History Of Iron Deficiency Anemia Research Articles

2720 Iron Pill-Induced Gastropathy in Elderly Patients: A Case Series Report

INTRODUCTION: Iron deficiency anemia is a global health problem with an estimated two billion cases worldwide. Oral iron supplementation is considered the first line treatment. However, recent studies favor the use of short-term IV iron especially in patients with drug tolerance and efficacy concerns. In this report, we present three cases of iron pill gastropathy in patient's whose clinical courses were complicated by gastric erosion, ulcer or gastrointestinal (GI) bleeding. All of our patients had a history of iron deficiency anemia and were being treated with oral ferrous sulfate. CASE DESCRIPTION/METHODS: The first case involved a 72-year-old male with multiple comorbidities was admitted to the hospital for an NSTEMI. Initial labs revealed severe microcytic anemia (Table 1). He denied any hematemesis, melena, or hematochezia. During his hospital stay, he underwent an EGD which showed several erosions in the antrum with no active hemorrhage or visible vessels. Biopsy taken from the erosions demonstrated reactive gastritis with chronic inflammation and focal pigmented deposits stained positive with iron dye. After establishing the diagnosis iron gastropathy, the patient was transitioned to IV iron. In a second case, an 81-year-old male presented with a three-day history of abdominal pain associated with nausea and vomiting. The patient was started on proton pump inhibitors, IV hydration, and antiemetics for suspected acute gastritis with complete resolution of the symptoms. Severe anemia on initial labs prompted an EGD, which showed a superficial ulcer in the gastric body with a caustic appearance. Microscopically, focal iron deposits were remarkable in the area of erosions and were consistent with iron gastritis. Lastly, an over-90-year-old female presented with acute shortness of breath. Initial labs revealed worsening iron deficiency anemia. An EGD showed erosions within the gastric body with mild superficial gastritis. Microscopically, biopsied erosions showed yellow deposits within the mucosa, which stained positive for iron. DISCUSSION: Iron pill gastropathy is an underrecognized condition particularly in the elderly. The liquid form of oral iron has been shown to be less toxic to the gastric mucosa compared to the tab formulation. Transition to liquid or IV iron should be considered in patients with iron gastropathy as use of iron pills can lead to gastric erosions, ulcers, and GI bleeding, which can worsen the underlying anemia and result in cardiovascular symptoms related to severe anemia.

MON-504 Osteomalacia During Pregnancy: Are Preventive Measures Enough to Avoid Future Fractures and Fetal Complications?

Title Osteomalacia during pregnancy; are preventive measures enough to prevent future fractures and fetal complications? Background We present a patient with a left hip fracture found to have FGF-23 induced osteomalacia whose clinical course was complicated by pregnancy. Clinical Case A 28 year old female with a history of iron deficiency anemia presented with left hip pain resulting in difficulty ambulating. Nine months prior, she had suffered a fall at home where she slid down nine steps on her left side, she developed pain in her left leg that prompted her to seek care in multiple emergency rooms; she was given acetaminophen for pain only. Seven months after the fall she started limping requiring a cane to ambulate, a week before admission, she had another mechanical fall where she slipped and fell landing again on her left hip after which she sought care. Further history revealed no regular intake of any medication including no inhaled or systemic steroids, regular menses and no symptoms of hyperthyroidism or malabsorption. Physical exam was pertinent for limited range of motion of her left leg. Blood tests were significant for alkaline phosphatase (ALP) 220 [30-95U/L], phosphorus 2.1 [2.5-5.0mg/dL], 25-OH vitamin D 14.80 [30-95pg/mL], Vitamin D 1,25(OH)2 <8 [18-72pg/mL], and Fibroblast Growth Factor 23 (FGF-23) 1241 [<180RU/ML]. Other labs included: Calcium 9.3 [8.2-10mg/dL], albumin 4.28 [3.5-5.70 g/dL], PTH 37.9 [15.0-65.0pg/mL], ALP isoenzymes: total ALP 202 [33-115 U/L], liver 44 [25-69%], bone 56 [28-66%], 24hr urine phosphorus 0.5 [0.3-1.3g/24hr] with under collected specimen , volume 1 liter and creatinine 0.9 [1-2 g/24hr], TSH 2.54 [0.35-4.70 uI/mL], cortisol after 1mg Dexamethasone was 0.3 [<1.8 mcg/dL]. The grossly elevated FGF-23 lead to a suspicion of tumor-induced osteomalacia, Imaging revealed stress fractures of the left aspect of the sacrum and left femoral neck. A bone scan was significant for diffuse lesions and bone densitometry showed osteoporosis in the lumbar region with a Z score of-2.5 and osteopenia of lumbar and femoral neck Z -1.9. Femoral neck biopsy was negative for malignancy. She underwent percutaneous pining of the femoral neck and was discharged with calcitriol, cholecalciferol and phosphate supplementation. An Octreotide scan obtained during follow-up was negative. Her phosphate levels have been difficult to manage even with high supplementation of phosphate, and further attempts to localize the tumor have been temporarily held as the patient is now pregnant. Conclusion This patient who initially presented with femoral neck and sacrum stress fractures and diagnosed with osteomalacia and hypophosphatemia allows us to learn and question what the appropriate treatment strategy should be to ensure both patient and fetus are adequately supplemented to prevent any future fractures in the mother and promote normal development of the fetus.

