Refractory iron deficiency anemia as an early manifestation of autoimmune gastritis in a teenager / Anemia ferropénica refractaria como presentación temprana de gastritis autoinmune en un adolescente

Abstract Autoimmune gastritis is an underdiagnosed disease in the pediatric population due to the absence of specific signs and symptoms and late clinical manifestations. Iron deficiency anemia has recently been identified as an early hematological manifestation, allowing an early diagnostic approach. We present the case of a Colombian teenager, with no history of autoimmunity, with refractory iron deficiency. He underwent extension studies; biopsies and serology compatible with autoimmune gastritis were documented, requiring parenteral iron in its evolution. This pathology is underdiagnosed in our context since early diagnosis requires a high index of suspicion to prevent associated complications.

Resumen La gastritis autoinmune es una enfermedad subdiagnosticada en la población pediátrica. Lo anterior se debe a la ausencia de signos y síntomas específicos y manifestaciones clínicas tardías. Recientemente se ha identificado la anemia ferropénica como una manifestación hematológica precoz, lo que permite un enfoque diagnóstico temprano. Se presenta el caso de un adolescente colombiano, sin antecedentes de autoinmunidad, con ferropenia refractaria, en el que se realizaron estudios de extensión y se documentaron biopsias y serología compatible con gastritis autoinmune, con requerimiento de hierro parenteral en su evolución. Esta patología es subdiagnosticada en nuestro medio, ya que el diagnóstico temprano requiere un alto índice de sospecha, lo que permite la prevención de las complicaciones asociadas.

Deficiência de Ferro na Insuficiência Cardíaca com Fração de Ejeção Reduzida: Fisiopatologia, Diagnóstico e Tratamento / Iron Deficiency in Heart Failure with Reduced Ejection Fraction: Pathophysiology, Diagnosis and Treatment

Resumo A deficiência de ferro (DF) ou ferropenia é uma importante comorbidade na insuficiência cardíaca com fração de ejeção reduzida (ICFER) estável, e muito prevalente tanto nos anêmicos como não anêmicos. A ferropenia na ICFER deve ser pesquisada por meio da coleta de saturação de transferrina e ferritina. Há dois tipos de ferropenia na IC: absoluta, em que as reservas de ferro estão depletadas; e funcional, onde o suprimento de ferro é inadequado apesar das reservas normais. A ferropenia está associada com pior classe funcional e maior risco de morte em pacientes com ICFER, e evidências científicas apontam melhora de sintomas e de qualidade de vida desses pacientes com tratamento com ferro parenteral na forma de carboximaltose férrica. O ferro exerce funções imprescindíveis como o transporte (hemoglobina) e armazenamento (mioglobina) de oxigênio, além de ser fundamental para o funcionamento das mitocôndrias, constituídas de proteínas à base de ferro, e local de geração de energia na cadeia respiratória pelo metabolismo oxidativo. A geração insuficiente e utilização anormal de ferro nas células musculares esquelética e cardíaca contribuem para a fisiopatologia da IC. A presente revisão tem o objetivo de aprofundar o conhecimento a respeito da fisiopatologia da ferropenia na ICFER, abordar as ferramentas disponíveis para o diagnóstico e discutir sobre a evidência científica existente de reposição de ferro.

Abstract Iron deficiency (ID) is an important comorbidity in heart failure with reduced ejection (HFrEF) and is highly prevalent in both anemic and non-anemic patients. In HFrEF, iron deficiency should be investigated by measurements of transferrin saturation and ferritin. There are two types of ID: absolute deficiency, with depletion of iron stores; and functional ID, where iron supply is not sufficient despite normal stores. ID is associated with worse functional class and higher risk of death in patients with HFrEF, and scientific evidence has indicated improvement of symptoms and quality of life of these patients with treatment with parenteral iron in the form of ferric carboxymaltose. Iron plays vital roles such as oxygen transportation (hemoglobin) and storage (myoblogin), and is crucial for adequate functioning of mitochondria, which are composed of iron-based proteins and the place of energy generation by oxidative metabolism at the electron transport chain. An insufficient generation and abnormal uptake of iron by skeletal and cardiac muscle cells contribute to the pathophysiology of HF. The present review aims to increase the knowledge of the pathophysiology of ID in HFrEF, and to address available tools for its diagnosis and current scientific evidence on iron replacement therapy.

Anemia y patología digestiva / Anemia and digestive diseases / Anemia e patologia digestiva

Cada vez más los pacientes diagnosticados con anemia son referidos al gastroenterólogo para su evaluación. La necesidad de realizar un adecuado planteo clínico y una correcta interpretación de las pruebas de diagnóstico ha motivado la revisión de este tema. Varios trastornos gastroenterológicos, con frecuencia, conducen a anemia como resultado de pérdidas sanguíneas, inflamación, malabsorción o a consecuencia de las terapias farmacológicas. En algunas patologías como la cirrosis, EII o neoplasias las causas son a menudo multifactoriales. Esta revisión, pretende proporcionar un enfoque útil para la práctica clínica. Para ello se ha revisado la información actualizada acerca de la patogénesis, diagnóstico y tratamiento de la anemia vinculada a patologías digestivas y se han confeccionados cuadros y algoritmos para facilitar su comprensión.

More and more patients diagnosed with anemia are referred to the gastroenterologist for evaluation. The need to carry out an adequate clinical approach and a correct interpretation of diagnostic tests has motivated this review. Several digestive diseases frequently lead to anemia because of blood loss, inflammation, malabsorption, or drug therapies. In some of them such as cirrhosis, IBD or neoplasms, the etiology is multifactorial. This review is intended to provide a useful approach to clinical practice. To this aim, updated information on the pathogenesis, diagnosis, and treatment of anemia related to digestive diseases has been reviewed, and tables and algorithms have been built to favor its understanding.

