Variable hematologic presentation of autoimmune gastritis: age-related progression from iron deficiency to cobalamin depletion

Blood ◽  
2006 ◽  
Vol 107 (4) ◽  
pp. 1673-1679 ◽  
Author(s):  
Chaim Hershko ◽  
Aaron Ronson ◽  
Moshe Souroujon ◽  
Itzhak Maschler ◽  
Judith Heyd ◽  
...  
Keyword(s):  
Iron Deficiency ◽  
Pernicious Anemia ◽  
Macrocytic Anemia ◽  
Gastrin Level ◽  
Autoimmune Gastritis ◽  
Cobalamin Deficiency ◽  
Deficiency Anemia ◽  
Age Cohorts ◽  
Age Related ◽  
Autoimmune Polyendocrine Syndrome

Iron deficiency is a known complication of achlorhydria and may precede the development of pernicious anemia. Among 160 patients with autoimmune gastritis identified by hypergastrinemia and strongly positive antiparietal antibodies, we explored the overlap between 83 subjects presenting with iron deficiency anemia (IDA), 48 with normocytic indices, and 29 with macrocytic anemia. Compared with macrocytic patients, patients with IDA were 21 years younger (41 ± 15 years versus 62 ± 15 years) and mostly women. All groups had a high prevalence of thyroid disease (20%) and diabetes (8%) suggestive of the autoimmune polyendocrine syndrome. Stratification by age cohorts from younger than 20 years to older than 60 years showed a regular and progressive increase in mean corpuscular volume (MCV) from 68 ± 9 to 95 ± 16 fl, serum ferritin levels from 4 ± 2 to 37 ± 41 μg/L, gastrin level from 166 ± 118 to 382 ± 299 pM/L (349 ± 247 to 800 ± 627 pg/mL), and a decrease in cobalamin level from 392 ± 179 to 108 ± 65 pg/mL. The prevalence of Helicobacter pylori infection was 87.5% at age younger than 20 years, 47% at age 20 to 40 years, 37.5% at 41 to 60 years, and 12.5% at age older than 60 years. These findings challenge the common notion that pernicious anemia is a disease of the elderly and imply a disease starting many years before the establishment of clinical cobalamin deficiency, by an autoimmune process likely triggered by H pylori.

The Hidden Face of Pernicious Anemia: Age-Related Progression of Autoimmune Gastritis from Iron Deficiency to Cobalamin Depletion.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 3603-3603
Author(s):  
Chaim Hershko ◽  
Aharon Ronson ◽  
Moshe Souroujon ◽  
Yzhak Maschler ◽  
Judith Heyd ◽  
...  
Keyword(s):  
Iron Deficiency ◽  
Atrophic Gastritis ◽  
Pernicious Anemia ◽  
Serum Gastrin ◽  
Screening Method ◽  
Intrinsic Factor ◽  
Autoimmune Gastritis ◽  
Deficiency Anemia ◽  
Age Cohorts ◽  
H Pylori

Abstract Because gastric acid secretion is critical for food iron absorption, iron deficiency is a known complication of the achlorhydria associated with pernicious anemia at presentation or following cobalamin (Cbl) treatment. In a previous study employing high serum gastrin and strongly positive antiparietal cell antibodies as a screening method for autoimmune atrophic gastritis, we have found a very high (27%) prevalence of atrophic gastritis among young subjects with iron deficiency anemia (IDA). The objectives of the present study were to explore the degree of overlap between patients presenting with atrophic gastritis and microcytic (MVC<80 fl) IDA on one hand, and those presenting with Cbl deficiency and normocytic (MCV 80–100 fl) or macrocytic (MCV>100 fl) anemia typical of pernicious anemia. Of 160 patients diagnosed with autoimmune gastritis presenting with iron, Cbl, or combined deficiency over the years 2001–2005, 83 presented with microcytic IDA, 48 with normocytic and 29 with macrocytic indices. Serum Cbl was abnormal in 100% of macrocytic, 92% of normocytic and 46% of microcytic subjects. IDA patients were 21 y younger (41 ±15 vs 62±15 y), predominantly female (78 vs 41%) and with a higher proportion of active H pylori infection (42 vs 21%). However, there were also marked similarities between all subgroups including a high prevalence of thyroid disease (20%) and diabetes (8%) known for their association with the autoimmune polyendocrine syndrome, and the rate of anti-intrinsic factor positivity was the highest (42% vs 31%) among IDA patients. Stratification by age cohorts from <20 to >60 y showed a very regular correlation, with progressive increase in MCV from 68±9 to 119±8 fl, serum ferritin from 4±2 to 37±41 μg/L, hypergastrinemia from 349±247 to 800±627 u/mL (normal 61±17), and a progressive decrease of Cbl from 392±179 in the youngest, to 108±65 pg/mL in the oldest age cohort. The prevalence of H pylori infection was 87.5% at age <20 y, 47% at 20–40 y, 37.5 % at 41–60 y and 12.5% at age > 60y implying a spontaneous elimination of H pylori by achlorhydria of increasing severity and duration. H pylori eradication by triple therapy in 24 patients resulted in a decrease in serum gastrin from 476±391 to 218±220 u/mL (paired t-test=0.00086) within 19± 12 months and complete remission of pernicious anemia in 2 patients. These findings challenge the common notion that pernicious anemia is a disease of the elderly manifested in megaloblastic anemia, and imply a disease starting many years before the establishment of clinical Cbl deficiency through an autoimmune mechanism directed against gastric parietal cells, likely triggered by H pylori by means of antigenic mimicry. Because of the added strain of young age and fertility on iron requirements, IDA may precede Cbl deficiency by many years until the crucial loss of remaining intrinsic factor in a proportion of patients terminating in typical pernicious anemia.