Plummer Vinson Syndrome in a Young African American Female: A Rare Entity

Plummer Vinson syndrome (PVS), also known as Paterson-Brown-Kelly syndrome, is a rare clinical condition characterized by a triad of iron deficiency anemia, esophageal webs, and dysphagia. PVS has been rarely reported in African American females. In this case, however, we report a 26-year-old African American female with a 10-year history of iron deficiency anemia, who presented with severe fatigue and dysphagia. Her work-up revealed severe iron deficiency anemia, and upper endoscopy showed two esophageal rings. A 26-year-old African American female presented with severe fatigue, headache, and dysphagia for 5 months. The dysphagia was predominantly to solid foods compared to liquids. Patient also has a 10-year history of iron deficiency anemia and has stopped taking iron supplementations for the last 2 years. Physical examination revealed severe conjunctival pallor but was otherwise normal. Routine investigations revealed severe microcytic anemia with hemoglobin of 4.2 g/dL, mean corpuscular volume of 62.5 fL, and a ferritin level of 2 ng/dL. A modified barium swallow study showed two esophageal impressions in the cervical region, which were concerning for esophageal webs. Patient later underwent an esophagogastroduodenoscopy (EGD) which showed two upper esophageal rings; one semi-circumferential at 15 cm and a second circumferential at 17 cm from the incisors. A pediatric size scope was used to bypass the rings. She was initiated on iron replacement therapy with no symptomatic improvement of her dysphagia after 6 months of treatment. She then had a follow up EGD with wire-guided savary dilation with 8 mm dilator which resulted in an immediate improvement of her symptoms. Patient remained symptom free in her 2 months follow-up. PVS is characterized by iron deficiency anemia, esophageal webs, and dysphagia. It is predominantly seen in middle aged Caucasian females. Our case is unique because only a few cases of PVS have been reported in African American females. PVS is also a precancerous condition. Therefore, patients with this syndrome are at increased risk of developing gastrointestinal squamous cell carcinomas. Since nutritional deficiency is one of the major causes of iron deficiency anemia, the improvement in nutritional status of populations worldwide has led to a decreased incidence of PVS. Dysphagia in PVS usually responds to iron supplementation. However, resistant cases may require endoscopic dilatation of the webs as in our patient.1776_A Figure 1. EGD image Showing the first upper esophageal web, 15 cm from the incisors.1776_B Figure 2. EGD image Showing the second esophageal web, 17 cm from the incisors.1776_C Figure 3. Esophageal ring post wire-guided savary dilation with a satisfactory mucosal tear shown.

A Case of Pneumatosis Cystoides Intestinalis in a Patient with COPD

Pneumatosis cystoides intestinalis (PCI) is a rare disease characterized by the presence of gaseous cysts containing nitrogen, hydrogen, and carbon dioxide in the intestinal wall. The exact etiology is unknown, however various theories have linked the occurrence of PCI to mechanical, bacterial, and pulmonary causes. Most patients with PCI remain asymptomatic, however some may present with a constellation of relatively non-specific symptoms including abdominal pain, abdominal distention, hematochezia, and constipation. Left untreated, severe complications including volvulus, adhesions, pneumoperitoneum, and bleeding can occur. A 70 year old male with a past medical history of iron deficiency anemia and COPD was evaluated for worsening microcytic anemia. A prior colonoscopy in 2014 showed nodular mucosa with normal biopsies. An esophagogastroduodenoscopy (EGD) showed only mild duodenitis. A drop in hemoglobin from 11.3 to 9.2 g/dl over 1 year prompted repeat colonoscopy. This revealed numerous submucosal cysts along the ileocecal valve, cecum, ascending colon, hepatic flexure, and transverse colon with overlying hemorrhagic mucosa which was friable and bled on contact. Biopsy of these firm submucosal cysts demonstrated an underlying air filled cavity with collapsibility, a finding consistent with pneumatosis cystoides intestinalis. He then underwent a CT of his chest, abdomen, and pelvis which showed colonic pneumatosis with small amount of pneumoperitoneum likely due to ruptured bleb in the setting of COPD. The etiology of PCI remains unknown, but is thought to be multifactorial. This finding can represent a wide variety of pathologies which range from life threatening to benign. Our patient had a longstanding history of COPD, it was felt that bleb rupture caused the gas to breach the bowel wall leading to formation of cysts. Asymptomatic patients can be observed because the cysts resolve spontaneously in about 50% of patients. In patients with significant symptoms, treatment consists of diet, antibiotics, or the use of hyperbaric oxygen. Urgent surgical intervention would be required for signs of hypotension, sepsis, elevated lactate, and imaging demonstrating gas within the vasculature, linear/cresenteric gas pattern, or small bowel gas. Our case highlights the importance of keeping a broad differential in evaluation of PCI and also to ensure that the patient does not have findings warranting urgent surgical evaluation.

