Iron and Vitamin Deficiency Anemia

By: Dr.Mohammed Mujeeb Baag.

Pathologist, Mawyah Clinics, Riyadh.

Blood consist of Red Blood Cells (RBCs) which transports oxygen from lungs to the body tissue.
RBCs have Hemoglobin (Hb) which consists of Iron. Deficiency or loss of Iron or increase demand of
Iron will cause defective oxygenation to tissue as low Hb production, this leads to Anemia. Anemia is
called if the Hb% is less than normal for specific age, < 12 in females, < 11 in pregnancy, and < 14 in
males.

AGE Yrs Hb gm/dL

(Normal Values)

0.6-4.0 11.0

5-9 11.5

10-14 12.0

Adult(M) 14.0

Adult(F) 12.0

Pregnancy 11.0

Fig no: 2, Normal RBC, WBC, &

Fig No: 3 Normal RBCs Platelets

Iron deficiency anemia:

Iron deficiency anemia is the commonest form of anemia nearly one third population of planet is
suffering from it. Iron deficiency anemia very common in young children and pregnant women
because of increased requirement due to fast growth. Milk fed babies after the age of six month are
more prone for the Iron deficiency anemia as milk does not have sufficient iron to meet the requirement
of babies hence in 3% of toddler it is seen. 2-5 % of the adolescent girls because of the fast growth also
suffer from this type of anemia. When it is seen in men it is usually because of the prolonged treatment
of the hyperacidity, ulcer treatment by H2 Blocker prolonged use or total or subtotal gastrectomy,
Infestation by the Hook worms, prolonged untreated heavy menses, sprue syndrome, and cancer. Very
little iron is lost from the body mainly by shedding of the intestinal mucosal cells and very little by skin
and the urine. The iron excreted by the woman is more than male because of the menstrual blood loss,
to compensate women have daily loss of 2 mg/day as compare to men only 1 mg/day. The iron is
mainly absorbed in the small intestine where iron absorption is enhanced by ascorbate and citrates
while it is reduced by presence of phytate and tannins. Iron deficiency develops when there is
prolonged iron loss, when the body stores are depleted and when the iron intake is not sufficient or the
absorption of iron is reduced. Patients usually develop symptoms like parasthesia (increased or
decreased sensation), tingling and numbness; Blackout, Giddiness, fissure or ulcers at the corner of
mouth. Burning or soreness of the tongue is seen. Craving to eat unusual substances like dirt, ice, chalk
(Pica); nail becomes brittle and spoon shaped (koilonychias), hair loss becomes prominent feature.
Laboratory diagnosis of IDA is done by Serum iron preferably fasting level which will be less than
normal level of 50-160 ug/dL (9-29 umol/L). Peripheral blood smear shows abnormally low
hemoglobinization of varying degree (Hypochromic), presence of small size RBC (Microcytes)
presence of Abnormal shaped RBCs (Poikilocytes), Decreased production of the Reticulocytes as iron
is low; after the start of treatment with iron the reticulocytes (new RBCs) increased in numbers with in
24 o 48 hrs, peak level of response seen in 4-5 days. (Fig: 4). Serum Iron binding capacity is increased
in IDA, while the % Saturation of TIBC is decreased. Serum Ferritin level is also decreased.

Fig no: 4; Microcytic Hypochromic

RBCs in Iron deficiency Anemia. Fig No: 5; Megaloblastic RBCs &Neutrophils.

It is recommended to treat the cause of heavy menses first, even if there is anemia then food which
contains high amount of iron can be taken sufficiently so as to replenish the iron load especially foods
like apple, banana, brinjal (egg plant), guava, all leafy vegetables and meat, liver, kidneys, brain
are advisable. If only diet is not sufficient to correct the anemia the Ferrous Iron tablets 200mg/day on
empty stomach or at least one hour after meals or Iron injections are advised by the doctor depending
on the severity of anemia the dose and period of treatment is decided. Usually the treatment is
continued more for 4-6 wks, even after the Hb level becomes normal, just to replenish the exhausted
iron storage in bone marrow.

Megaloblastic Anemia: (Cobalamine (B12) & Folic acid Vitamin Deficiency

Megaloblastic Anemia).Vitamins Cobalamine and Folic acid is needed for the maturation of the
nucleus. The requirement of these vitamins is increased in the early child hood, adolescent girls,
pregnancy, and cancer patients because of increased cellular multiplication. Also these vitamins are
stored inside liver in minimal quantity; if either the requirement is increased or the intake is decreased
then this may lead to Megaloblastic anemia. This is characterized by the presence of large RBCs,
hyper-segmented Neutrophils (> 5 lobes) along with the decreased in platelet count. (Fig: 5) These
changes are because of the disproportion in the nuclear cytoplasmic maturation. Cells before they enter
in blood stream attains larger size, hyper-segmentation, RBCs are larger size with low Hb
concentration and MCV (mean corpuscular volume), etc.

Vitamin Cobalamine is synthesized by the gut flora; also it is present in all animal tissue. After
ingestion it is attached to the intrinsic factor in acid medium of stomach and carried to the small
intestine where it gets absorbed. Disturbances in the ingestion, carriage and absorption will cause
deficiency. Patient on antibiotic therapy, strict vegetarian (not even Eggs and Milk), patient of peptic or
gastric ulcer on prolonged use of H2 blockers, achlorohydria (absence of acid in stomach) because of
removal of stomach (gastrectomy), tropical sprue, Mal absorption syndrome, genetic absence of
intrinsic factor(Pernicious Anemia) or presence of antibodies to intrinsic factor, Infestation by the Fish
Tape worm Diphyllbothrium latum are usually prone for Megaloblastic anemia secondary to
Cobalamine deficiency.

Similarly, Vitamin Folic Acid can cause Megaloblastic anemia. Folic acid is found in wide variety of
food such as egg, milk, leafy vegetables, yeast, fruits, liver, and also formed by the intestinal bacteria.
Folates are extremely heat sensitive hence prolonged cooking > 20 minutes in large water in the
absence of reducing agents will destroy folates. Folates are also present in the fresh milk but prolonged
heated milk; powdered milk lack folates, Infants and the pregnant mother require more folates as
compare to others hence more prone for folic acid deficiency. Prolonged use of some drugs like anti-
biotic, anti-convulsants like phenytoin, Phenobarbital, and primidones, also rarely prolonged use of
contraceptives may cause folic acid deficiency. Inadequate utilization of folic acid is seen in
antimetabolic treatment in cancer patients and in alcoholics where the liver is already damaged there is
also nutritional intake problems. Usually the treatment consists of either Cobalamine therapy or the
combine therapy both by Cobalamine & Folic acid, along with the dietary instructions.