Cada vez mais pacientes diagnosticados com anemia são encaminhados ao gastroenterologista para avaliação. A necessidade de realizar uma abordagem clínica adequada e uma interpretação correta dos testes de diagnóstico motivou a revisão deste tema. Vários distúrbios gastroenterológicos freqüentemente levam à anemia como resultado de perda de sangue, inflamação, má absorção ou pelas próprias terapias farmacológicas. Em algumas patologias como cirrose, DII ou neoplasias, as causas costumam ser multifatoriais. Esta revisão visa fornecer uma abordagem útil à prática clínica. Para esse fim, foram revisadas informações atualizadas sobre a patogênese, o diagnóstico e o tratamento da anemia associada à patologia digestiva e foram elaboradas tabelas e algoritmos para facilitar seu entendimento.

Indicadores do estado corporal do ferro e indicadores de inflamação durante o tratamento da doença inflamatória intestinal em crianças e adolescentes / Body iron status indicators and inflammation indicators during inflammatory bowel disease therapy in children and adolescentes

ABSTRACT BACKGROUND: The treatment of patients with inflammatory bowel disease (IBD) consists of the induction and maintenance remission of the disease. Iron status indicators would be useful for the diagnosis of iron deficiency anemia, whereas the inflammation indicators would be for the diagnosis of chronic disease anemia. OBJECTIVE: To assess body iron status indicators and inflammation indicators during the treatment of IBD, consisted of conventional or infliximab therapy in children and adolescents. METHODS: A case-control study of a sample of 116 individuals, of which 81 patients with IBD, 18 of them receiving conventional therapy, 20 infliximab therapy, and 43 who were in remission of the disease, and 35 healthy (control group) children and adolescents. Iron status and inflammation indicators were investigated at baseline, and 2 and 6 months of both therapies - conventional and infliximab. RESULTS: The mean age was 12.1±4.3 years. At baseline, both groups - conventional therapy and infliximab - presented significant differences in most markers studied compared to the control group. After 2 months of conventional therapy, hemoglobin and serum iron levels were lower than those of the control group; and red cells distribution width (RDW), total iron-binding capacity, transferrin receptor/ferritin ratio, and interleukin-6 were higher than the control group. After 2 months of infliximab treatment, hemoglobin and serum iron levels were lower than those of the control group; and RDW, soluble transferrin receptor, soluble transferrin receptor/ferritin ratio, and interleukin-6 were higher than the control group. After 6 months of conventional therapy, hemoglobin and serum iron levels were lower than those of the control group, and RDW and interleukin-6 were higher than those of the control group. After 6 months of infliximab treatment, the hemoglobin and serum iron levels were lower than the control group, and RDW, soluble transferrin receptor, soluble transferrin receptor/ferritin ratio, erythrocyte sedimentation rate, and platelets were higher than the control group. Regarding patients under treatment for at least one year (remission group), all markers studied, except transferrin, were similar to the control group. CONCLUSION: In conclusion, there were some contradictions among the different body iron status indicators and inflammation indicators at two and 6 months of treatment with conventional and infliximab therapy, however after one year of treatment, as shown by the remission group, all indicators studied, except transferrin, were similar to healthy children and adolescents.

RESUMO CONTEXTO: O tratamento de pacientes com doença inflamatória intestinal (DII) consiste na indução e manutenção da remissão da doença. Os indicadores do estado corporal do ferro seriam úteis para o diagnóstico da anemia por deficiência de ferro, enquanto os indicadores de inflamação para o diagnóstico da anemia da doença crônica. OBJETIVO: Avaliar os indicadores do estado corporal do ferro e os indicadores de inflamação durante o tratamento da doença inflamatória intestinal, com terapia convencional ou infliximabe em crianças e adolescentes. MÉTODOS: Estudo de caso-controle de uma amostra de 116 indivíduos, sendo 81 pacientes com DII, dos quais 18 com terapia convencional, 20 infliximabe e 43 em remissão da doença, e 35 crianças e adolescentes saudáveis (grupo controle). Os indicadores do estado do ferro e os indicadores de inflamação foram avaliados no início, 2 e 6 meses de dois tipos de tratamento - terapia convencional e terapia com infliximabe. RESULTADOS: A média de idade foi de 12,1±4,3 anos. No início do tratamento, ambos os grupos - terapia convencional e infliximabe - apresentaram diferenças significantes com relação à maioria dos marcadores estudados comparados ao grupo controle. Após 2 meses de terapia convencional, os níveis de hemoglobina e ferro sérico foram inferiores em comparação ao grupo controle; e amplitude de distribuição dos eritrócitos (RDW), capacidade total de ligação do ferro, razão entre o receptor de transferrina solúvel e ferritina e interleucina-6 foram superiores aos do grupo controle. Após 2 meses de tratamento com infliximabe os níveis de hemoglobina e ferro sérico foram inferiores em comparação ao grupo controle, e RDW, receptor de transferrina solúvel e interleucina-6 foram superiores aos do grupo controle. Após 6 meses de terapia convencional, os níveis de hemoglobina e ferro sérico foram inferiores aos do grupo controle, e RDW e interleucina-6 superiores aos do grupo controle. Após 6 meses de tratamento com infliximabe, os níveis de hemoglobina e ferro sérico foram inferiores comparados ao grupo controle, e RDW, receptor de transferrina solúvel, razão receptor de transferrina solúvel e ferritina, taxa de sedimentação de eritrócitos e plaquetas foram superiores ao do grupo controle. Quanto aos pacientes que estavam em tratamento há mais de um ano (grupo remissão), todos os marcadores, exceto a transferrina, foram similares ao grupo controle. CONCLUSÃO: Houve contradições entre os diferentes indicadores do estado corporal do ferro e dos indicadores de inflamação aos 2 e 6 meses de tratamento com terapia convencional e infliximabe, no entanto após um ano de tratamento, conforme observado pelo grupo em remissão, todos os indicadores estudados, exceto a transferrina, foram semelhantes aos das crianças e adolescentes saudáveis.

