Helicobacter pylori infection in children with refractory iron deficiency anemia [RIDA]

ABSTRACT

The prevalence of iron deficiency anemia [IDA] varies widely between developed and developing countries and is related to many factors. If iron therapy does not produce the expected results, patient compliance with the prescribed medication should be insured, and if confirmed, the diagnosis of IDA should be reevaluated. Continued iron therapy in the absence of iron deficiency can produce iron overload. Refractory Iron Deficiency Anemia accounts for about 15% of all IDA. Previous reports by many authors suggested that there was a relation between Helicobacter pylori [H. pylori] infection and IDA. The aim of the present work is to determine the prevalence of H. pylori infection among patients with RIDA, to describe the clinical presentation of H. pylori infection among these patients and to determine the value of serum immunoglobulin G, and immunohistochemistery in diagnosing H. pylori infection and finally to describe the histopathological changes in gasrtic biopsy of these patients. The study included 40 cases with RIDA [Hb < 10gm/dl, not responding to oral iron therapy for three months]. They were attending the Hematology unit and children hospital, Assuit University during the period June 2003 to May 2004. They were 31 males and 9 females and their ages ranged from 4 to 13 years. The study also included 10 apparently healthy children of matched age and sex as a control group. Children with positive Tuberculin test, PEM, malabsorption particularly Celiac disease, myeloproliferative, connective tissue disease and those with repeated overt blood loss were excluded from the study. In addition to careful history taking and thorough clinical examination, the following investigations were done complete blood picture, urine analysis, stool analysis for three consecutive days, stool analysis for occult blood, serum iron, TIBC, serum ferritin, Hb electrophoresis and serum IgG for H. pylori. Patients were subjected to upper gastrointestinal endoscopy and gastric biopsies were taken for Monoclonal antibody against H. pylori [1HC], and for pathological changes by H and E stain. Identification of H. pylori using other stains namely Giemsa and Leung was also done. Triple therapy was given to eradicate H pylori infection and follow up by hem atological profile and iron status was done. Out of the cases with RIDA, 40% were heart failure and 47.5% received repeated blood transfusion >4 times during the study period. Serum IgG for H. pylori was positive in 32.5% of cases and in 20% of the control. IHC staining for H. pylori was positive in 50%. Sensitivity of IgG for H. pylori was 60%, specificity was 95%, positive predictive value was 92%, negative predictive value was 70% and accuracy was 76%. There was significantly higher frequency of RAP among cases positive for H. pylori IgG than among negative ones. There was also a significantly higher frequency of anemic heart failure and repeated blood transfusion among positive cases for IgG than the negative ones. H. pylori organisms were detected in 50% of the cases by IHC staining. There was significantly higher frequency of positive IHC for H. pylori among cases > 6 years and among males. There was significantly higher frequency of RAP in the positive cases for H. pylori by IHC than in the negative cases. In addition, the frequency of cases with Hb heart failure, and repeated blood transfusion was significantly higher in the positive cases for H. pylori by IHC than in the negative cases. H. pylori could be detected by Giemsa stain in 37.5%, by Leung stain in 32.5% and by H and E stain in 25% of the cases. The frequency of chronic inflammatory cells in gastric biopsy was 77.5%, activity was present in 12.5%, atrophy was present in 7.5% and normal gastric biopsy was present in 22.5%. Lymphoid follicles were present in 7 cases. Eradication of H. pylori infection was followed by improvement of the hematological profile and iron status without iron therapy. H. pylori infection is not uncommon in cases with RIDA. The main presentation of H. pylori in the studied cases was RAP, anemic heart failure that needs repeated blood transfusion, indicating that RIDA with H. pylori is probably a severe form of anemia. IgG for H. pylori is not a reliable method for diagnosis of H. pylori infection in hospital based studies. IHC staining with specific monoclonal antibody against H. pylori is more accurate than other stains and even than serum IgG in identifying H. pylori infection and it is also more reliable to reveal the spiral shaped H. pylori or coccoid forms even with very low concentration. Endoscopic gastritis was the main presenting feature as shown by chronic inflammatory cells in the histopathological specimens. Cases of RIDA without an apparent cause have to be investigated for H. pylori infection. Eradication of H. pylori by oral triple therapy amoxicillin, clanithromycin and omeprazole for 2 weeks should be given in suspected cases with RIDA of unexplained etiology RIDA can be corrected by this therapy even without iron supplementation