A rare cause of B-symptoms and polyarthritis.

Gastric Adenocarcinoma in patients with Roux-en-Y Gastric bypass: A case series

A 12-year-old previously healthy boy presents with leg cramps for 2 weeks and spasms of his hands since yesterday. He also complains of nausea, bloating, epigastric pain, and recurrent watery and loose stools for 1 month. Currently, he is taking lansoprazole for epigastric pain without any relief. He also has a history of involuntary weight loss of 10 lb over 2 months. The family history contains no findings of note. On physical examination, the boy's weight is 36 kg (25th percentile) and height is 140 cm (10th percentile) and he exhibits a positive Trousseau sign and negative Chvostek sign. Remaining physical signs, including on abdominal examination, are normal. Laboratory evaluation shows hypocalcemia (total calcium of 5.3 mg/dL [1.3 mmol/L], ionized calcium of 2 mg/dL [0.5 mmol/L], and corrected calcium of 6.1 mg/dL [1.5 mmol/L]) as well as hypoalbuminemia (3 g/dL [30 g/L]). Serum magnesium measures 1.6 g/dL. CBC shows Hgb of 9.3 g/dL (93 g/L), Hct of 29% (0.29), WBC count of 9.9×103/μL (9.9×109/L), platelet count of 471×103/μL (471×109/L), mean corpuscular volume of 67 fL, and reticulocyte count of 1% (0.01). Results of the iron studies are consistent with iron deficiency anemia, with a serum iron concentration of 6 μg/dL (1.07 μmol/L) (31 to 144 μg/dL [5.5 to 25.8 μmol/L]), transferrin saturation of 3% (0.3), and serum ferritin less than 5 ng/mL (11.23 pmol/L) (21 to 275 ng/mL [47.2 to 617.9 pmol/L]). ESR is 46 mm/h and CRP is 9.5 mg/dL (normal <0.05 mg/dL). His serum 25-hydroxyvitamin D concentration is low at 5.7 ng/mL (14.2 nmol/L) (normal, 32 to 100 ng/mL [79.9 to 249.6 nmol/L]) and serum parathyroid hormone, urine calcium, and creatinine values are within normal limits. His tetany and hypocalcemia resolve with calcium replacement. Additional evaluation leads to the diagnosis. …

Bone Marrow Iron in CKD: Correlation With Functional Iron Deficiency

Transferrin saturation of more than 60% has been identified as a cancer risk factor. It is unclear whether dietary iron intake increases the risk of cancer among individuals with transferrin saturation of less than 60%. The purpose of this study was to examine the association of dietary iron intake and the risk of cancer among adults with increased transferrin saturation. Analysis of a cohort study, the National Health and Nutrition Examination Survey I Epidemiologic Follow-Up Study, was performed. US adults (aged 25 to 74 years at baseline) were followed up from baseline in 1971-1974 to 1992 (N = 6,309). A total of 7.3% of the US population had a serum transferrin saturation of more than 45% at baseline. Intake of dietary iron was essentially uncorrelated with transferrin saturation (r = 0.04). Compared with individuals who had normal serum transferrin saturation and low dietary iron intake, individuals whose serum transferrin saturation was more than 45% and who had high dietary iron intake also had an increased adjusted relative risk of cancer (2.24; 95% confidence interval [CI], 1.02-4.89). Increased risk was not found for individuals with a transferrin saturation of more than 45% but a normal dietary iron intake (hazard ratio, 1.02; 95% CI, 0.69-1.49). Transferrin saturation levels could be set as low as 41%, and the individuals with high transferrin saturation and high dietary iron intake would still have an increased adjusted relative risk of cancer (hazard ratio, 2.00; 95% CI, 1.04-3.82). Among persons with increased transferrin saturation, a daily intake of dietary iron more than 18 mg is associated with an increased risk of cancer. Future research might focus on the benefits of dietary changes in those individuals with increased serum transferrin saturation.

