Skill Checkup: An Active Woman With Vertigo, Fatigue, Leg Cramps, and Often Chews on Ice

James L. Harper, MD


November 01, 2021

Because of the patient's history, iron deficiency anemia is a key consideration. However, it is important to consider other causes of anemia in the differential diagnosis. Iron deficiency should never be thought of as an isolated disease, but rather as the consequence of other diseases, which may include impaired iron absorption, loss of body iron in the urine, cancer, chronic inflammation, or gastrointestinal bleeding. Internal bleeding may be caused by an ulcer, gastritis, parasites, cancer, or urinary tract bleeding. In addition, insufficient absorption can be caused by intestinal surgery (bypass). Although iron deficiency is the most common cause of anemia, a broad differential diagnosis is especially relevant in older patients or those with chronic inflammatory conditions.

Common symptoms of iron deficiency anemia include paleness, fatigue, dyspnea, headache, alopecia, dry skin, dry hair, cognitive dysfunction, and vertigo. Patients can usually pinpoint the onset of their symptoms.

Celiac disease is a common cause of iron deficiency anemia, even in asymptomatic patients (with Crohn's disease or celiac disease, reduced stomach acid from these conditions or prescription medicine can increase the likelihood of anemia). Although this possibility is made less likely by the fact that the patient does not have gastrointestinal symptoms, it is still important to exclude potential sources of bleeding.

Alpha thalassemia can mimic iron deficiency anemia because both conditions are characterized by microcytic red blood cells. In iron deficiency anemia, unlike thalassemia, target cells will typically not be present, and anisocytosis and poikilocytosis are not marked. (The procedures used to find a source of bleeding in patients with iron deficiency anemia do not have diagnostic value in patients with thalassemia.) Lead exposure seems relatively unlikely without signs of gastrointestinal, renal, or cardiovascular toxicity.


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