Abstract
A 16-year-old girl was referred by her paediatrician for evaluation of persistent microcytic anemia. Two years previously, she presented to her local hospital complaining of fatigue and weakness. At that point, her hemoglobin level was 46 g/L, with a low mean corpuscular volume and decreased iron and ferritin levels. She had no evidence of gastrointestinal bleeding and was otherwise healthy. Furthermore, she reported a regular menstruation cycle without increase in blood loss. She received a blood transfusion and was started on iron supplements, to which she had a good response as her hemoglobin level rose up to 129 g/L. Her clinical symptoms also resolved and iron supplementation was discontinued one year later. However, on follow-up, her hemoglobin level dropped to 85 g/L. Again, her iron stores were considerably low. A hemoglobin electrophoresis was normal. She still had no history of overt bleeding, but one of three fecal occult blood tests was positive. She was then evaluated in our centre. The physical examination was unremarkable apart from a small hemangioma of the tongue. Both upper endoscopy and colonoscopy showed no source of bleeding. A small bowel follow-through was normal. Further investigations revealed the diagnosis.
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