Utilidad clínica del equivalente de hemoglobina reticulocitaria en niños en hemodiálisis / Clinical usefulness of the reticulocyte hemoglobin equivalent in children on hemodialysis

Introducción. La anemia por deficiencia de hierro en hemodiálisis es frecuente. Para su detección se utiliza la ferritina sérica y la saturación de transferrina (ST). El equivalente de hemoglobina reticulocitaria (RET-He) es un análisis que no se modifica en estados inflamatorios y refleja directamente el hierro disponible en médula ósea.Objetivo. Explorar la capacidad diagnóstica de deficiencia absoluta de hierro del RET-He y evaluar su correlación con marcadores tradicionales de ferropenia.Población y métodos. Estudio retrospectivo que comparó RET-He con ferritina y ST en niños en hemodiálisis atendidos en el Hospital Garrahan entre julio de 2016 y julio de 2019. Resultados. En 164 observaciones realizadas en 40 niños, se encontró correlación positiva débil entre hemoglobina y RET-He (r 0,35, p < 0,001), positiva significativa entre ST y RET-He (r 0,52, p < 0,001), negativa baja entre hemoglobina y ferritina (r -0,19, p 0,02) y ausencia de correlación entre hemoglobina y ST (r 0,05, p 0,5). El 50 % presentaba anemia; la ferropénica fue por marcadores tradicionales en el 13 % y por RET-He en el 44 %. El RET-He mostró sensibilidad del 90,9 % (IC 95: 57,1-99,5 %), especificidad del 74,5 % (IC 95: 66,7-81 %), valor predictivo negativo del 99,1 % (IC 95: 94,5-99,9 %) y positivo del 20,4 % (IC 95: 10,7-34,7 %) para detectar anemia ferropénica con valor de corte de 29 picogramos.Conclusiones. Pese a su capacidad limitada, el RET-He como biomarcador de deficiencia de hierro aumenta la detección de anemia ferropénica en niños en hemodiálisis

Introduction. Iron-deficiency anemia is common in hemodialysis patients. Serum ferritin and transferrin saturation (TS) are used for its detection. The reticulocyte hemoglobin equivalent (RET-He) is a marker that is not altered by inflammatory conditions and directly reflects iron availability in the bone marrow.Objective. To explore the diagnostic capability of RET-He to detect absolute iron deficiency and assess its correlation with traditional markers of iron deficiency.Population and methods. Retrospective study comparing RET-He with ferritin and TS in children on hemodialysis seen at Hospital Garrahan between July 2016 and July 2019.Results. In 164 observations carried out in 40 children, a weak positive correlation was found between hemoglobin and RET-He (r = 0.35, p < 0.001), a significant positive correlation between TS and RET-He (r = 0.52, p < 0.001), a low negative correlation between hemoglobin and ferritin (r = -0.19, p = 0.02), and a lack of correlation between hemoglobin and TS (r = 0.05, p = 0.5). Anemia was observed in 50 %; iron-deficiency anemia was detected by traditional markers in 13 % and by RET-He in 44 %. RET-He showed a sensitivity of 90.9 % (95 % CI: 57.1-99.5 %), a specificity of 74.5 % (95 % CI: 66.7-81 %), a negative predictive value of 99.1 % (95 % CI: 94.5-99.9 %), and a positive predictive value of 20.4 % (95 % CI: 10.7-34.7 %) to detect iron-deficiency anemia with a cut-off value of 29 pg.Conclusions. Despite its limited capability, the use of RET-He as a biomarker of iron deficiency increases the detection of iron-deficiency anemia in children on hemodialysis.

Manifestações orofaciais associadas aos diferentes tipos de anemias / Orofacial manifestations associated with different types of anemia

Introduction: Anemias correspond to hematological disorders that can present in the oral cavity and face. Objective: To review the literature on the main types of anemic disorders and their orofacial manifestations, considering the aspects of interest to dentists. Methodology: This is a literature review, in which articles were selected in Portuguese and English, indexed in the Scielo, Medline/Pubmed and Lilacs databases with the descriptors: Anemia, Oral Manifestations, Jaw Abnormalities and their correspondents in Portuguese language. Literature review: Anemic disorders associated with orofacial signs and symptoms include mainly Iron-Deficiency, Megaloblastic, Fanconis, Sickle Cell, Thalassemia and Aplastic Anemia. The manifestations vary from burning and painful symptoms in the tongue, pallor of lips and mucosa, stomatitis, atrophic glossitis, angular cheilitis, susceptibility to candidiasis and peri-odontal disease. Also, dental changes, hyposalivation, malocclusion, osteomyelitis of the jaw, paraesthesia of the mental nerve and orofacial pain are included. Conclusion: These manifestations can be the first signs of the presence of anemia, which gives the dentist an important role in early diagnosis and proper management of dental treatment.

Introdução: As anemias correspondem a distúrbios hematológicos que podem apresentar manifestações na cavidade oral e face. Objetivo: Revisar a literatura acerca dos principais tipos de distúrbios anêmicos e suas manifestações orofaciais, considerando os aspectos de interesse aos cirurgiões-dentistas. Metodologia: Trata-se de uma revisão de literatura, em que foram selecionados artigos em português e inglês, indexados nas bases de dados do Scielo, Medline/Pubmed e no Lilacs, com os descritores: Anemia, Oral Manifestations, Jaw Abnormalities e seus correspondentes na língua portuguesa. Revisão de literatura: Os distúrbios anêmicos associados aos sinais e sintomas orofaciais incluem principalmente a Anemia Ferropriva, Megaloblástica, de Fanconi, Falciforme, Talassemia e Anemia Aplástica. As manifestações variam de ardência e sintomatologia dolorosa em língua, palidez de lábios e mucosa, estomatite, glossite atrófica, queilite angular, suscetibilidade a candidíase e doença periodontal. Ainda, englobam-se as alterações dentárias, hipossalivação, má oclusão, osteomielite da mandíbula, parestesia do nervo mental e dor orofacial. Conclusão: Essas alterações podem ser os primeiros sinais da presença da anemia, o que confere ao cirurgião-dentista um importante papel no seu diagnóstico precoce e condução adequada ao tratamento odontológico.

