Is a serum iron level of 65, with a ferritin level of 27 and Total Iron Binding Capacity (TIBC) of 270, indicative of iron deficiency anemia in an elderly male?

Iron Deficiency Confirmed in This Elderly Male

Yes, this is definitively low and represents iron deficiency that warrants thorough gastrointestinal investigation. A ferritin of 27 ng/mL in an elderly male is unequivocally diagnostic of depleted iron stores and requires the same investigational approach as iron deficiency anemia, regardless of whether frank anemia is present 1, 2.

Interpretation of These Iron Parameters

Your patient has clear-cut iron deficiency based on multiple converging parameters:

• Ferritin 27 ng/mL: This is diagnostic of iron deficiency. In elderly patients without active inflammation, ferritin <30 μg/L confirms iron deficiency 1, 2. Even accounting for ferritin being an acute-phase reactant that can be falsely elevated by inflammation, a value of 27 is definitively low 2.

• Transferrin saturation 24%: While this is above the classic threshold of <16% used to define absolute iron deficiency 2, it still represents suboptimal iron availability when combined with the low ferritin 3.

• TIBC 270: This is within normal range (typically 250-370 μg/dL), but the combination of low ferritin with this TIBC confirms iron deficiency rather than anemia of chronic disease 2.

• Serum iron 65: This is low-normal to low (normal range typically 60-170 μg/dL for males), further supporting iron deficiency 2.

Clinical Significance in Elderly Males

Iron deficiency in elderly males is uncommon and highly significant:

• Iron deficiency anemia is relatively uncommon in young men and elderly males, but when found, the yield of gastrointestinal pathology is considerably higher than in women of the same age 2.

• In one study of elderly hospitalized patients with ferritin ≤50 μg/L who underwent investigation, a potential gastrointestinal cause was identified in 60% of anaemic patients and 54% of non-anaemic patients 4.

• Malignancy was identified in patients with ferritin levels in the 18-45 μg/L range in multiple studies 5.

Mandatory Investigation Algorithm

Both upper and lower gastrointestinal tract evaluation should be performed unless contraindications exist:

1. Upper endoscopy with duodenal biopsies to evaluate for:

   • Gastric or duodenal malignancy
   • Celiac disease (present in 2-3% of iron deficiency cases)
   • Other mucosal lesions
   • Upper GI pathology is found in 30-50% of cases 1

2. Colonoscopy or CT colonography to evaluate for:

   • Colorectal malignancy
   • Angiodysplasia
   • Other colonic lesions
   • Dual pathology (lesions in both upper and lower GI tracts) occurs in approximately 10% of cases 1

3. Consider additional factors that may contribute in elderly patients:

   • Medication review (aspirin, anticoagulants, NSAIDs) 2
   • Chronic kidney disease assessment (check creatinine/GFR) 2
   • Dietary history 2

Important Caveats

The risks and benefits of invasive investigation must be carefully weighed:

• In elderly patients with major comorbidities, significant frailty, or limited life expectancy, the decision to pursue invasive endoscopy should be individualized based on performance status 2, 1.

• CT colonography may be a more attractive alternative to colonoscopy for some older individuals who are poor candidates for invasive procedures 2.

• However, for most elderly males with confirmed iron deficiency and reasonable functional status, the potential to identify treatable malignancy justifies investigation 1.

Common pitfall: Many clinicians underinvestigate iron deficiency in elderly patients. Studies show that only 26 of 49 (53%) hospitalized elderly patients with non-macrocytic anemia of unknown cause received adequate investigation 5. Don't fall into this trap—iron deficiency in an elderly male is never "just age-related" and demands explanation 2, 1.