How I treat unexplained refractory iron deficiency anemia

Blood ◽  
2014 ◽  
Vol 123 (3) ◽  
pp. 326-333 ◽  
Author(s):  
Chaim Hershko ◽  
Clara Camaschella
Keyword(s):  
Celiac Disease ◽  
Iron Deficiency ◽  
Iron Deficiency Anemia ◽  
Young Patients ◽  
Autoimmune Gastritis ◽  
Cobalamin Deficiency ◽  
Deficiency Anemia ◽  
Strong Impact ◽  
Age Cohorts ◽  
H Pylori

AbstractEndoscopic gastrointestinal workup fails to establish the cause of iron deficiency anemia (IDA) in a substantial proportion of patients. In patients referred for hematologic evaluation with unexplained or refractory IDA, screening for celiac disease, autoimmune gastritis, Helicobacter pylori, and hereditary forms of IDA is recommended. About 4% to 6% of patients with obscure refractory IDA have celiac disease, and autoimmune gastritis is encountered in 20% to 27% of patients. Stratification by age cohorts in autoimmune gastritis implies a disease presenting as IDA many years before the establishment of clinical cobalamin deficiency. Over 50% of patients with unexplained refractory IDA have active H pylori infection and, after excluding all other causes of IDA, 64% to 75% of such patients are permanently cured by H pylori eradication. In young patients with a history suggestive of hereditary iron deficiency with serum ferritin higher than expected for IDA, mutations involving iron trafficking and regulation should be considered. Recognition of the respective roles of H pylori, autoimmune gastritis, celiac disease, and genetic defects in the pathogenesis of iron deficiency should have a strong impact on the current diagnostic workup and management of unexplained, or refractory, IDA.

Resolving the Riddle of Obscure Iron Deficiency Anemia.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 371-371
Author(s):  
Chaim Hershko ◽  
Julian Patz ◽  
Aharon Ronson
Keyword(s):  
Iron Deficiency ◽  
Atrophic Gastritis ◽  
Iron Deficiency Anemia ◽  
Reproductive Age ◽  
Autoimmune Gastritis ◽  
Deficiency Anemia ◽  
Age Cohorts ◽  
Iron Treatment ◽  
H Pylori ◽  
Autoimmune Atrophic Gastritis