Discriminant indexes to simplify the differential diagnosis between iron deficiency anemia and thalassemia minor in individuals with microcytic anemia

SUMMARY INTRODUCTION: Microcytic anemias are very common in clinical practice, with iron deficiency anemia (IDA) and thalassemia minor (TT) being the most prevalent. Diagnostic confirmation of these clinical entities requires tests involving iron metabolism profile, hemoglobin electrophoresis, and molecular analysis. In this context, several discriminant indices have been proposed to simplify the differential diagnosis between IDA and TM. OBJECTIVE: The aim of this paper was to demonstrate the clinical relevance of the use of discriminant indices in individuals with microcytic anemia to simplify the differential diagnosis between iron deficiency anemia and minor thalassemia. METHODS: A bibliographic and cross-sectional search was performed in the PubMed, SciELO and LILACS databases, using the following descriptors: iron deficiency anemia, thalassemia minor, and differential diagnosis. RESULTS: More than 40 mathematical indices based on erythrocyte parameters have been proposed in the hematological literature in individuals with microcytosis. Green & King indexes (IGK), Ehsani index, and erythrocyte count (RBC) had excellent performances, especially when their efficacy was observed in adults and children. CONCLUSIONS: Confirmatory tests for differential diagnosis between IDA and TM require time-consuming and costly methods. Despite the excellent performances of IGK, Ehsani index, and RBC, none of them presented sufficient sensitivity and specificity to establish a diagnosis. However, they can provide a powerful additional tool for diagnostic simplification between IDA and TM.

RESUMO INTRODUÇÃO: Anemias microcíticas são muito comuns na prática clínica, sendo a anemia ferropriva (AF) e a talassemia menor (TM) as mais prevalentes. A confirmação diagnóstica dessas entidades clínicas requer testes que envolvem o perfil do metabolismo do ferro, eletroforese de hemoglobinas e análises moleculares. Nesse contexto, vários índices discriminantes têm sido propostos para simplificação do diagnóstico diferencial entre AF e TM. OBJETIVO: O objetivo deste artigo foi demonstrar a relevância clínica da utilização de índices discriminantes em indivíduos com anemia microcítica, para simplificação do diagnóstico diferencial entre anemia ferropriva e talassemia menor. MÉTODOS: Foi realizada uma pesquisa bibliográfica e transversal nas bases de dados PubMed, SciELO e Lilacs, utilizando-se os seguintes descritores: anemia ferropriva, talassemia menor e diagnóstico diferencial. RESULTADOS: Mais de 40 índices matemáticos baseados em parâmetros eritrocitários foram propostos na literatura hematológica em indivíduos com microcitose. Os índices de Green & King (IGK), o índice de Ehsani e a contagem de eritrócitos (RBC) obtiveram excelentes desempenhos, especialmente quando sua eficácia foi observada em adultos e crianças. CONCLUSÕES: Testes confirmatórios para o diagnóstico diferencial entre AF e TM demandam métodos que consomem bastante tempo e alto custo. Apesar dos excelentes desempenhos do IGK, do índice de Ehsani e do RBC, nenhum deles possui sensibilidade e especificidade suficientes para firmar diagnóstico. No entanto, podem fornecer uma poderosa ferramenta adicional para simplificação diagnóstica entre AF e TM.

Screening de hemoglobina en una población de lactantes / Hemoglobin screening test in a population of infants / Teste de triagem de hemoglobina em uma população de lactentes

La deficiencia de hierro es la causa más frecuente de anemia en pediatría. Su detección precoz, tratamiento correcto y profilaxis adecuada, constituyen una prioridad sanitaria en nuestro país. Objetivo: Describir el screening de hemoglobina realizado en lactantes con edades comprendidas entre 8 y 12 meses, usuarios de un centro de atención pediátrico de Montevideo, en el período comprendido entre 2 de mayo y 31 de octubre de 2015 y evaluar factores de riesgo de anemia ferropénica presentes. Se revisaron sus historias clínicas, consignando datos epidemiológicos, antecedentes perinatales, alimentación recibida y si recibieron suplementación con hierro adecuada. Se registró si se había realizado la medición de hemoglobina por punción digital y el valor medido. Se comparó la prevalencia de factores de riesgo entre niños con y sin anemia. En el período evaluado fueron asistidos 62 niños: 3 pretérminos de 34 semanas o menos; 15 con peso al nacer menor a 3000 gramos; 42 con lactancia materna exclusiva durante 6 meses; 54 con alimentación complementaria adecuada; 45 con suplementación de hierro. Se realizó la medición de hemoglobina por punción digital a 55 niños. Tenían anemia 28 niños (82 % leve). No se encontró asociación de padecer anemia con los factores de riesgo estudiados excepto el cumplimiento de la profilaxis con suplemento de hierro. Concluimos que la prevalencia de anemia en este grupo fue elevada y que la suplementación con hierro es importante para su prevención.

Iron deficiency is the most frequent cause of anemia in pediatrics. Its early detection, correct treatment and adequate prophylaxis, constitute a health priority in our country. Objective: Describe the hemoglobin screening performed in infants aged between 8 and 12 months, users of a pediatric care center from Montevideo, in the period covered between May 2 and October 31, 2015 and evaluate factors of Risk of iron deficiency anemia present. Their clinical histories were reviewed, including epidemiological data, perinatal records, and diet received and if they received adequate iron supplementation. It was recorded if the hemoglobin measurement had been performed by digital puncture and the measured value. The prevalence of risk factors among children with and without anemia was compared. In the evaluated period, 62 children were assisted: 3 preterm subjects of 34 weeks or less; 15 birth weight less than 3,000 grams; 42 exclusive breastfeeding for 6 months; 54 adequate complementary feeding; 45 iron supplementation. The hemoglobin was measured by digital puncture to 55 children. 28 of them had anemia (82 % mild). No association of anemia was found with the risk factors studied except compliance with prophylaxis with iron supplementation. We conclude that the prevalence of anemia in this group was high and that iron supplementation is important for its prevention.

