The patient must have anemia (hemoglobin less than 13 g/dL in men and 12 g/dL in women).  Results:  A cumulative total representing the total number of positive findings for each of these conditions will be provided.  Background statements will also be provided for each selection below that provide supporting comments for the final diagnosis.

Background

      Anemia is defined as a decrease in the total amount of red blood cells (RBCs) or hemoglobin in the blood and is present when it falls below certain thresholds depending on the age, gender, and race of the patient.   Based on WHO criteria, the lower limit of normal in adults is 13 g/dL in men and 12 g/dL in women. The blood hemoglobin concentration may more accurately indicate the total red cell mass compared with the hematocrit.  The various types of anemia are due to blood loss (usually gastrointestinal bleeding, trauma, others),  decreased red blood cell production (iron deficiency, a lack of vitamin B12, folic acid, thalassemia, and a number of neoplasms), or increased red blood cell breakdown ( genetic conditions such as sickle cell anemia, infections e.g. malaria, and certain autoimmune diseases).  The type of anemia can also be classified based on the size of the red blood cells (microcytic - smaller, macrocytic - larger, or normocytic - normal size)  and the amount of hemoglobin present in each cell -  hypochromic (paler than normal - less red) or normochromic (normal color).

 Symptoms vary greatly and depend on the onset and the individual's ability to compensate for a loss in oxygen-carrying capacity. Anemia with a slow onset may go undetected or present with vague symptoms including tiredness, weakness, shortness of breath, poor concentration or reduced exercise tolerance. Anemia that occurs rapidly often has more obvious symptoms such as confusion, mental status changes, lightheadedness, loss of consciousness, palpitations, respiratory distress, or hypotension. Symptoms are often more severe if there is underlying coronary artery disease, congestive heart failure, or intrinsic pulmonary or cerebrovascular disease. Typical signs exhibited may include pallor (pale skin, lining mucosa, conjunctiva and nail beds), however, further testing is required to confirm the diagnosis.

 Iron-deficiency anemia is defined as a decrease in the number of red blood cells or the amount of hemoglobin in the blood due to a decrease in iron and is estimated to cause approximately half of all anemia cases globally. Iron is a critical component of hemoglobin and about 70% of the iron found in the body is bound to hemoglobin. Iron is primarily absorbed in the small intestine This type of anemia may be related to blood loss ( uterine fibroids, stomach ulcers, colon cancer, urinary tract bleeding, other sources), insufficient dietary intake, or poor absorption of iron from food (may occur as a result of an intestinal disorder such as inflammatory bowel disease or celiac disease, or surgery such as a gastric bypass).

      Sources of iron:
Iron deficiency anemia can be prevented by eating a diet containing sufficient amounts of iron or by iron supplementation. Foods high in iron include meat, nuts, spinach, and foods made with iron-fortified flour.

   Other possible symptoms and signs include:

• Irritability
  
• Angina (chest pain)
  
• Tingling, numbness, or burning sensations
  
• Glossitis (inflammation or infection of the tongue)
  
• Angular cheilitis (inflammatory lesions at the mouth's corners)
  
• Koilonychia (spoon-shaped nails) or nails that are brittle
  
• Poor appetite
  
• Dysphagia (difficulty swallowing)
  

Anemia of chronic disease -  'Anemia of chronic inflammation'   is a form of anemia seen in chronic infection, chronic immune activation, and neoplastic disease. The diagnosis can be difficult, especially if it coexists with iron deficiency. Other contributing causes of anemia should be ruled out.   Anemia of chronic disease is usually mild but can be severe. It is usually normocytic, but can be microcytic.

In anemia of chronic inflammation without iron deficiency, ferritin is normal or high, reflecting the fact that iron is sequestered within cells, and ferritin is being produced as an acute phase reactant. In iron deficiency anemia ferritin is low. Total iron-binding capacity (TIBC) is high in iron deficiency, reflecting production of more transferrin to increase iron binding; TIBC is low or normal in anemia of chronic inflammation.

References

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2. Beata I, Mason BJ, and Thompson EG. Anemias. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. New York, NY: McGraw-Hill Inc; 2005:1806-1817.
   
   
3. Cook JD. Diagnosis and management of iron-deficiency anaemia. Best Pract Res Clin Haematol 2005;18:319-32.
   
   
4. Guyatt GH, Oxman AD, Ali M, Willan A, McIlroy W, Patterson C. Laboratory diagnosis of iron-deficiency anemia: an overview. J Gen Intern Med. 1992 Mar-Apr;7(2):145-53.
   
   
5. Lopez A, Cacoub P, Macdougall IC, Peyrin-Biroulet L. Iron deficiency anaemia. Lancet. 2016 Feb 27;387(10021):907-16. doi: 10.1016/S0140-6736(15)60865-0. Epub 2015 Aug 24.
   
   
6. Wians FH Jr, Urban JE, Keffer JH, Kroft SH. Discriminating between iron deficiency anemia and anemia of chronic disease using traditional indices of iron status vs transferrin receptor concentration. Am J Clin Pathol. 2001 Jan;115(1):112-8.  [Pubmed]
   
   
7. Zarychanski, R; Houston, DS (Aug 12, 2008). "Anemia of chronic disease: a harmful disorder or an adaptive, beneficial response?". CMAJ : Canadian Medical Association Journal. 179 (4): 333–7. [Pubmed]