Abstract Conventional endoscopic and radiographic methods fail to identify a source of gastrointestinal blood loss in about one third of males and post-menopausal females and in most women of reproductive age with iron deficiency anemia (IDA). Such patients are often referred for hematologic evaluation. In recent years there is increasing awareness of non-bleeding conditions with abnormal iron absorption as possible causes of unexplained IDA. Both H pylori gastritis and autoimmune atrophic gastritis are associated with impaired gastric acidity interfering with iron absorption. In a prospective study performed in a community hematology clinic, 300 consecutive IDA patients were screened for non-bleeding GI conditions including celiac disease (antiendomysial antibodies), autoimmune atrophic gastritis (hypergastrinemia with strongly positive antiparietal cell antibodies) and H pylori gastritis (IgG antibodies confirmed by urease breath test). Their mean age was 39±18 y, and 251 of 300 (84%) were women. A likely cause of IDA was identified in 93% of patients. As expected in a population of females of reproductive age, only 10% had a source of gastrointestinal bleeding identified. There were 13 new cases of adult celiac disease (4%). A history suggestive of menorrhagia was present in 32%. Autoimmune atrophic gastritis was documented in 77 IDA patients (26%) of whom 39 had coexistent H pylori infection. H pylori infection was the only positive finding in 57 patients (19%). To exclude the compounding effect of menstrual blood loss in evaluating the role of H pylori in the pathogenesis of IDA, we have focused on the 29 male IDA patients with negative gastrointestinal workup, poor initial response to oral iron treatment, and a high prevalence of H pylori infection (25 of 29). Following H pylori eradication, all patients achieved normal hemoglobin levels with follow-up periods ranging from 4 to 69 months (38±15 months mean± 1SD). This was accompanied by a significant decrease in H pylori IgG antibodies and serum gastrin. Sixteen patients discontinued iron treatment, maintaining normal hemoglobin and ferritin and may be considered cured. Remarkably, 4 of the 16 achieved normal hemoglobin without ever having received oral iron after H pylori eradication. To define the relation between IDA-associated autoimmune gastritis, and pernicious anemia, we studied 160 patients with autoimmune gastritis including 83 subjects presenting with IDA, 48 presenting with normocytic indices, and 29 with macrocytic anemia. Stratification by age cohorts of autoimmune gastritis from <20 to >60 y showed coexistent H pylori infection in 87.5% at age <20 y, 47% at 20–40 y, 37.5% at 41–60 y, but only 12.5% at age > 60y. With increasing age cohorts, there was a regular and progressive increase in MCV from 68±9 to 95±16 fl, serum gastrin from 349±247 to 800±627 u/mL, and a decrease in cobalamin from 392±179 to 108±65 pg/mL. Conclusions: The favorable long-term clinical results of H pylori eradication offer strong evidence for a cause-and-effect relation between H pylori and IDA. A proportion of H pylori patients will develop autoimmune gastritis. Our findings in autoimmune gastritis imply a disease presenting as IDA many years before the establishment of clinical cobalamin deficiency. It is likely caused by an autoimmune process triggered by antigenic mimicry between H pylori epitopes and major autoantigens of the gastric mucosa. Recognition of H pylori and autoimmune gastritis as common causes of obscure iron deficiency anemia should have a strong impact on the efficacy of diagnostic workup and management of unexplained, or refractory iron deficiency anemia.

scholarly journals Prevalence of Iron Deficiency Anemia in Anemic Patients: A Hospital Based Study

2018 ◽  
Vol 6 (2) ◽  
pp. 41-45 ◽  
Author(s):  
Satyendra Kumar Mishra ◽  
Surendra Marasini ◽  
Badri Kumar Gupta ◽  
Krishna Kumar Agrawal ◽  
Narayan Gautam
Keyword(s):  
Iron Deficiency ◽  
Iron Deficiency Anemia ◽  
Serum Ferritin ◽  
Iron Status ◽  
Macrocytic Anemia ◽  
High Rate ◽  
Deficiency Anemia ◽  
Peripheral Smear ◽  
Significant Difference ◽  
Detailed Medical History

Introduction: In developing countries like Nepal, iron deficiency anemia (IDA) is one of the major concern. The high rate incidence has been related to insufficient  iron  intake, accompanied  by chronic  intestinal  blood  loss  due  to parasitic  and  malarial infections. Therefore, a study was conducted to evaluate the prevalence of IDA in anemic patients of Universal College of Medical Sciences-Teaching Hospital (UCMS-TH), South Western region, Nepal. Material and Method It was a hospital based cross sectional study comprised of 100 anemic patients. Their detailed medical history and lab investigations, focusing on hematological parameters were documented. Peripheral smear examination and serum ferritin estimation were done to observe red cell morphology and iron status respectively.  Results: This study revealed that out of 100 anemic patients, 35% were that of IDA. The most affected age group was 21-40 years with frequency 42.55%. IDA was more common in females (42.85%) than in male (21.62%). Out of 100 anemic patients, microcytic hypochromic anemia was predominant in 47% followed by macrocytic anemia (31%) and then normocytic normochromic anemia (22%). Out of 47 microcytic hypochromic anemic patients, 12 had normal serum ferritin. There was a statistical significant difference in Hb (p=0.011), MCV (p=0.0001), MCH (p=0.0001), MCHC (p=0.0001) and serum ferritin (p=0.0001) among all types of anemia. There was a statistical significant positive correlation of ferritin with Hemoglobin (0.257, p= 0.01), MCV (0.772, p= 0.0001), MCH (0.741, p=0.0001) and MCHC (0.494, p=0.0001).  Conclusion: The peripheral smear in conjunction with serum ferritin estimation needs to be included for susceptible individuals to screen the IDA and other types of anemia. 

B₁₂-deficiency anemia in the work of the nurse

2021 ◽  
pp. 76-80
Author(s):  
Vsevolod Vladimirovich Skvortsov ◽  
Anastasia Romanovna Ponomareva
Keyword(s):  
Bone Marrow ◽  
Pernicious Anemia ◽  
Megaloblastic Anemia ◽  
Macrocytic Anemia ◽  
Neurological Symptoms ◽  
Deficiency Anemia ◽  
Morphological Abnormalities ◽  
Clinical Symptomatology

B₁₂-deficiency anemia (megaloblastic anemia, pernicious anemia, Addison-Birmer disease), characterized by progressive hyperchromic, macrocytic anemia, hypersegmentation of neutrophil nuclei, megaloblastic erythropoiesis and morphological abnormalities of other hematopoietic growths in the bone marrow; Unlike other anemias, B₁₂-deficiency anemia is often associated with the development of pathological psycho-neurological symptoms (funicular myelosis).This article deals with problems of etiology, pathogeny, clinical symptomatology, approaches to detection and treatment of B₁₂-deficiency anemia.