A deficiência de ferro é a causa mais frequente de anemia em pediatria. Sua detecção precoce, tratamento correto e profilaxia adequada constituem uma prioridade de saúde em nosso país. O objetivo do presente trabalho é descrever a prevalência de anemia em um centro de atendimento de primeiro nível e os fatores de risco associados. Foi realizado um estudo observacional, descritivo, retrospectivo, incluindo crianças entre 8 e 12 meses de idade, que receberam controle sanitário entre maio e outubro de 2015. Suas histórias clínicas foram revisadas, incluindo dados epidemiológicos, registros perinatais e dieta recebida. e se receberam suplementação adequada de ferro. Foi registrado se a medição de hemoglobina foi realizada por punção digital e o valor medido. A prevalência de fatores de risco entre crianças com e sem anemia foi comparada. No período avaliado, 62 crianças foram atendidas: 3 prematuros de 34 semanas ou menos; 15 peso ao nascer inferior a 3000 g; 42 amamentação exclusiva por 6 meses; 54 alimentação complementar adequada; 45 suplementação de ferro. A hemoglobina foi medida por punção digital para 55 crianças. Eles tiveram 28 crianças anemia (82 % leve). Não foi encontrada associação de anemia com os fatores de risco estudados, exceto a adesão à profilaxia com suplementação de ferro. Conclui-se que a prevalência de anemia nesse grupo foi alta e que a suplementação de ferro é importante para sua prevenção.

Reacción decidual endometrial: un efecto inesperado del dispositivo intrauterino liberador de Levonorgestrel. Reporte de caso / Decidual endometrial reaction: an unexpected effect of the levonorgestrel-releasing intrauterine device. Case report

RESUMEN La reacción decidual que se genera en el endometrio involucra el estroma y las glándulas, esta ocurre por sobre estimulación de la progesterona en el tejido. Es inducida por el dispositivo liberador de levonogestrel, el cual es utilizado para el tratamiento de la hemorragia uterina anormal en mujeres postmenopáusicas. Sin embargo, dada su amplia gama terapéutica, sus efectos secundarios no siempre son predecibles y no existe mucha evidencia en la literatura que correlacione la susceptibilidad de la paciente con la aparición de este cuadro morfológico. Se presenta un reporte de caso de mujer posmenopáusica que recibió este tratamiento por 17 meses y presento una reacción decidual exagerada con el objetivo de dar a conocer la presentación histopatológica de la reacción decidual poco documentada y aumentar los conocimientos relacionados con el dispositivo intrauterino.

ABSTRACT The decidual reaction that is generated in the endometrium involves the stroma and the glands, this occurs due to over stimulation of progesterone in the tissue. It is induced by the levonogestrel-releasing device, which is used for the treatment of abnormal uterine bleeding in postmenopausal women. However, given its wide therapeutic range, its side effects are not always predictable and there is not much evidence in the literature that correlates the patient's susceptibility to the appearance of this morphological case. We present a case report of a postmenopausal woman who received this treatment for 17 months and presented an exaggerated decidual reaction in order to publicize the histopathological presentation wich is poorly documented and increase knowledge related to the intrauterine device.

Guía de práctica clínica para el diagnóstico y manejo de la anemia en pacientes con enfermedad renal crónica / Clinical practice guideline for the diagnosis and management of anemia in patients with chronic kidney disease

La Guía de Práctica Clínica (GPC) tratará sobre la el diagnóstico y manejo de la anemia asociada a ERC en el paciente adulto, en el ámbito de todos los niveles de atención, servicios o unidades que presten servicios de a pacientes con Enfermedad Renal Crónica, en lo que corresponda a cada nivel.

Necesidades de investigación para el diagnóstico de anemia en poblaciones de altura / Diagnosis of anemia in populations at high altitudes

Tanto la deficiencia como la sobrecarga de hierro son situaciones que ponen en riesgo la salud y la vida de las personas, por lo que es importante mantener su homeostasis. Como la hemoglobina contiene 70% del hierro del organismo, la OMS recomienda su medición para determinar la prevalencia de anemia por deficiencia de hierro (ID), a pesar que ellos mismos reconocen que la anemia no es específica de ID. Como la hemoglobina aumenta con la altitud de residencia, la OMS recomienda corregir el punto de corte para definir anemia en la altura. Una objeción a esta corrección es que el aumento de la hemoglobina en la altura no es universal ni aumenta de manera lineal. Además, las poblaciones de mayor antigüedad generacional tienen menos hemoglobina que las más recientes. En infantes, niños, gestantes y adultos, la prevalencia de anemia usando hemoglobina corregida es 3-5 veces mayor que usando marcadores del estatus de hierro. Los programas estatales buscan combatir la anemia mediante la suplementación de hierro; no obstante, resultan ineficaces, especialmente en las poblaciones de altura. Entonces, ¿hay deficiencia de hierro en la altura? Los niveles de hepcidina sérica, hormona que regula la disponibilidad de hierro, son similares a los de nivel del mar indicando que en la altura no hay deficiencia de hierro. Un problema adicional al corregir la hemoglobina por la altura, es que las prevalencias de eritrocitosis disminuyen. En conclusión, la corrección del punto de corte de la hemoglobina en la altura para determinar deficiencia de hierro es inadecuada.

Iron deficiency and overload are risk factors for numerous poor health outcomes, and thus the maintenance of iron homeostasis is vital. Considering that hemoglobin contains 70% of the total iron in the body, the World Health Organization (WHO) recommends the measurement of iron levels to calculate the rate of iron deficiency anemia (IDA), although WHO recognizes that IDA is not the only cause of anemia. As hemoglobin increases with altitude, WHO recommends correcting the cut-off point to define anemia at high altitudes. An objection to this correction is that the increase in hemoglobin at high altitudes is not universal and is not linear. In addition, individuals in older age groups have lower hemoglobin levels than those in younger age groups. In infants, children, pregnant women, and adults, the prevalence of anemia using corrected hemoglobin is 3-5 times higher than that using markers of iron status. State programs seek to control anemia by means of iron supplementation. However, these programs are ineffective, particularly for high-altitude populations. Therefore, the occurrence of iron deficiency at high altitudes is controversial. The serum levels of the hormone hepcidin, which regulates iron availability, are similar in individuals at high altitudes to those of individuals at sea level, indicating that iron deficiency does not occur at high altitudes. An additional problem when correcting hemoglobin at high altitudes is that the frequency of erythrocytosis is decreased. In conclusion, the correction of the cut-off point of hemoglobin at high altitudes to determine iron deficiency is inadequate.