Cameron Lesions - An Uncommon Cause of Overt Gastrointestinal Hemorrhage

Cameron lesions are erosions or ulcerations commonly found in patients with hiatal hernias, which can lead to both chronic, and at times, life-threatening acute bleeding. Cameron lesions have been reported at a prevalence rate between 3.3 and 5.2% in patients with hiatal hernias undergoing esophagogastroduodenoscopy (EGD), however those without evidence of hiatal hernia on EGD still carry a risk of .66% (1, 2). These lesions can be inferred from a patient with a known diagnosis of hiatal hernia and a history of iron deficiency anemia, a positive fecal occult blood test or overt evidence of gastrointestinal bleeding such as melena, hematochezia, or visible blood loss. The following case report presents a 77-year-old female who presented with altered mental status. The patient, subsequently had a hgb of 7 and findings of frank GI hemorrhage due ultimately to Cameron lesions. The patient is a 77 year old female with a past medical history of dementia, depression, insomnia, Alzheimer's, Parkinson's osteoarthritis and hypertension was brought by Emergency Medical Services from an assisted living facility to Larkin Hospital Palm Spring Campus for confusion and AMS. The ALF nursing staff states the patient had a copious amount of melena. Chest x-ray was significant for large hiatal hernia. Complete blood count revealed a hemoglobin level of 7 and a mean corpuscular volume of 70. Iron studies were ordered which revealed iron deficiency. An EGD was performed that demonstrated multiple large circumferential Cameron ulcers that were non-bleeding and a large 5 cm hiatal hernia. The source of the bleed was determined to be the ulcers and medical management was initiated. The patient began treatment with a proton pump inhibitor and continued iron supplementation. The patient was then discharged once her hemoglobin proved stable. This case demonstrates a rare cause of frank GI hemorrhage. The incidence of Cameron lesions is liable to increase. Hiatal hernias are associated with an increased body mass index (BMI) (8). As our society moves to an ever-increasing national average for BMI, bleeding secondary to Cameron lesions should be placed on the differential and an EGD should be carefully performed. More research needs to be performed on surveillance for these patient's once a cameron ulcer and lesion has been found to be a cause of overt GI bleeding.

Knowledge about the prevalence of Iron Deficiency Anemia and its associated risk factors in females in Saudi Arabia

Background: despite the modern society and available healthy food, iron deficiency anemia is common in Saudi Arabia woman. Iron deficiency anemia is very common in women due to many risk factors like heavy menses and eating food that is not rich in iron. Knowing the prevalence of iron deficiency anemia and its associated risk factors in Saudi Arabia can provide a useful knowledge in avoiding these risk factors and improving the overall health. Objectives: Iron deficiency anemia is increasingly common worldwide. This study aims to assess the prevalence of iron deficiency anemia and its associated risk factors in women in Saudi Arabia. Methods: Across-sectional study on the prevalence of iron deficiency anemia was randomly carried out among women (1638 participants) in different social media platforms of Saudi Arabia during the period from February to April 2018. Results: In 43.5% of the participants have been suffering from iron deficiency anemia, only 10.1% had a blood transfusion as a consequence of the anemia, 42.6% have sought medical help, 32.8% had heavy menses, 48.5% had a positive family history of iron deficiency anemia, only 15.4% had hypothyroidism disease, 57.2% don’t eat iron rich food and only 7.9% were pregnant. Conclusion: Our result showed that huge number of the participants was suffering from iron deficiency anemia in Saudi Arabia.

Capsule Retention Caused by Jejunal Adenocarcinoma

We present a case of a 64-year-old man with a medical history of iron deficiency anemia, diabetes and hypertension who presented to our hospital for investigation of abdominal pain. The patient reported that two weeks prior to developing abdominal pain he was being worked up with his private gastroenterologist for iron deficiency anemia. At the time he underwent upper and lower endoscopy as well as video capsule endoscopy. To investigate the abdominal pain that patient underwent CT Abdomen which revealed retained capsule and circumferential mid-jejunal mass. To confirm the diagnosis and retrieve the capsule a push enteroscopy was performed but it was impossible to remove the capsule endoscopically due to narrow lumen from the Jejunal mass. The patient underwent laproscopic partial resection of the small bowel and pathology revealed adenocarcinoma of the Jejunum.2507_A Figure 1. Jejunal adenocarcinoma2507_B Figure 2. CT abdomen with retained capsule due to jejunal mass2507_C Figure 3. jejunal mass on push enteroscopy

Prevalence of anemia and associated factors in women of childbearing age in rural Lebanon

