin saturation Other laboratory tests, such as erythrocyte protoporphyrin, serum transferrin receptor, and reticulocyte hemoglobin content, may prove to be more reliable measures of iron deficiency, but they are not routinely used Other laboratory tests, such as erythrocyte protoporphyrin, serum transferrin receptor, and reticulocyte hemoglobin content, may prove to be more reliable measures of iron deficiency, but they are not routinely used

24. Iron deficiency anemia TREATMENT: TREATMENT: Oral therapy — Ferrous sulfate (3 mg/kg of elemental iron, once or twice daily between meals for four weeks) should produce a rise of greater than 1 gm/dL in patients with iron deficiency. Oral therapy — Ferrous sulfate (3 mg/kg of elemental iron, once or twice daily between meals for four weeks) should produce a rise of greater than 1 gm/dL in patients with iron deficiency. Blood transfusion — Transfusion therapy is rarely necessary for severe IDA, even with hemoglobin concentrations of 4 to 5 gm/dL. Blood transfusion — Transfusion therapy is rarely necessary for severe IDA, even with hemoglobin concentrations of 4 to 5 gm/dL.