Anemia ferropénica en niños menores de un año usuarios de CASMU-IAMPP: prevalencia y factores asociados / Iron deficiency anemia in children younger than 1 year old users of CASMU-IAMPP: prevalence and associated factors

Resumen Introducción: la anemia ferropénica es un problema de salud nacional. Existen recomendaciones para su prevención. Para su diagnóstico temprano se incorporó a partir de 2014 la medición de la hemoglobina por punción digital entre los 8-12 meses de edad. Objetivo: determinar la prevalencia de anemia en lactantes usuarios de CASMU-IAMPP e identificar factores asociados. Material y métodos: se estudiaron lactantes entre 8-12 meses, a quienes se realizó medición de hemoglobina por punción digital, entre julio-diciembre 2014. Se describió la prevalencia de anemia. Se describieron las características de los niños con anemia y se compararon con las de un grupo control de niños sin anemia. Resultados: en el período evaluado se realizó hemoglobina digital a 95% de los lactantes entre 8-12 meses, 18,3% presentaba anemia. El 65,9% incorporó carne a la alimentación en forma tardía, 28,6% recibía dosis incorrecta de hierro suplementario y 23,4% no adhería al tratamiento. Los niños con anemia, en comparación con el grupo control, no presentaron mayor prevalencia de prematurez, peso al nacer menor a 3000 g, embarazo gemelar, anemia en el embarazo, suplementación con hierro en el embarazo, pecho directo exclusivo durante 6 meses, o inicio adecuado de alimentación complementaria. En los niños con anemia se detectó una falla en el inicio oportuno de la suplementación con hierro en dosis adecuada así como una mala adherencia al tratamiento. Discusión: debe alertar un 20% de niños con anemia en una población seleccionada en general con recursos económicos adecuados. Se debe insistir en la incorporación temprana de carne a la alimentación e inicio adecuado de la suplementación con hierro en dosis adecuada recomendando una buena adherencia al tratamiento.

Summary Introduction: iron deficiency anemia is a health problem in Uruguay. In 2014, hemoglobin measurement by digital puncture in infants between 8 and 12 months was introduced as a screening method for early diagnosis. Objective: to determine anemia prevalence in infants between 8 and 12 months in the institution (CASMU-IAMPP), and to identify associated factors. Method: infants between 8 and 12 months were studied with hemoglobin measurement by digital puncture from July to December of 2014. The characteristics of the children with anemia were described and compared with the control group. The data were obtained from the medical record and by means of a telephone survey. Results: 804 children were evaluated with hemoglobin measurement by digital puncture, 145 presented anemia (18.03%). The characteristics presented by children with anemia (n=143) were compared with the control group of children without anemia (n=143). There was no significant difference in the distribution by sex, prematurity prevalence, weight under 3.000 g, twin pregnancy, exclusive breastfeeding, and adequate initiation of replacement treatment. Children with anemia presented problems in the initiation of iron supplementation, doses of supplementary iron were adequate, although adherence to treatment was bad (p<0.05). Discussion: the fact that 20% of children from a socio-economic sector with adequate resources have anemia is rather alarming. Early consumption of meat and adequate initiation of iron supplementation in the right doses must be encouraged, as well as a good adherence to treatment.

Diagnóstico de la deficiencia de hierro: aspectos esenciales / Diagnosis of iron deficiency: essencial features

Se estima que un tercio de la población mundial es anémica, la mayoría por deficiencia de hierro. La anemia por deficiencia de hierro es la etapa final de un prolongado periodo de balance negativo del mineral. Aunque es raro que esta anemia sea causa de muerte, su impacto sobre la salud es significativo. En los adultos, se asocia con fatiga, síndrome de las piernas inquietas, pica, etc; en los neonatos, con retraso del crecimiento y desarrollo y; en los adolescentes, con disminución del aprendizaje y alteraciones conductuales. No existe una prueba única para diagnosticar la deficiencia de hierro; aunque la disminución de la ferritina sérica o de la saturación de la transferrina, con una capacidad total de fijación de hierro elevada, son elementos sugestivos. Se revisan las características clínicas y de laboratorio de esta entidad(AU)

It is estimated that one-third of the world's population is anemic, the majority being due to iron deficiency. Iron deficiency anemia is the result of a large negative iron balance period. Iron deficiency anemia rarely causes death, but the impact on human health is significant. In adults, it is associated with fatigue, restless legs syndrome, pica; in neonates, delayed growth and development and, in adolescents, decrements in learning and behavioral abnormalities. No single test is diagnostic of ID unless the serum ferritin is low or the percent transferring saturation is low with an elevated total iron binding capacity are suggestive. Clinical and laboratory features of the disease are discussed(AU)

¿Puede usarse el receptor soluble de transferrina para diagnosticar anemia ferropénica y evaluar la respuesta al hierro en lactantes con desnutrición aguda moderada? / Can soluble transferrin receptor be used in diagnosing iron deficiency anemia and assessing iron response in infants with moderate acute malnutrition?