This community-based, cross-sectional survey was conducted to determine the prevalence of anemia and iron deficiency anemia (IDA) and their association with nutritional behavior and other determinants. Arabic-speaking women, aged 15–49 years old, residing in Lebanon’s rural areas were included. Demographic and behavioral characteristics, obstetrical and gynecological history, personal and family medical history, and dietary intake data were collected. Predictors of anemia and IDA were determined using logistic regression. A total of 578 women were included (Lebanese: 55.2%; Syrian: 43.3%) in which 35.5% had anemia and 23.2% had IDA. The mean number of pregnancies was 3.1 ± 3.0 (number of children: 2.5 ± 2.5). In total, 30% had a personal history of anemia or IDA, 29% a family history of anemia, and 20% a family history of IDA. Iron-rich products were consumed by > 90% of the women, whereby > 66.7% mentioned eating liver, tuna, dates and nuts. Syrian nationality (OR = 2.21; CI 95%: 1.38–3.54), age (OR = 1.03, CI 95%: 1.00–1.06), personal history of anemia (OR = 1.97; CI 95%: 1.31–2.95), consumption of dates (OR = 2.07, CI 95%: 1.29–3.31), molasses (OR = 1.61; CI 95%: 1.03–2.51), and soft drinks > 5 times/week (OR = 1.66; CI 95%: 1.09–2.53) were predictors of anemia. Syrian nationality (OR = 1.73, CI 95%: 1.14–2.62), number of pregnancies (OR = 1.08; CI 95%: 1.01–1.15), period > 8 days (OR = 2.01, CI 95%: 1.07–3.80), consumption of eggs (OR = 0.48; CI 95%: 0.25–0.90), dates (OR = 2.58, CI 95%: 1.49–4.46), and coffee or tea (OR = 1.59, CI 95%: 1.03–2.45) were predictors of IDA. Anemia and IDA are prevalent in women of childbearing age in rural Lebanon. Intervention programs for raising the population’s awareness about IDA’s risk factors and proper nutrition must be implemented.

Pseudomelanosis of the Upper GI Tract: A Rare Endoscopic Finding

Pseudomelanosis is a rare, incidental finding in the upper gastrointestinal tract. It is characterized by dark, pigmented inclusions in the histiocytes of the lamina propria. The exact etiology is unknown, but it has been associated with medical conditions like chronic renal disease, hypertension, and diabetes mellitus as well as the use of various medications, including hydralazine and iron supplements. We present two cases with this uncommon endoscopic finding. The first case is a 51 year old male with prior medical history of iron deficiency anemia with use of iron supplementation in the past, chronic kidney disease stage 4, and hypertension who presented with anemia. His medications included hydralazine. EGD was performed which revealed purplish discoloration of the gastric mucosa. Pathology showed gastric mucosa with mild foveolar hyperplasia and lamina propria histiocytes containing melanin-like pigment, consistent with pseudomelanosis. Prussian blue stain was positive for iron. The second case is of a 80 year old female with ESRD on hemodialysis and hypertension who was evaluated for iron deficiency anemia. Her medication list included hydralazine and ferrous sulfate. EGD was performed which revealed abnormal dark pigmentation of the distal antrum and duodenum. Biopsies of both areas revealed groups of histiocytes containing granular black pigment at the tips of the duodenal villi and in the superficial gastric antral mucosa. Prussian blue stain was positive for iron. Pseudomelanosis in the stomach and duodenum is a rare endoscopic finding. Duodenal pseudomelanosis was first described by Bisordi and Kleinman in 1976 and gastric pseudomelanosis by Treeprasertuk et al. in 2000. Iron is the most common medication associated with this condition. The hyperpigmentation in pseudomelanosis is attributed to uptake of exogenous substances by macrophages and formation of pigmented deposits. The etiology of pseudomelanosis is not known, nor is there any reported association with malignancy or fibroproliferative disease. To our knowledge, the 51 year old patient described here is the youngest patient with gastric pseudomelanosis described in the literature.Figure: Dark pigmentation of duodenal mucosa.Figure: Discoloration of gastric mucosa.Figure: Prussian blue stain positive for iron.

Single Cause, Dual Presentation: Inferior Pancreatico-duodenal Artery Pseudoaneurysm as a Cause of Hemorrhagic Shock and Obstructive Jaundice

Pseudoaneurysm of the inferior pancreaticoduodenal artery (IPDA) is very rare. We report the case of a patient with hemorrhagic shock secondary to a bleeding pseudoaneurysm of the IPDA, also causing obstructive jaundice by virtue of its size and location. To our knowledge, this is the first such reported case in the United States. A 45-year-old male with history of iron deficiency anemia, chronic pancreatitis and alcohol abuse presented with severe right upper quadrant (RUQ) abdominal pain for 1 week. On presentation, vitals were stable and physical examination revealed RUQ abdominal tenderness and scleral icterus. Laboratory study showed hemoglobin 6.1 g/dl, alkaline phosphatase 416U/L, GGT 230 U/L, AST 76 U/L, ALT 132 U/L, total bilirubin 4.4 mg/dl, and direct bilirubin 3.4 mg/dL. Computed tomography (CT) of the abdomen with intravenous contrast showed a pseudoaneurysm arising from the IPDA (6.5x4.1x4.3 cm), acute on chronic pancreatitis and obstruction of biliary tree due to mass effect from pseudoaneurysm, marked intra and extrahepatic biliary dilation with the common bile duct measuring 17 mm and distended gallbladder. Mesenteric angiography also revealed the aneurysm but not amenable to embolization. The patient's abdominal pain worsened and developed hemorrhagic shock requiring additional resuscitation. Stat CT angiography showed increased size of the pseudoaneurysm, and a new hyperdense material within the small bowel loops. Exploratory laparotomy revealed large amount of intraluminal blood in second part of duodenum and a large pseudo aneurysm entering second part of duodenum that was ligated. Distal gastrectomy with duodenotomy with lysis of adhesions was done. LFTs trended down and jaundice resolved after procedure. Pseudoaneursym of IPDA is a rare complication of chronic pancreatitis. The mortality is 90-100% with acute hemorrhage in untreated patients and 12-50% even with aggressive treatment. Even though, most common presentation of pseuodaneusym is acute GI bleed, other presentations should not be overlooked. As shown in this case, our patient presented with obstructive jaundice. Direct pressure over the pancreaticobiliary ducts can cause recurrent pancreatitis and jaundice. Mesenteric angiography is the gold standard diagnostic test. Treatment options include angiographic embolization and surgical treatment. Early multidisciplinary approach with diagnostic and therapeutic interventions is needed to improve the outcome and decrease mortality.Figure: CT abdomen with contrast: Pseudoaneursym of inferior pancreaticoduodenal artery (arrow).Figure: Mesenteric Angiography:Pseudoaneursym of inferior pancreaticoduodenal artery(arrow).

