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

2. 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

3. Chief Complaints
Pale skin for 2-3 months

4. 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

5. 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

6. 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(+)

7. 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

9. Initial Lab

10. 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

11. 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)

12. 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

13. 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

14. Initial Lab

15. 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

16. Lab

19. Lab

20. 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

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

22. 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.

24. 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.

25. 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.

26. 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

27. 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

28. Treatment

29. 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

30. Thank you for your attention