Iron Deficiency Anemia Essay – “Tasting For Eating Ice” and “Spooning Of Nails” case study
Case Study 2:
A 36 year old woman is seen for easy fatigue for many months. She is now 24 weeks pregnant with her 3rd child in 3 years. She does not see any obstetrician and does not take any prenatal vitamins. Lately, she has developed a taste for eating ice shavings. She has no other complaint. Family and past history are negative. She does not smoke or drink. Physical examination is positive for pale conjunctiva, mild spooning of nails, and a II/VI systolic murmur at left lower sternal border. Stools are negative for occult blood. Iron Deficiency Anemia Essay – “Tasting For Eating Ice” and “Spooning Of Nails” case study.
Labs: Complete blood count (CBC) – Hg 7.1 gm/dl, Hct 23%, WBC 5,400/mm3 (differential is normal), platelets 450,000/mm3; Mean Corpuscular volume (MCV) is 74 fl (normal 85-95 fl); Red cell Distribution Width (RDW) is 17.1% (normal 13-15).
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Please answer the following:
– Explain the significance “tasting for eating ice” and spooning of nails.
– What are you differential diagnoses for this patient and why?
– What further tests would you like to do in this patient to confirm your diagnosis?
– Based on your diagnosis, what is your therapeutic strategy for treatment of this woman’s condition?
Explanation of the Importance of “Tasting For Eating Ice” And “Spooning Of Nails”
The phrase “tasting for eating ice” has been used to describe the client’s craving for substances which have no nutritive value, a condition medically referred to as pica. From a medical perspective, the “taste for eating ice” is also known as pagophagia and is a symptom of iron deficiency anemia which commonly occurs among pregnant women and children Iron Deficiency Anemia Essay – “Tasting For Eating Ice” and “Spooning Of Nails” case study. In this case, iron deficiency anemia tends to develop gradually as blood is slowly lost. A person can, therefore, fail to show any signs until the stores of iron are totally depleted and the production of red blood cells is compromised (Wu, Lesperance & Bernstein, 2016). It is at this point that patients develop fatigue and other symptoms. It is worth knowing that fatigue usually occurs due to lack of circulating hemoglobin and proteins depletion which need iron in their structural formulation. Iron Deficiency Anemia Essay – “Tasting For Eating Ice” and “Spooning Of Nails” case study. However, the severity is usually dependent on the degree of anemia. Research suggests that it is the dysfunctional nature of non-hemoglobin proteins that have deleterious effects such as ice tasting (Wu, Lesperance & Bernstein, 2016).
Pica was initially renowned in the 6th century in a woman who was pregnant. Since this period, there are many cases related to Pica that have been reported where most patients have acknowledged behaviors such as pagophagia (ingesting ice cubes), geophagia (clay) and amylophagia (dry pasta). It should be noted that, despite the fact that pica has been noted to commonly occur among children with disabilities in development and pregnant women, it has also been observed among women and men of all ethnicities and ages. However, it is more prevalent among persons with a lower socio-economic status. According to the World Health Organization, globally, between 25-35% of cases in pica involve children, 30% are gravid women and 10-20% are persons with disabilities in learning (Auerbach & Adamson, 2016) Iron Deficiency Anemia Essay – “Tasting For Eating Ice” and “Spooning Of Nails” case study.
“Spooning of nails” medically known as koilonychia, is a primary characteristic of chronic iron deficiency anemia where the nails appear to have a spoon shape: thinner than usual with outer edges that have turned up. In other cases, the nail can even crack and the outer part comes out of the nail bed. In such cases, iron deficiency may be as a result of inadequate intake of dietary iron, malnutrition, intestinal bleeding or inability to efficiently absorb enough iron from the diet (Auerbach & Adamson, 2016). As in this case, it is more likely that it was as a result of multiple pregnancies within a very short period of time. This presentation should, therefore, prompt for an immediate diagnosis of chronic iron deficiency anemia.
Differential Diagnoses for This Patient
Chronic Iron Deficiency Anemia: the patient presented with complaints of easy fatigue which had sustained for many months and reported not to take any vitamins despite being pregnant. This patient experienced fatigue since she lacked enough red blood cells to transport essential nutrients and oxygen to vital organs of the body. Therefore, the organs worked much harder to produce the energy needed by the body (Abu-Ouf & Jan 2015). This generally translated to less energy leading to feelings of exhaustion. In pregnancy, the risk for iron deficiency anemia increases since there is an increase in the maternal requirements and demands from the developing placenta and fetus (Breymann, 2015). There is also an increase in the mass of the erythrocytes and an expansion in maternal blood volume to support the developing fetus. This is the reason pregnant mothers are highly recommended to take additional 0.9-1.0 grams of iron, which the client never did. Iron Deficiency Anemia Essay – “Tasting For Eating Ice” and “Spooning Of Nails” case study.
The clients also acknowledged having an ice eating taste and a physical examination revealed that she was pale, had spoon-shaped nails and a systolic murmur that could be heard at the left lower sternal border. An ice-eating taste revealed the clients craving for non-nutritional substances, a condition known as pica which is a characteristic symptom of iron deficiency anemia (Auerbach & Adamson, 2016). The client’s paleness could relate to the laboratory findings of: a hemoglobin level of 7.1 gm/dl, which is way below the standard value of 11g/dl, a mean corpuscular volume of 74fl which was below the normal range of 85-95 fl and the red cell distribution width of 17.1% that had exceeded the normal range of 13-15(Auerbach & Adamson, 2016).