Transient Hepatitis B Surface Antigen Positivity Following Vaccination

Background Interpretation of hepatitis B virus (HBV) testing is notoriously challenging. An under-recognized pitfall is transient positivity of hepatitis B surface antigen (HBsAg) following immunization in healthy individuals. We present the case of a patient who was referred for a positive HBsAg following routine immunization. Case A 21-year-old female was referred for possible HBV infection following routine testing for sexually transmitted infections (STIs). The patient had a past medical history of iron deficiency anemia and irregular menses. She had unprotected intercourse with a single partner 5 months prior to evaluation, and denied medications, prior surgery, transfusion of blood products, or intravenous drug use. Her paternal grandfather had an unknown type of liver cancer, but neither of her parents had any known liver disease. Review of the patient's medical record revealed she underwent her second HBV vaccination the day before her primary physician ordered STI testing. A viral hepatitis panel was drawn 30 hours following her vaccination, and was qualitatively positive for HBsAg, which prompted extensive follow-up lab testing and Gastroenterology consultation. The patient's physical exam was without stigmata of chronic liver disease, and was otherwise unremarkable. Repeat testing drawn 6 days after vaccination demonstrated normal liver-associated enzymes, and negative hepatitis B surface antibody (HBsAb), HBsAg, anti-hepatitis B core IgG and IgM, hepatitis B e-antigen and antibody, and undetectable HBV DNA by PCR. Discussion Current HBV vaccines utilize purified HBsAg derived from recombinant yeast and may result in transient HBsAg positivity, which has been reported in a variety of patient populations. The reported incidence ranges from 13-32%, and the phenomenon is particularly common in end-stage renal disease and hemodialysis patients. HBsAg positivity has been reported as early as 6 hours following vaccination, typically peaks by 2-3 days, and nadirs by 14 days. Our patient's HBsAg positivity reverted within 6 days of vaccine exposure, but if testing is indicated or clinical uncertainty exists, we recommend deferring at least 2 weeks following vaccination. Conclusions Transient HBsAg positivity is common following vaccination, and usually does not extend beyond 14 days. Deferring HBV testing for an appropriate period may prevent not only patient anxiety, but also expensive and unnecessary follow-up testing and specialist consultation.

Iron deficiency anemia in gastric cancer: A single site retrospective cohort study.

188 Background: Gastric cancer is highly prevalent amongst men and women. While many studies have identified the prevalence and association of iron deficiency anemia (IDA) in all cancer patients, few have focused on the gastric cancer population. The primary objective of this study was to determine the proportion of patients with gastric cancer who developed IDA, and chemotherapy induced anemia (CIA) at our institution. Secondary objectives were to identify types and frequencies of IDA therapies used. Methods: A retrospective study was carried out in 110 consecutive gastric cancer patients from 2006 to 2014 at St. Michael’s Hospital, Toronto, Canada. Patient demographics, previous history of IDA, and IDA based therapies were reviewed. IDA was defined as hemoglobin (Hb) &lt; 130 g/L in men and &lt; 120g/L in women and iron deficiency (ID) was defined as a ferritin &lt; 15m/L. SAS 9.3 was used to calculate frequencies and proportions. Results: Of the 110 patients (median age 68.5 [interquartile range (IQR): 58-76]), 72 (65%) were male. Most patients were diagnosed at stage IV (35%) with a mean Hb of 118 g/L (standard deviation (SD): 19.7 g/L). Only 18 (16%) patients had a history of IDA prior to cancer diagnosis, and 63 (57%) had IDA at time of gastric cancer diagnosis. Only 29 patients (45%) had ferritin levels tested at first oncology visit. Of the 110 patients, 71 patients had an open (32%) or laparoscopic (68%) surgery. A total of 66 patients received chemotherapy, and 50 (76%) developed CIA. In this sample, 9 (14%) experienced a chemotherapy dose delay and 20 (30%) had a dose reduction. At last follow up, 87 (79%) of patients were diagnosed with IDA. Red blood cell (RBC) transfusions were most frequently prescribed (95%), compared to oral (29%) or intravenous iron (12%). Conclusions: A total of 87 (79%) gastric cancer patients were diagnosed with IDA and nearly all patients received a RBC transfusion. We found that the diagnosis of IDA increased by 22% from the time of gastric cancer diagnosis to last follow up. There was a high proportion of IDA in our gastric cancer population despite inconsistent screening for ID. This highlights the need for consistent screening and targeted therapy for ID to reduce transfusions and improve quality of life in this patient population.

