HAEMATOLOGY 1

An 80-year-old female is brought to your office, by her son, because of severe fatigue. She lives alone and is suffering from severe degenerative joint disease, which puts her in a house arrest-type state. Her son usually helps with getting grocery. Her only other medical problem is hypertension. She takes hydrochlorothiazide and acetaminophen. Her vitals are stable. On examination, she has pallor, and evidence of severe degenerative joint disease. Which of the following is the most likely cause of pallor in this patient?

A. Vitamin D deficiency
B. Vitamin C deficiency
C. Iron deficiency
D. Folate deficiency
E. Chronic hemolysis
F. Anemia of chronic disease
G. Vitamin B12 deficiency
H. Copper deficiency

Explanation:
The following points are to be noted in this clinical vignette. This is a geriatric patient with pallor and fatigue. Her medical history is significant for severe degenerative joint disease and HTN. With the given information, it is obvious that her fatigue is most likely due to anemia. Iron deficiency is the most common cause of anemia in elderly patients; the iron deficiency is most likely secondary to a nutritional deficiency, in this case. Other very common cause of IDA in elderly patients is chronic blood loss; however this patient has no complaints suggestive of chronic blood loss (such as gastritis, PU, diverticulitis, etc.).

Choice F: Anemia of chronic disease (ACD) is seen in patients with chronic illnesses. This is usually seen with infectious, inflammatory, or neoplastic diseases. Also, more recently, this has been noted in patients with severe trauma, heart disease, and diabetes mellitus. This patient has chronic degenerative joint disease, but it should be noted that inflammatory joint disease and not degenerative joint disease cause ACD. The pathophysiology involves defective utilization of the iron by the RBC precursors, secondary to inflammatory mediators.

Choice A: Vitamin D deficiency can occur in a patient who does not go out of the house, or is in a house arrest state; however, this would cause osteomalacia, and not anemia.

Choice B: Vitamin C deficiency is also common among elderly patients who consume a diet poor in vitamin C, and it would cause scurvy. This patient has no clinical features suggestive of scurvy.

Choices D and G: A diet poor in green leafy vegetables and meat can cause folate or vitamin B-12 deficiency, respectively, which could lead to megaloblastic anemia. No information on the patient's diet is given in this vignette. It is also important to note that IDA is the most common anemia in the elderly.

Choices E and H: This patient does not have any clinical features suggestive of copper deficiency or chronic hemolysis. Chronic hemolysis and copper deficiency can also cause IDA.