How to manage a patient with anemia, glossitis, and angular carcinoma?

Management of Anemia with Koilonychia, Glossitis, and Angular Cheilitis

The most effective management approach for a patient with anemia presenting with koilonychia, glossitis, and angular cheilitis is to diagnose and treat iron deficiency anemia with oral iron supplementation (ferrous sulfate 325 mg daily) for 3-6 months while investigating the underlying cause through upper and lower GI endoscopy. 1, 2

Diagnostic Approach

Clinical Presentation Assessment

• The triad of koilonychia (spoon-shaped nails), glossitis (inflamed tongue), and angular cheilitis (cracks at corners of mouth) strongly suggests iron deficiency anemia 1
• These oral manifestations are classic signs of iron deficiency and can be seen in conditions like Plummer-Vinson syndrome, which carries an increased risk of squamous cell carcinoma 3

Initial Laboratory Workup

1. Complete blood count with indices (MCV, RDW)
2. Iron studies:
   • Serum ferritin (<30 μg/L indicates iron deficiency)
   • Transferrin saturation (<15% in iron deficiency)
   • Total iron-binding capacity (elevated in iron deficiency)
3. Vitamin B12 and folate levels (to rule out concurrent deficiencies)
4. C-reactive protein (to assess for inflammation) 2

Differential Diagnosis

• Iron deficiency anemia (most likely given the clinical presentation)
• Pernicious anemia (vitamin B12 deficiency)
• Mixed nutritional deficiency anemia
• Anemia of chronic disease 2, 4

Treatment Algorithm

Step 1: Iron Supplementation

• First-line treatment: Ferrous sulfate 325 mg daily or on alternate days 2
• Continue treatment for 3-6 months after normalization of hemoglobin to replenish iron stores 2
• Monitor hemoglobin response at 4-8 weeks after initiating therapy 1

Step 2: Investigate Underlying Cause

• In men and postmenopausal women: Gastroscopy and colonoscopy should be performed as first-line GI investigations to rule out malignancy 1
  • CT colonography is a reasonable alternative if colonoscopy is not suitable
• In premenopausal women: Consider heavy menstrual bleeding as a potential cause while still evaluating for GI sources 1, 2

Step 3: Manage Specific Oral Manifestations

• Glossitis and angular cheilitis typically improve with iron replacement
• Topical antifungal treatment may be needed for angular cheilitis if there is secondary Candida infection 1

Step 4: Additional Considerations

• If vitamin B12 deficiency is also present (common in patients with glossitis), administer vitamin B12 supplementation 5, 4
• Test for anti-intrinsic factor antibodies and gastric parietal cell antibodies if pernicious anemia is suspected 1, 6

Special Considerations

Monitoring Response

• Reticulocyte count should increase within 5-7 days of starting iron therapy
• Hemoglobin should rise by approximately 1-2 g/dL every 2-3 weeks 2
• If no response after 4-8 weeks, reassess diagnosis and adherence to treatment 1

Warning Signs Requiring Urgent Attention

• Severe anemia (Hb <7 g/dL) with hemodynamic instability may require blood transfusion
• Dysphagia (may indicate Plummer-Vinson syndrome with esophageal webs) requires prompt endoscopic evaluation due to increased risk of malignancy 3

Pitfalls to Avoid

1. Failing to investigate the underlying cause: Iron deficiency anemia in adults, particularly men and postmenopausal women, requires GI investigation even if symptoms improve with iron supplementation 1
2. Misdiagnosing mixed deficiency states: Patients may have concurrent iron and vitamin B12/folate deficiencies, especially with oral manifestations like glossitis 4, 6
3. Overlooking malignancy risk: Patients with longstanding iron deficiency and oral manifestations (especially Plummer-Vinson syndrome) have increased risk of upper GI and esophageal malignancies 3
4. Inadequate duration of treatment: Continuing iron therapy for 3-6 months after hemoglobin normalization is essential to replenish iron stores 2

By following this structured approach, the underlying cause of anemia can be identified and treated while simultaneously addressing the nutritional deficiency and its manifestations, leading to improved patient outcomes and quality of life.