A Case of Plummer-Vinson Syndrome and Celiac Disease

Introduction: Plummer-Vinson syndrome is a triad of iron deficiency anemia, dysphagia, and cervical esophageal web. Celiac disease and Plummer-Vinson syndrome are both known to be associated with iron deficiency. There are very few reported cases of both being seen in the same patient. We report a case of a female found to have Plummer-Vinson syndrome along with celiac disase. Case report: We present a case of a 48 year old female with a long standing history of iron deficiency anemia. She had been following up with her primary care physician for a number of years for iron deficiency anemia and had extensive workup done. She required intermittent blood transfusions and was on B12 and Iron. She had been seen by gastroenterology 5 years prior to this visit, at that time it was recommended she have an upper endoscopy and colonoscopy which she refused due to being pregnant at the time. She was told to follow up with gastroenterology for an upper endoscopy and colonoscopy after her pregnancy was over. Years later she re-presented with anemia and dysphagia. An upper endoscopy and colonoscopy were scheduled. Upper endoscopy demonstrated a benign appearing intrinsic stenosis 24 cm from the incisors. A pediatric endoscope was required to traverse the web-like stenosis in the proximal esophagus. Duodenal biopsies were taken to check for celiac disease. Colonoscopy showed the entire colon to be normal. Duodenal biopsies were consistent with immune-mediated injury such as gluten sensitivity. She was thought to have Plummer-Vinson syndrome in the setting of iron deficiency anemia secondary to celiac disease. It was recommended that the patient adhere to a gluten free diet. The patient was scheduled for upper endoscopy for esophageal dilation but was again lost to follow-up. Conclusion: Plummer-Vinson syndrome is a triad of iron deficiency anemia, dysphagia, and a cervical esophageal web. Celiac disease and Plummer Vinson syndrome are rarely seen coinciding together in the same patient. Important point to remember is that if a patient is thought to have Plummer-Vinson syndrome they should be worked up for celiac disease as a cause of iron deficiency anemia. This case demonstrates this importance of keeping in mind that Plummer-Vinson syndrome and celiac disease can coexist in the same patient.

Validation Study of the Composite Score to Identify Von Willebrand Disease in Children.

The diagnosis of type 1 von Willebrand disease (VWD) presents a diagnostic challenge in children. In fact, 25% or more of children with VWD may be diagnosed only after they experience postoperative bleeding. We previously described a 4-variable composite score that has 92.5% sensitivity and 95% specificity for diagnosing VWD in children with known VWD when 2 of 4 criteria are positive: (1) Tosetto bleeding score ≥ 1; (2) family history of VWD; (3) personal history of iron deficiency anemia; and/or (4) positive James early bleeding score. The purpose of this study was to prospectively validate a composite score of ≥ 2 for identifying children with VWD. Children without a previously diagnosed bleeding disorder presenting for hematology evaluation were enrolled. Sensitivity, specificity, positive, and negative predictive value of the composite score was determined. A total of 193 subjects were enrolled from 12 participating centers were included in the analysis. Forty-seven children had type 1 VWD, including 11 with von Willebrand Ristocetin Cofactor (VWF):RCo < 30 IU/dL, 14 subjects with a VWF:RCo 30 to 39 IU/dL, and 22 with a VWF:RCo 40 to 49 IU/dL. Including all 4 variables, a composite score of ≥ 2 had a sensitivity of 63.6% to 76.0%, specificity of 33.5% to 35.1%, negative predictive value of 76.9% to 93.8%, and positive predictive value of 5.5% to 25%. The negative predictive value of the composite score was robust, especially at lower VWF:RCo suggesting that VWD testing could be eliminated in nearly a third of children referred for VWD testing.

Eyes can See What Mind Can’t see

A 55 year old Caucasian female with a history of Iron deficiency anemia with hemoglobin of 6.1 gm/dl was admitted from her hematologist office for a Venofer infusion. She had profound confusion on presentation. Physical examination was pertinent for fever of 101οF, and laboratory data pertinent for elevated blood sugars of 590 mg/dl, leukocytosis of 10.3 K/UL with bandemia of 13%, elevated AST 170 U/L, ALT 184 U/L, and normal alkaline phosphate and total bilirubin. She was subsequently found to have Strep. Viridian bacteremia and CT scan of Chestabdomen-pelvis revealed multiple hepatosplenic masses consistent with malignancy or abscesses. Liver biopsy showed benign liver cells with a background of acute and chronic inflammatory cells and abscess (*image shown). She was treated with long term course of Ceftriaxone via PICC line.

Pernicious Anemia with Autoimmune Hemolytic Anemia: A Case Report and Literature Review.

Pernicious anemia is a common cause of vitamin B12 deficiency. Here, we discuss a case of a young woman who presented with severe anemia along with a history of iron deficiency anemia. After a review of her clinical presentation and laboratory data, we identified an autoimmune hemolytic anemia and a concomitant pernicious anemia. The concurrence of both these hematological diagnoses in a patient is rare.