Cord serum ferritin levels, fetal iron status, and neurodevelopmental outcomes: Correlations and confounding variables

Plasma soluble transferrin receptor assay when screening for iron-deficiency in an unselected population of elderly anaemic patients

Evidence Of Relative Iron Deficiency in Apheresis Platelet Donors Correlates With Donation Frequency

Iron deficiency is prevalent in women and patients with chronic kidney disease (CKD). Iron deficiency is not only related to anemia but contributes to adverse consequences for the kidney as well. Whether iron status is associated with renal outcomes after considering sex and anemia in patients with CKD stage 1–4 is unclear. Thus, we investigated the association of iron or iron saturation with renal outcomes in a CKD cohort. During a follow-up of 8.2 years, 781 (31.2%) patients met the composite renal outcome of renal replacement therapy and a 50% decline in renal function. In linear regression, iron was associated with sex, hemoglobin (Hb), and nutritional markers. In a fully adjusted Cox regression model, the male patients with normal iron had a significantly decreased risk of renal outcomes (hazard ratio (HR) 0.718; 95% confidence interval (CI) 0.579 to 0.889), but the female patients did not exhibit this association. The non-anemic patients (Hb ≥ 11 g/dL) had a decreased risk of renal outcomes (HR 0.715; 95% CI 0.568 to 0.898), but the anemic patients did not. In the sensitivity analysis, transferrin saturation (TSAT) showed similar results. When comparing iron and TSAT, both indicators showed similar prognostic values. In conclusion, iron deficiency, indicated by either iron or iron saturation, was associated with poor renal outcomes in the male or non-anemic patients with CKD stage 1–4.

Many hospitalized anemic patients do not undergo appropriate evaluation. We hypothesized that specific clinical variables were likely to be important in triggering evaluation for iron deficiency anemia. We prospectively identified 637 consecutive anemic patients without acute gastrointestinal bleeding admitted over a three-month period to medical inpatient teams of two teaching hospitals and examined clinical variables that predicted diagnostic evaluation. Serum ferritin or serum transferrin saturation (TS) were measured in 43% (271/637) of subjects and were low in 38% (102/271). Predictors of serum ferritin or TS measurement included low hemoglobin concentration and a history of iron supplementation. Predictors of iron deficiency included low hemoglobin concentration (OR 1.9, 95% CI 1.06-3.5) and low mean cell volume (OR 4.6, 95% CI 2.5-8.6). Of 102 patients with iron deficiency anemia, 31% underwent endoscopic evaluation, and 39% had serious gastrointestinal lesions. The only significant predictor of having an endoscopic evaluation was a positive fecal occult blood test (FOBT) (OR 5.2, 95% CI 1.7-16.2). In patients with anemia, tests to ascertain iron status are not appropriately performed in hospitalized patients. Patients found to have iron deficiency anemia who are FOBT-positive undergo endoscopic evaluation more frequently than FOBT-negative patients.

*University of Lancashire, Lancashire, United Kingdom; †University of Milano, Milano, Italy; ‡University of Lund, Malmo, Sweden; §Hopital des Enfants Malades, Paris, France; Hopital Necker Enfants-Malades, Paris, France, ¶Umea University, Umea, Sweden; #University of Munich, Munich, Germany; **Free University of Amsterdam, Amsterdam, The Netherlands; ††Royal Veterinary and Agricultural University, Frederiksberg, Denmark; ‡‡CHUV University Hospital, Lausanne, Switzerland; §§University of Liege, Liege, Belgium; Medical University of Warsaw, Warsaw, Poland; and ¶¶University of Glasgow, Glasgow, United Kingdom