Objetivo. Evaluar la eficacia del receptor soluble de transferrina (RST) en el diagnóstico de la anemia ferropénica (AF) y en la evaluación de la respuesta al hierro en los lactantes con desnutrición aguda moderada (DAM). Población y métodos. Se reclutó a lactantes con valores de hemoglobina (Hb) inferiores a los valores umbrales de anemia para su edad y con anemia hipocrómica/microcítica observada en el frotis de sangre periférica. La DAM se definió como un puntaje Z de peso/estatura de entre < -2 y -3. Se compararon los valores del hemograma, los parámetros férricos y el RST entre 41 lactantes con DAM y anemia (grupo DA), 32 lactantes con anemia sin DAM (grupo A) y controles saludables (n= 30). Una vez completado el tratamiento de la anemia y la desnutrición, se repitieron las evaluaciones. Resultados. Además de los índices hematológicos compatibles con AF, los valores de hierro sérico (Fe) y saturación de transferrina (ST) eran significativamente menores, mientras que el valor de transferrina era significativamente mayor en los grupos DA y A en comparación con los controles (p < 0,001). Los valores de ferritina y proteína C-reactiva (PCR) eran significativamente más elevados en el grupo DA (p < 0,05 para la ferritina, p < 0,01 para la PCR). El valor medio del RST fue similar en ambos grupos (DA y A) (p > 0,05) y significativamente mayor que en los controles (p < 0,001). Después del tratamiento con hierro, el RST disminuyó en los grupos DA y A (p < 0,001) a valores similares a los observados en los controles. El RST se correlacionó negativamente con la Hb durante todo el estudio (grupo DA: r= -0,350, p < 0,05; grupo A: r= -0,683, p < 0,01). Conclusiones. Dado que los valores del RST en los grupos DA y A disminuyeron después del tratamiento con hierro, consideramos que este parámetro no estuvo afectado por la DAM ni la inflamación y puede usarse, por sí solo, para detectar la AF y supervisar la respuesta al tratamiento en los lactantes con DAM.

Objective. To evaluate the efficacy of soluble transferrin receptor (sTfR) in diagnosing iron deficiency anemia (IDA) and evaluating iron response in infants with moderate acute malnutrition (MAM). Population and methods. Infants withhemoglobin (Hb) levels lower than threshold values for anemia for their ages and hypochromic/ microcytic anemia on peripheral smear were recruited. MAM was defined as weight/height z score < -2 to -3. Complete blood count (CBC), iron parameters and sTfR were compared among 41 infants with MAM and anemia (MA group), 32 infants with anemia without MAM (group A), and healthy controls (n= 30). Following anemia and malnutrition treatment, tests were repeated. Results. Besides hematological indices compatible with IDA, serum iron (Fe) and transferrin saturation (TS) were significantly lower, while transferrin was significantly higher in MA and A groups compared to controls (p <0.001). Ferritin and C-reactive protein (CRP) were significantly higher in MA group (p <0.05 ferritin, p <0.01 for CRP). Mean sTfR was similar in both MA and A groups (p >0.05) and significantly higher than controls (p <0.001). Following iron treatment, sTfR decreased inboth MA and A groups (p <0.001) to similar values as controls. sTfR was negatively correlated to Hb throughout the study (for MA group, r= -0.350, p <0.05; for A group, r= -0.683, p <0.01). Conclusions. As sTfR values in both MA and A groups decreased following iron treatment, we believe that this parameter was not influenced by MAM or inflammation; and it alone can be used to detect IDA and monitor treatment response in infants with MAM.

Anemia ferropénica en niños menores de 5 años / Iron-deficiency anemia in children under 5 years

Introducción: El hierro es un componente esencial de la hemoglobina, junto con el ácido fólico y la vitamina B12, cuya función es esencial en la oxigenación del organismo. La anemia es una de las principales manifestaciones de los problemas nutricionales en el país y la asociación a parasitismo, incrementa la deficiencia de hierro. Entre los grupos que pueden tener grandes demandas en hierro se tienen a los bebés prematuros, los que no lactaron y los adolescentes. Objetivo: Exponer las revisiones bibliográficas sobre la anemia ferropénica en niños menores de 5 años. Resultados: La deficiencia de hierro es la causa más frecuente de anemia en el niño, observándose en mayor medida en edad preescolar, especialmente entre los 6 y 24 meses de edad. El estado nutricional de hierro de una persona depende del balance determinado por la interacción entre contenido en la dieta, biodisponibilidad, pérdidas y requerimientos por crecimiento. El tratamiento debe apuntar a corregir la anemia, almacenar hierro en depósitos y corregir la causa primaria. Conclusiones: La estrategia ideal para prevenir la deficiencia de hierro consiste en practicar la lactancia materna exclusiva por 6 meses, con la administración de sales de hierro a partir del tercero o cuarto mes de vida. A partir de los 6 meses de edad, la alimentación complementaria debe basarse en cereales suplementados con hierro (fumarato ferroso) y en la carne o su jugo como alimentos primarios

Introduction: Iron is an essential component of hemoglobin, along with folic acid and vitamin B12, whose function is essential in the oxygenation of the body. Anemia is one of the main manifestations of nutritional problems in the country and the association with parasitism increases iron deficiency. Among the groups that may have great demands on iron are premature babies, those who did not breastfeed and adolescents. Objective: To present the bibliographic reviews on iron deficiency anemia in children under 5 years of age. Results: Iron deficiency is the most frequent cause of anemia in the child, being observed to a greater extent in pre-school age, especially between 6 and 24 months of age. The nutritional status of a person's iron depends on the balance determined by the interaction between content in the diet, bioavailability, losses and requirements for growth. Treatment should aim to correct anemia, store iron in deposits and correct the primary cause. Conclusions: The ideal strategy to prevent iron deficiency is to practice exclusive breastfeeding for 6 months, with the administration of iron salts from the third or fourth month of life. From 6 months of age, supplementary feeding should be based on cereals supplemented with iron (ferrous fumarate) and in meat or its juice as primary foods

Severe iron deficiency anaemia caused by hookworm infestation - a case report - case report

Iron deficiency anaemia is a common clinical problem referred to gastroenterologists for diagnostic evaluation. While hookworm infestation is a known cause of chronic gastrointestinal blood loss, affected patients are usually asymptomatic and only 10% develop anaemia.1,2 Herein we present a case of recurrent profound iron deficiency anaemia caused by hookworm infestation

