B2

A 26-year-old malnourished woman presented with a 4-day history of mouth pain and a 3-month history of fatigue, general malaise, and palpitations. Physical examination revealed pallor of the conjunctiva and nail beds, as well as as the following photo:

1. Name this condition.


Laboratory studies revealed a hemoglobin level of 30 g per liter, a platelet count of 45,000 per cubic millimeter, and a leukocyte count of 4100 per cubic millimeter. More lab studies were not done due to financial restrictions in the Brazilian clinic you were working at. Knowing that the local area had a high prevalence of hookworm infection, what lab studies would you pursue if you could order more? 

 A peripheral blood smear shows the following:

2. Describe what abnormalities you see, if any. 

3. What is your leading diagnosis? Two clinical features have already been mentioned. Name a third.  Name 3 things that could cause it.


4. What would you expect the following labs to show in your diagnosis? (increase, decrease, stay the same)
- MCV
- serum iron, iron saturation
- serum ferritin
- TIBC, RDW


5. Put the following Stages of the etiology of this patient’s disease in order.

Decreased serum iron
Absent Iron Stores
Normocytic normochromic anemia
Decreased serum ferritin
Increased TIBC
Microcytic hypochromic anemia
Decreased Iron saturation




Intraoral examination revealed an abscess, which was drained. The patient underwent blood transfusion; the repeat hemoglobin level was 71 g per liter, and there was clinically significant improvement in her systemic symptoms. 


6. In what form is Iron absorbed? Where is it mostly absorbed?


7. Your patient starts to complain she has trouble swallowing solid objects, but is able to drink fluids. What new syndrome comes to mind and what other clinical features are a part of it? 

Clue:

Ben T.
(Clinical Vignette Adapted from NEJM)