A Case of Plummer-Vinson Syndrome and Celiac Disease

Introduction: Plummer-Vinson syndrome is a triad of iron deficiency anemia, dysphagia, and cervical esophageal web. Celiac disease and Plummer-Vinson syndrome are both known to be associated with iron deficiency. There are very few reported cases of both being seen in the same patient. We report a case of a female found to have Plummer-Vinson syndrome along with celiac disase. Case report: We present a case of a 48 year old female with a long standing history of iron deficiency anemia. She had been following up with her primary care physician for a number of years for iron deficiency anemia and had extensive workup done. She required intermittent blood transfusions and was on B12 and Iron. She had been seen by gastroenterology 5 years prior to this visit, at that time it was recommended she have an upper endoscopy and colonoscopy which she refused due to being pregnant at the time. She was told to follow up with gastroenterology for an upper endoscopy and colonoscopy after her pregnancy was over. Years later she re-presented with anemia and dysphagia. An upper endoscopy and colonoscopy were scheduled. Upper endoscopy demonstrated a benign appearing intrinsic stenosis 24 cm from the incisors. A pediatric endoscope was required to traverse the web-like stenosis in the proximal esophagus. Duodenal biopsies were taken to check for celiac disease. Colonoscopy showed the entire colon to be normal. Duodenal biopsies were consistent with immune-mediated injury such as gluten sensitivity. She was thought to have Plummer-Vinson syndrome in the setting of iron deficiency anemia secondary to celiac disease. It was recommended that the patient adhere to a gluten free diet. The patient was scheduled for upper endoscopy for esophageal dilation but was again lost to follow-up. Conclusion: Plummer-Vinson syndrome is a triad of iron deficiency anemia, dysphagia, and a cervical esophageal web. Celiac disease and Plummer Vinson syndrome are rarely seen coinciding together in the same patient. Important point to remember is that if a patient is thought to have Plummer-Vinson syndrome they should be worked up for celiac disease as a cause of iron deficiency anemia. This case demonstrates this importance of keeping in mind that Plummer-Vinson syndrome and celiac disease can coexist in the same patient.

Sclerosing angiomatoid nodular transformation of spleen (SANT) – case report and literature review

Introduction Sclerosing angiomatoid nodular transformation (SANT) of the spleen is a rare benign vascular lesion of spleen of unknown aetiology. Case history A 74-year-old female presented with a 6 month history of iron deficiency anaemia and raised C-reactive protein. A full body CT scan showed an exophytic mass involving the anterior pole of the spleen measuring up to 6 cm in maximum dimension. No other abnormalities or relevant past history was noted. The clinical differential diagnoses were lymphoma or metastatic tumour, and thus a splenectomy was performed. Macroscopically, the spleen showed a well-demarcated tumour with red-brown nodules and central speckled area of fibrosis. The histology revealed a lesion composed of complex slit- like vascular spaces interspersed with spindle to ovoid cells and numerous inflammatory cells. On immunohistochemistry, all the nodules expressed CD31, CD34, SMA and CD30. EBER and IgG4 stains were negative. The lesion was finally diagnosed as a SANT. Discussion SANT is thought to be a reactive process rather than a true neoplasm. They may represent the final common pathway of a variety of splenic lesions including inflammatory pseudotumours. SANT may be related to IgG4 disease or EBV virus. They show upregulation of CD30 with respect to normal spleen. Splenectomy is usually the standard curative treatment.

A Rare Case of Attenuated Familial Adenomatous Polyposis

Introduction: Attenuated familial adenomatous polyposis (AFAP) is a rare, less-aggressive subset of familial adenomatous polyposis (FAP). We report a rare case of AFAP presenting as symptomatic iron deficiency anemia. Case Report: A 61-year-old female with a history of iron deficiency anemia, on iron replacement therapy, with a base line hemoglobin of 8.5 g/dL presented with complaints of fatigue and a 26-pound weight gain over a 6-month period. The patient denied melena, hematochezia, hematemesis and change in stool caliber, color or shape. The patient reports a family history of unknown colon cancer in her father at age 76 years, mother at age 78 years, and sister at age 48 years. Physical exam findings are unremarkable. Labs: hemoglobin 5.8 g/dL, WBC 10.3 K/uL, Fe 21 ug/dL, Fe% Sat 5%, and TIBC 419 ug/dL. Colonoscopy was positive for sporadic polyps (2-3) in the rectum, sigmoid, and descending colon, innumerable polyps (estimated to be less than 100) in the cecum, transverse colon, and ascending colon, culminating into a 10-cm-long circumferential ulcerated mass beginning distal to the ileocecal valve. Biopsies were positive for invasive adenocarcinoma. The patient elected to undergo treatment with colectomy. Discussion: AFAP is a subset of FAP. FAP is a rare manifestation of colorectal adenomatous disease in which without treatment will lead to a lifetime cancer risk as high as 100%. FAP typically presents as hundreds to thousands of adenomas in the colon and rectum, usually before the age of 30 years, with progression to cancer before the patient is 40 years old. FAP is responsible for less than 1% of all gastrointestinal cancers. AFAP is less aggressive than FAP, in that the patient develops less than 100 colorectal polyps and is usually diagnosed in their 40s with progression to colorectal cancer in their 60s. Like FAP, AFAP patients have a lifetime cancer risk as high as 100%. Recent studies have demonstrated that AFAP is an autosomal dominant disease that may be caused by mutations in the adenomatous polyposis coli gene (APC) or the mutY homologue gene (MUTYH), but the exact mechanism of the disease in unknown. AFAP most commonly presents with vague abdominal complaints, constipation, lower abdominal pain, or anemia. AFAP is most commonly diagnosed by colonoscopy. Prophylactic colectomy is recommended for the prevention of progression to colorectal cancer, however, it has been reported that AFAP can have extracolonic manifestations, such as gastroduodenal lesions. Conclusion: AFAP is a rare, less-aggressive subtype of FAP, characterized by fewer polyps and with an older age of onset, diagnosis, and progression to colorectal cancer.

