What is the recommended treatment for a patient with low ferritin level, hypochromic anemia, and leukopenia?

Treatment for Low Ferritin, Hypochromic Anemia, and Leukopenia

The recommended treatment for a patient with low ferritin (19 ng/mL), hypochromic anemia (Hb 8.3 g/dL), and leukopenia (WBC 6.0 K/mcL) is oral iron supplementation with ferrous sulfate 200 mg twice daily for at least 3 months, continuing until 3 months after hemoglobin normalizes. 1

Diagnostic Assessment

This patient presents with:

• Low ferritin (19 ng/mL) - below the normal range (20-350 ng/mL)
• Severe hypochromic anemia with low hemoglobin (8.3 g/dL) and low hematocrit (27.0%)
• Microcytosis (MCV 96.8 fL - within normal range but at the higher end)
• Low RBC count (2.79 M/mcL)
• Normal aPTT (35.8 sec)

Confirming Iron Deficiency

The British Society of Gastroenterology guidelines state that serum ferritin is the single most useful marker of iron deficiency anemia (IDA) 2. With a ferritin of 19 ng/mL, this patient has confirmed iron deficiency, as values <30 ng/mL are diagnostic of iron deficiency 1, 3.

The hypochromic red cells and low hemoglobin are consistent with iron deficiency anemia. As noted in the guidelines, MCH is probably a more reliable marker of iron deficiency than MCV, as it is less dependent on storage and counting machines 2.

Treatment Algorithm

1. First-line therapy: Oral iron supplementation

   • Ferrous sulfate 200 mg twice daily 1
   • Continue for at least 3 months and for 3 months after hemoglobin normalizes 1
   • Add ascorbic acid (vitamin C) 250-500 mg twice daily to enhance iron absorption 1

2. Monitoring response

   • Check hemoglobin in 2-4 weeks to assess response 1
   • A good response is defined as a hemoglobin rise ≥10 g/L within a 2-week timeframe 2
   • Monitor ferritin and transferrin saturation monthly 1

3. If inadequate response (Hb increase <1.0 g/dL after 14 days)

   • Consider switching to intravenous iron therapy 1
   • Evaluate for causes of poor response:
     • Malabsorption (celiac disease, gastric surgery)
     • Ongoing blood loss
     • Inflammatory conditions
     • Non-compliance

4. Additional investigations

   • Screen for celiac disease as recommended by guidelines 2
   • Evaluate for gastrointestinal blood loss, especially in this patient with severe anemia 2
   • Consider upper and lower GI investigations if no clear cause is identified 2

Special Considerations

Severity of Anemia

The patient's hemoglobin of 8.3 g/dL indicates severe anemia. The British Society of Gastroenterology guidelines note that "the lower the hemoglobin the more likely there is to be serious underlying pathology and the more urgent is the need for investigation" 2. Therefore, prompt investigation of the underlying cause is essential.

Leukopenia

While the WBC count is reported as 6.0 K/mcL, which is within the normal range (4.6-12.4 K/mcL), careful monitoring is warranted as iron deficiency can sometimes affect other cell lines.

Potential Pitfalls

1. Failure to investigate underlying cause

   • Iron deficiency in adults always warrants investigation for underlying causes, particularly gastrointestinal blood loss 2, 1
   • Do not simply treat the anemia without determining why the patient is iron deficient

2. Inadequate duration of treatment

   • Continuing iron therapy for 3 months after normalization of hemoglobin is essential to replenish iron stores 1

3. Misinterpreting response

   • A good response to iron therapy (Hb rise ≥10 g/L within 2 weeks) is highly suggestive of absolute iron deficiency, even if iron studies are equivocal 2

4. Overlooking malabsorption

   • Screen for celiac disease in all patients with iron deficiency anemia 2

Conclusion

This patient has clear evidence of iron deficiency anemia requiring oral iron supplementation while investigating the underlying cause. The severity of anemia (Hb 8.3 g/dL) warrants prompt evaluation, particularly for gastrointestinal sources of blood loss. Treatment should continue for at least 3 months after hemoglobin normalizes to fully replenish iron stores.