Iron-Refractory Iron Deficiency Anemia in an 11-year-old Girl.

1. Neeraja Swaminathan, MBBS* 2. Scott M. Lieberman, MD, PhD† 3. Sharathkumar Bhagavathi, MD‡ 4. Anjali Sharathkumar, MD, MS* 1. *Division of Pediatric Hematology Oncology 2. †Division of Pediatric Rheumatology, Allergy and Immunology, Stead Family Department of Pediatrics 3. ‡Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA An 11-year-old previously healthy girl presents to a pediatric hematology clinic with a 2-year history of iron deficiency anemia (IDA). She was diagnosed as having IDA by her pediatrician when routine blood work showed microcytic anemia with low serum iron and ferritin levels (Table 1 shows serial laboratory values during the patient course). She was advised to take a daily multivitamin with iron. She eats a balanced diet, reports no learning difficulties, and is an active soccer player. She has no pica or constitutional symptoms and no recent travel. She is premenarchal. On examination the patient has conjunctival pallor with normal vital signs, no heart murmur, and no hepatosplenomegaly or lymphadenopathy. Her development is at Tanner stage 2, and her body mass index is in the 49th percentile. View this table: Table 1. Serial Laboratory Studies in Our Patient from Detection of Microcytic Hypochromic Anemia Through Treatment of Definitive Diagnosis Initial evaluation in the hematology clinic shows a low hemoglobin level of 7.1 g/dL (71 g/L) (reference range, 11.9–15.0 g/dL [119–150 g/L]), a low mean corpuscular volume of 66 fL (reference range, 79–95 fL), a high red cell distribution width of 20.1% (reference range, 9%–14.5%), a normal reticulocyte count of 67,500×103/µL (×109/L) (reference range, 12,000–130,000×103/µL [×109/L]), a low serum iron level of 16 µg/dL (2.9 µmol/L) (reference range, 37–145 µg/dL [6.6–25.9 µmol/L]), a low iron saturation of 4% (reference range, 27%–44%), and normal levels of ferritin and lead at 55.9 ng/mL (55.9 µg/L) (reference range, 13–150 ng/mL [13–150 µg/L]) and less than 3.3 µg/dL (<0.16 µmol/L) (reference range, 0–10 µg/dL [0–0.48 µmol/L]), respectively. Liver function is normal, including liver enzyme levels and renal function test results. The blood smear shows microcytic hypochromic red blood cells with anisopoikilocytosis. Stool guaiac testing is negative. Based on biochemical evidence of …