Validation Study Of The Composite Score To Identify Von Willebrand Disease in Children

BackgroundThe diagnosis of type 1 von Willebrand disease (VWD), the most common inherited bleeding disorder, presents a diagnostic challenge in children. In the absence of a prior hemostatic challenge in children, a VWD diagnosis may be missed by the Tosetto bleeding score, as it is based, in part, on bleeding symptoms, i.e. with surgery, menses, or childbirth, that may not occur until after childhood. In fact, 25% or more of children with VWD may be diagnosed only after they experience postoperative bleeding. Other bleeding scores, such as the James score, which assesses early life bleeding, e.g. cephalohematoma, macroscopic hematuria, and umbilical stump, post-circumcision, post-venipuncture bleeding, has been validated in children with VWD, but early life bleeding events are uncommon in VWD. We previously described a 4-variable Composite Score that has 92.5% sensitivity and 95% specificity for diagnosing VWD in children < 11 years of age, when at least two of four criteria are positive: 1) Tosetto bleeding score ≥ 1; 2) family history of VWD or bleeding; 3) personal history of iron deficiency anemia; and/or 4) positive James early bleeding score. The purpose of this study was to validate a Composite Score of ≥ 2 (i.e. at least 2 of 4 variables positive) for identifying children with VWD. MethodsWe designed and conducted a prospective validation study to determine the accuracy of the Composite Score for identification of children (<11 years of age) with VWD. Following parental consent, children without a prior history of VWD undergoing VWD testing were enrolled, and survey data were collected including personal bleeding history (including Tosetto and James scores), history of iron deficiency anemia, and family history of VWD or bleeding. Results of VWD testing were collected, including VWF:RCo, VWF:Ag, and VIII:C in addition to VWF multimers, if performed. Survey data and bleeding scores were compared between those with and without VWD, defined by VWF:RCo <30 (NIH 2008 criteria), or <40, or <50 IU/dL. Prior to study, it was determined that a Composite Score ≥ 2 would have 90% power to identify VWD defined by VWF:RCo <0.30 IU/dL, and 80% power to identify VWD by VWF:RCo <40 IU/dL. Categorical variables were compared using chi-square or Fischer's exact test. Continuous variables were compared using two-sample t-test or Wilcoxon's rank sum test. Sensitivity, specificity, positive and negative predictive value of the Composite Score of ≥ 2 to diagnose VWD were determined. ResultsA total of 195 subjects were enrolled from 12 participating centers from 2010-2013, of whom 193 patients with no missing data were included in the analysis. A total of 81 (41.9%) children had type 1 VWD, including 11 (5.7%) with VWF:RCo <30 IU/dL (Group A), 24 (12.4%) with VWF:RCo <40 IU/dL (Group B), and 46 (23.8%) with VWF:RCo <50 IU/dL (Group C); the remainder with VWF:RCo ≥50 IU/dL were unaffected. There were no significant demographic differences between groups: overall 54.9% were male, 82.4% were Caucasian, and the mean age was 4.7 years. A composite score of ≥ 2 had 63.6%, 75%, and 67.4% sensitivity in diagnosing type 1 VWD in Groups A, B, and C respectively; 33.5%, 34.9%, and 34% specificity in diagnosing type 1 VWD, respectively; and 93.8%, 90.8%, and 76.9% negative predictive value, respectively. Based on the performance of the composite, with VWD being defined by a VWF:RCo of <30, <40, or <50 IU/dL, 31.6%, 30.6%, and 25.9% of subjects, respectively, had a negative composite score and therefore would not have required VWD testing. DiscussionThis is the first study to prospectively validate the Composite Score to identify children with type 1 VWD. Although the sensitivity and specificity of the Composite Score were lower than in the original study (above), the latter included only VWD subjects, while this validation study included all, VWD and non-VWD, undergoing testing. The negative predictive value of the Composite Score was robust, especially at lower VWF:RCo, and indicates that VWD testing could be eliminated in nearly a third of children referred for VWD testing. Given the difficulty of diagnosing VWD in children, the Composite Score may be an important screening tool for diagnosis of type 1 VWD in children. Disclosures:Kerlin:Bayer Healthcare US: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; NovoNordisk A/S: Consultancy, Honoraria.