Investigating microcytic anaemia
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3154 (Published 07 June 2013) Cite this as: BMJ 2013;346:f3154All rapid responses
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Given the fact that the haematological issue addressed by the authors dealt solely with microcytic anaemia(1), there remains a lack of guidance on the investigation of hypochromic anaemia when it occurs in the absence of microcytosis.
The latter phenomenon was identified in a study which enrolled adults with serum ferritin < 18 mcg/l, but an analysis was not made of further investigations undertaken in those subjects(2). Without the benefit of evaluation of either serum iron or serum ferritin status, a more recent study made a retrospective analysis of red blood cell (RBC) indices in patients admitted to a major Australian teaching hospital over a 2 year period. Among 238 patients with preoperative anaemia, hypochromia (mean corpuscular haemoglobin < 27 pg) was more common than microcytosis (mean corpuscular volume < 80 fl) (19.3% vs 5.9%). Despite this, none of the patients had ferritin or iron studies performed by the statewide pathology service in the preceding 8 weeks(3).
In view of the fact that hypochromia can occur in the absence of microcytosis even when serum ferritin is unequivocally subnormal (serum ferritin < 10 mcg/l)(4), guidance is required (and this appeared to have been lacking in the Australian study)(3) as to how these patients should be investigated.
References
(1) Uprichard WO., Uprichard J
Investigating iron deficiency anaemia
BMJ 2013;347:34-36
(2) Jolobe OM
Prevalence of hypochromia(without microcytosis) vs microcytosis(without hypochromia) in iron deficiency
Clin Lab Haematol 2000;22:79080
(3) David O., Sinha R., Robinson K., Cardones D
The prevalence of anaemia, hypochromia and microcytosis in preoperative cardiac surgical patients
Anaesth Intensive Care 2013;41:316-321
(4)Jolobe OMP., Rakicka H
Significance of low serum ferritin levels in elderly in-patients(letter)
Postgrad Med j 1993;69:892
Competing interests: No competing interests
Re: Investigating microcytic anaemia
In response to the recent article “Investigating microcytic anaemia”1, could I suggest that a management approach should be influenced by local factors?
There is a high prevalence of iron deficiency anaemia in Aboriginal children in the Northern Territory of Australia. We do not see thalassaemia trait in this population.
Regarding investigations, serum ferritin, serum iron and total iron binding capacity are not useful in our patients with mild to moderate anaemia, as they often have chronic infections: misleading results are commonly found due to the increased inflammatory load.
Regarding treatment, a tendency to extremely poor adherence to oral iron treatment in our population has led to the widespread use of iron by intramuscular injection2.
References
1. Uprichard WO., Uprichard J. Investigating iron deficiency anaemia. BMJ 2013;347:34-36
2. CARPA Standard Treatment Manual: a clinic manual for primary health care practitioners in remote and rural communities in Central and Northern Australia. 5th Edition, 2009
Competing interests: No competing interests