A new index to discriminate between iron deficiency anemia and thalassemia trait

BACKGROUND: The most common microcytic and hypochromic anemias are iron deficiency anemia and thalassemia trait. Several indices to discriminate iron deficiency anemia from thalassemia trait have been proposed as simple diagnostic tools. However, some of the best discriminative indices use parameters in the formulas that are only measured in modern counters and are not always available in small laboratories. The development of an index with good diagnostic accuracy based only on parameters derived from the blood cell count obtained using simple counters would be useful in the clinical routine. Thus, the aim of this study was to develop and validate a discriminative index to differentiate iron deficiency anemia from thalassemia trait. METHODS: To develop and to validate the new formula, blood count data from 106 (thalassemia trait: 23 and iron deficiency: 83) and 185 patients (thalassemia trait: 30 and iron deficiency: 155) were used, respectively. Iron deficiency, ß-thalassemia trait and a-thalassemia trait were confirmed by gold standard tests (low serum ferritin for iron deficiency anemia, HbA2 > 3.5% for ß-thalassemia trait and using molecular biology for the a-thalassemia trait). RESULTS: The sensitivity, specificity, efficiency, Youden's Index, area under receiver operating characteristic curve and Kappa coefficient of the new formula, called the Matos & Carvalho Index were 99.3%, 76.7%, 95.7%, 76.0, 0.95 and 0.83, respectively. CONCLUSION: The performance of this index was excellent with the advantage of being solely dependent on the mean corpuscular hemoglobin concentration and red blood cell count obtained from simple automatic counters and thus may be of great value in underdeveloped and developing countries.

THE PREVALENCE OF CELIAC DISEASE IN PATIENTS WITH IRON-DEFICIENCY ANEMIA IN CENTER AND SOUTH AREA OF IRAN

Background - Celiac disease is an immune-mediated enteropathy due to a permanent sensitivity to gluten in genetically susceptible people. Iron-deficiency anemia is the most widely experienced anemia in humans. Iron-deficiency anemia additionally is a common extra intestinal manifestation of celiac disease. Objective - To investigate correlation between tTg levels and histological alterations and then to determine the prevalence of celiac disease in Center and South area patients of Iran with iron deficiency anemia. Methods - A total of 402 patients aged 12-78 years who presented with iron-deficiency anemia were included in this study. Hemoglobin, mean corpuscular volume and serum ferritin were determined. Venous blood samples for anti-tissue transglutaminase antibody immunoglobuline A and G were obtained from these patients. Upper gastrointestinal endoscopy was recommended to patients who had positive serology. Results - Of 402 patients with iron-deficiency anemia, 42 (10.4%) had positive serology for celiac disease. The small intestine biopsy of all patients with positive serology showed pathological changes (Marsh I, II & III). There was not significant difference in the mean hemoglobin level between iron-deficiency anemia patients with celiac disease and without celiac disease, duodenal biopsy results did not show significant relationship between the severity of pathological changes and levels of anti-tTG IgG (P -value: 0/869) but significant relationship was discovered between pathological changes and levels of anti-tTG IgA (P -value: 0/004). Conclusion - Screening of celiac disease by anti-tissue transglutaminase antibody should be completed as a routine investigation in patients with iron-deficiency anemia. Also physicians must consider celiac disease as a possible reason of anemia in all patients with iron deficiency anemia.

Contexto - A doença celíaca é uma enteropatia imunomediada, devido a uma sensibilidade permanente ao glúten em pessoas geneticamente suscetíveis. A anemia por deficiência de ferro é a anemia mais frequente em seres humanos e, além disso, é uma manifestação extra intestinal comum da doença celíaca. Objetivo - Investigar a correlação entre níveis de imunoglobulina de anticorpos anti-transglutaminase tissular A (anti-tTG IgA) e G (IgG anti-tTG) e alterações histológicas e, em seguida, determinar a prevalência de doença celíaca no Centro e Sul do Irã em pacientes com anemia por deficiência de ferro. Métodos - Foram incluídos neste estudo um total de 402 pacientes com idades entre 12-78 anos, que apresentavam anemia por deficiência de ferro. Hemoglobina, volume corpuscular médio e ferritina sérica foram determinados. Amostras de sangue venoso para imunoglobulina de anti-tTG IgA e IgG anti-tTG foram obtidas nestes pacientes. Endoscopia gastrointestinal foi recomendada para pacientes que tiveram sorologia positiva. Resultados - Dos 402 pacientes com anemia por deficiência de ferro, 42 (10,4%) tiveram sorologia positiva para doença celíaca. A biópsia do intestino delgado de todos os pacientes com sorologia positiva mostrou alterações patológicas (Marsh I, II e III). Não houve diferença significativa no nível de hemoglobina média entre os pacientes com deficiência de ferro com ou sem a doença celíaca. O resultado da biopsia duodenal não mostrou relação significativa entre a gravidade das alterações patológicas e níveis de IgG anti-tTG (P -valor: 0/869), mas descobriu-se relação significativa entre as alterações patológicas e níveis de anti-tTG IgA (P -valor: 0/004). Conclusão - A pesquisa de doença celíaca por dosagem de anticorpo anti-transglutaminase tissular deve ser completada como investigação de rotina em pacientes com anemia por deficiência de ferro. Os clínicos devem considerar a doença celíaca como um possível causa de anemia em todos os pacientes com anemia ferropriva.

Guía de práctica clínica para el diagnóstico y tratamiento de la anemia por deficiencia de hierro en niñas, niños y adolescentes en establecimientos de salud del primer nivel de atención / Clinical practice guideline for the diagnosis and treatment of iron deficiency anemia in children and adolescents in primary care health facilities

Contribuir en la mejora del estado de salud de las niñas, niños y adolescentes en el marco de la atención integral de salud. Estandarizar los criterios técnicos para el diagnóstico y tratamiento de la anemia por deficiencia de hierro en las niñas, niños y adolescentes em establecimientos de salud del primer nivel de atención.