A low MCV and a high RDW have been associated with iron deficiency anemia. While the MCV divides the client’s anemia into micro, normal and macro whose classifications have different differential diagnoses, the RDW tends to measure anisocytosis. Iron Deficiency Anemia Essay – “Tasting For Eating Ice” and “Spooning Of Nails” case study. Therefore, an MCV of 74 fl is indicative of microcytic anemia (Wu, Lesperance & Bernstein, 2016). Since the patient had been anemic for several months and in a pregnancy state, her heart is forced to pump more blood in order to compensate for the oxygen that lacked in blood. While this is a risk for anemic heart failure, it was the reason the patient had a systolic murmur which could be heard at the left lower sternal border (Anand & Gupta, 2018). This makes Iron deficiency anemia the most probable diagnosis for this patient.
Thalassemia: The clinical signs and symptoms that the patient presented with were characteristic of thalassemia syndrome. However, her RDW was elevated and the MCV was low. Patients with thalassemia usually have a normal RDW and a low MCV (Wu, Lesperance & Bernstein, 2016). Based on this explanation, a diagnosis of thalassemia is less likely.
Anemia of Chronic Disease (Renal Failure, Rheumatoid Arthritis): The client’s clinical presentation of prolonged fatigue, ice eating taste, spoon-shaped nails, paleness, and a systolic murmur can similarly be found in anemic patients with chronic diseases. However, this patient has apparently not reported having any chronic disorders. Although her MCV was low as seen in anemia of chronic disorder, the RDW was high. In chronic disease, the RDW is always normal (Auerbach & Adamson, 2016). This excludes anemia of Chronic Disease as a possible diagnosis.
Additional Tests to Do In This Patient to Confirm the Diagnosis
To confirm the diagnosis of Chronic Iron Deficiency Anemia, further tests that I would do are as follows:
Serum Iron and Ferritin: the serum iron test will measure the ferric ion associated with Transferrin. Under normal circumstances, the values usually range from 12.7-35.9mol (60-90g/dl). In case the serum iron levels turn out to be reduced, it may precede alterations in the morphology and indices of red blood cells (Wu, Lesperance & Bernstein, 2016). It is worth noting that, all iron transported in the body is usually bound in the ferrous form to transferrin, the corresponding iron-binding protein. Therefore, serum iron is the iron bound in transferrin. In some patients with thalassemia and Sideroblastic anemia, the concentration level of serum is always increased (Auerbach & Adamson, 2016) Iron Deficiency Anemia Essay – “Tasting For Eating Ice” and “Spooning Of Nails” case study.
Saturation and Total Iron-binding capacity: iron concentration is important for the saturation of the transferring sites where iron binds. Therefore, it can be used to measure the concentration of transferrin. The normal range is 45.2-77.7mol/L (250-410g/dl). It is worth knowing that transferring is usually 30% bound to iron, it carries 2 atoms of iron in each molecule and is a reflection of the measure of serum transferrin. Therefore, it can be measured through the saturation of all binding sites available (Wu, Lesperance & Bernstein, 2016). The normal values for transferrin are 170-370mg/dl. The level of serum iron is usually low in patients with iron deficiency anemia, the serum iron is always low, the TIBC is high and transferrin saturation is decreased to less than 16%. In anemia of chronic disease and Thalassemias, the serum iron is always normal, the TIBC may be normal or decreased and transferrin saturation decreased to less than 16 % (Auerbach & Adamson, 2016). Iron Deficiency Anemia Essay – “Tasting For Eating Ice” and “Spooning Of Nails” case study.
Therapeutic Strategy for the Management of This Client
I will prescribe the client Ferrous Sulfate 325mg PO TID which is an iron supplement. She will also be prescribed vitamin supplements for the entire duration of her pregnancy and an additional 6-8months after delivery (Auerbach & Adamson, 2016). After the first 2 weeks following the initiation of these supplements, the client will have to return for a follow-up to find the reticulocyte response which will be expected to be less than 10%. Within 8 weeks, her hemoglobin will be expected to be within normal range. Even after the levels return normal, iron replacement therapy will be prolonged for the purposes of restoring iron stores in the bone marrow. Iron Deficiency Anemia Essay – “Tasting For Eating Ice” and “Spooning Of Nails” case study.
References
Auerbach, M., & Adamson, J. W. (2016). How we diagnose and treat iron deficiency anemia. American journal of hematology, 91(1), 31-38.
Abu-Ouf, N. M., & Jan, M. M. (2015). The impact of maternal iron deficiency and iron deficiency anemia on a child’s health. Saudi medical journal, 36(2), 146. Iron Deficiency Anemia Essay – “Tasting For Eating Ice” and “Spooning Of Nails” case study
Anand, I. S., & Gupta, P. (2018). Anemia and iron deficiency in heart failure: current concepts and emerging therapies. Circulation, 138(1), 80-98.
Breymann, C. (2015, October). Iron deficiency anemia in pregnancy. In Seminars in hematology (Vol. 52, No. 4, pp. 339-347). WB Saunders.
Wu, A. C., Lesperance, L., & Bernstein, H. (2016). Screening for iron deficiency. Policy Statement, 23, 171-177. Iron Deficiency Anemia Essay – “Tasting For Eating Ice” and “Spooning Of Nails” case study