Primary non-Hodgkin lymphoma (NHL) of the gastrointestinal tract (GI) is rare with incidence of 10-15% of all NHL cases and 1-4% of all GI tumors. The most common sites of involvement include the stomach, small intestines, colon and rectum. The presentation is usually non-specific leading to delay in diagnosis. A 49-year-old male patient with history of gastroesophageal reflux disease (GERD) presented with a 3-month history of abdominal discomfort and early satiety, this was associated with fatigue, night sweats and 20 lbs weight loss. On physical examination, he had tender right sided cervical lymphadenopathy (LAD) with several palpable, tender abdominal masses. Laboratory work up was significant for microcytic anemia with hematocrit of 39.8, mean corpuscular volume (MCV) 79.8, iron level 42 and iron saturation 11.1%. Ultrasonography (US) of the abdomen showed LAD near the umbilicus. Given his symptoms and laboratory work up, he underwent a colonoscopy that showed a single 1 cm ulcer in the descending colon (Fig. 1). Biopsy of the ulcer showed cells with expansion of the lamina propria by large atypical lymphocytes with irregular nuclear contour, single prominent nucleoli and moderate cytoplasm. Immunohistochemical stains of the cells were positive for CD20 and CD79a. The final diagnosis was diffuse large B-cell lymphoma (DLBCL), germinal center B cell-like (GCB) subtype. Positron Emission Tomography - Computed Tomography (PET-CT) was positive for uptake in cervical, mediastinal, and abdominal nodes. He was started on combination chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP). He finished 6 cycles of R-CHOP with a negative repeat PET-CT consistent with remission.1550 Figure 1 No Caption available.Primary colorectal lymphoma is rare representing only 0.2 — 0.6% of all colorectal malignancies. The most common symptoms at presentation are abdominal pain and weight loss. DLBCL is the most common histological subtype. Computed Tomography (CT), US and PET-CT are helpful in suggesting the diagnosis by locating the tumor and its extension. Colonoscopy usually shows a fungating mass, infiltrative or ulcerative lesions. Distinct types of DLBCL are identified by gene expression profiling with the most common subtypes are GCB and activated B cell-like (ABC) DLBCL. The GCB has better survival compared to ABC. Management of DLBCL usually involves chemotherapy, radiation, surgery or a combination with R-CHOP chemotherapy being first line.

Comparative analysis of clinical, anamnestic, and laboratory and instrumental data of patients with chronic heart failure (CHF) and iron deficiency (ID) diagnosed according to the AHA/ESC/RSC criteria, and CHF patients diagnosed with ID based on decreased transferrin saturation (TSAT) ≤19.8% or serum iron (Fe) ≤13 μmol/l. An additional analysis of the ID-CHF-RF study was performed. The analyzed population included 498 patients (198 women) with CHF. In addition to the ID criteria provided by the protocol (AHA/ESC/RSC criteria: ferritin &lt;100 μg/l or ferritin from 100 to 299 μg/l and TSAT&lt;20%), concentrations of ID biomarkers were assessed, which showed high sensitivity and specificity for the diagnosis of ID compared to the morphological picture of the bone marrow (TSAT&lt;19.8% or Fe ≤13 μmol/l). Subgroups of patients with ID determined only by the AHA/ESC/RSC criteria, only by the TSAT≤19.8% and Fe ≤13 μmol/l criteria, and by both were analyzed. ID diagnosed by the AHA/ESC/RSC criteria was found in 83.1% of patients. The TSAT ≤19.8% and Fe ≤13 μmol/l criteria revealed ID in 74.5% of patients. In 341 patients (76.8%), ID was diagnosed using both criteria. Patients with ID diagnosed by the TSAT≤19.8% and Fe≤13 μmol/l criteria, compared with patients with ID diagnosed by the AHA/ESC/RKO criteria, had a 50% lower Fe (9.8 μmol/l vs. 19.4 μmol/l) and a higher incidence of anemia (43.3% vs. 23.3%) and diabetes mellitus (DM) (36.7% and 24.7%). Also, these patients had higher values of body mass index (BMI) and NT-proBNP concentration (2317 [1305;9092] vs. 1691 [709;3856] pg/ml), and lower LV EF values (41.5 [29.0;54.5]% vs. 45.0 [34.0;54.0]%), respectively. The most severe course of CHF and the greatest changes in laboratory tests associated with ID and anemia were observed in patients with ID determined by two criteria. Patients in this group were older, with a higher BMI, more frequent presence of atrial fibrillation, and higher NT-proBNP (4182 [1854;9341] pg/ml). Patients with isolated low ferritin are characterized by less severe clinical and functional impairment compared to patients with low TSAT or Fe. At the same time, patients with ferritin higher than 300 μg/l and low TSAT and/or Fe were characterized by very severe CHF and a low functional status, although this may not be related with ID. Thus, the use of the ferritin-based criteria of ID may lead to overdiagnosis of ID in some patients and, at the same time, miss some of the most "severe" patients who likely require the ID correction. Patients with ID who show a decrease in all three parameters are likely to benefit most from Fe supplementation. It is advisable to perform additional studies on the effect of Fe supplements on the course and prognosis of the disease in this cohort of patients.

Pediatric Heart Failure: Cardiac Ejection Fraction with Cardiomyopathy Decreased to 21% in Iron Deficient from 37% in Iron Sufficient Children

We demonstrate that simple correlation between the various tests of iron status is not sufficient for examining their value in diagnosing iron deficiency (ID). Three degrees of ID are recognized: Iron depletion (ID grade I) is defined by decreased total body iron and normal iron support to erythropoiesis, as diagnosed by decreased storage iron, decreased ferritin, normal sideroblast count, normal zinc protoporphyrin (ZPP), and transferrin saturation >15%. When the iron supply to erythropoiesis becomes insufficient, as diagnosed by transferrin saturation < or = 15%, increased ZPP, and decreased sideroblast count, iron-deficient erythropoiesis (ID grade II) occurs. When finally hemoglobin is below its normal range, iron-deficiency anemia (ID grade III) results. The various tests for ID cannot be compared without taking into account the severity of the deficiency. Depending on the grade of ID examined, the correlation of markers seen in our patients' data varied considerably. We conclude that a "best" marker of ID does not exist. However, the different tests efficiently complement each other by detecting different stages and individually show the clinical extent of ID. Ferritin reflects the iron stores. ZPP indicates whether the ID in a given patient is clinically relevant or not. Finally, the extent of a clinically relevant ID can be assessed by the measured ZPP, hemoglobin concentration, and red cell indices.

Various reasons such as malignancies and chronic infections may cause weight loss in kidney transplant patients. In this report, iron overload as a rare cause of weight loss in a kidney transplant patient is presented. Forty-seven-year-old male patient who transplanted from a deceased donor 5 years ago was hospitalized because of 20 kg of weight loss. In medical history, he had history of hemodialysis for 89 months and received 100–300 mg of intravenous iron therapy per week before transplantation and transfused eight units of blood. In physical examination, weight and height were 45 kg and 185 cm, respectively. Respiratory and cardiac auscultation was normal. Laboratory results revealed as follow: glucose 76 mg/dL, urea 60 mg/dL, creatinine 1.35 mg/dL, aspartate aminotransferase 74 U/L, alanine aminotransferase 77 U/L, C-reactive protein 2.59 mg/dL, albumin 3.3 g/dL, globulin 3.4 g/dL, white blood cells 3200/mm3, hemoglobin 13.1 g/dL and platelets 190,000/mm3. Chest and abdominal tomography didn’t reveal any pathology. Portal Doppler ultrasound showed signs of early cirrhosis. Viral and autoimmune hepatitis markers were negative. Ferritin was 5300 ng/mL and transferrin saturation was 82%. In liver biopsy, hemosiderosis was diagnosed and heterozygous H63D gene mutation was detected. Totally, 19 units of phlebotomy were performed. Liver function tests and serum ferritin decreased gradually. At outpatient follow-up in 6 months, he returned to former weight. In conclusion, there can be several causes of weight loss in kidney transplant patients. Iron overload can come across as a rare cause of weight loss. In these patients, ferritin levels should be checked and diagnosis should be clarified by liver biopsy and gene mutation analysis.