Prevalence of Iron Deficiency and Iron Deficiency Anemia in Syrian Infants

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 5975-5975
Author(s):  
Lama A Youssef ◽  
Issam N Albaroudi ◽  
Majed Khodder
Keyword(s):  
Iron Deficiency ◽  
Iron Deficiency Anemia ◽  
Complete Blood Count ◽  
Conflicts Of Interest ◽  
Binding Capacity ◽  
Primary Care Clinic ◽  
Macrocytic Anemia ◽  
Cow Milk ◽  
Deficiency Anemia ◽  
Care Clinic

Abstract Background: Iron deficiency (ID), with or without anemia, is the most common micronutrient malnutrition problem worldwide. Iron deficiency anemia (IDA) in infancy is linked to long-term motor and cognitive deficits. Infants and children in developing countries are particularly vulnerable to ID due to a negative iron balance resulting from increasing demands for growth that surpass dietary supplies. Recently, health reports have emerged on rising child malnutrition due to shortages of children’s foods and medicines in Syria. Nevertheless, factual data on prevalence are lacking. Objective: To estimate the prevalence of ID and IDA in a cohort of non-displaced Syrian infants living in Damascus between November, 2011 and March, 2013. Design/Methods: This was a prospective observational study conducted at the Children’s Hospital-based primary care clinic in Damascus. Information on type of feeding milk (maternal, iron-fortified formula or cow milk), and demographic characteristics was collected by face-to-face interviews with the parents of the study subjects. Hematological profile (complete blood count, reticulocytes and reticulocyte hemoglobin content (CHr)), and biochemical tests including serum ferritin and iron, and total iron-binding capacity were carried out. ID and IDA were diagnosed according to the 2010 American Academy of Pediatrics guidelines. Results: Out of 155 infants assessed for eligibility, 135 infants met the inclusion criteria and were evaluated for iron deficiency. The average age was 12.4 ± 5.5 months (mean ± SD), and female to male ratio was 57:78. Only 31 (23%) of the study subjects were iron sufficient and not anemic, whereas 97 (72%) had ID, 75 (55.5%) had IDA, and 7 (5.2%) had non-iron deficiency anemia (thalassemia, hemolytic anemia, and macrocytic anemia). Prevalence of ID was statistically higher in males than females (85.33% vs. 62.26% respectively) (P=0.003). IDA was more prevalent in infants living in the countryside (76.25%) in comparison with their urban peers (53.84%) (p=0.04). Unexpectedly, ID and IDA were similarly prevalent regardless of the predominant type of milk fed to the infants (P >>0.05). Conclusion: Our results unveil high prevalence of ID and IDA in Syrian infants between 2011 and 2013. Higher rates are expected in displaced infants and in remote regions of the country. These alarming findings call for immediate national and international collaborative efforts to provide iron supplementation and correct other existing malnutrition in Syrian children. Disclosures No relevant conflicts of interest to declare.

Serum erythropoietin (EST) titers in anemia

Blood ◽  
1981 ◽  
Vol 58 (6) ◽  
pp. 1164-1170 ◽  
Author(s):  
G de Klerk ◽  
PC Rosengarten ◽  
RJ Vet ◽  
R Goudsmit
Keyword(s):  
Bone Marrow ◽  
Iron Deficiency ◽  
Pernicious Anemia ◽  
Iron Deficiency Anemia ◽  
Megaloblastic Anemia ◽  
Hemoglobin Concentration ◽  
Significant Negative Correlation ◽  
Pure Red Cell Aplasia ◽  
Deficiency Anemia ◽  
Mouse Liver Cell

Erythropoietin (ESF) titers were determined in sera from patients with different types of anemia using the fetal mouse liver cell bioassay. An inverse relationship was found between hemoglobin concentration and ESF titer. However, ESF titers differed markedly between patients at comparable degrees of anemia. Several groups of patients were distinguished on the basis of the activity of their erythroid bone marrow. In each of these groups, a significant negative correlation was found between the hemoglobin concentration and the logarithm of the ESF titer. ESF titers in patients with pure red cell aplasia were fourfold higher than those in patients with iron-deficiency anemia and tenfold higher than those in patients with megaloblastic anemia and homozygous sickle cell anemia at comparable hemoglobin concentrations. Following the initiation of specific therapy in patients with pernicious anemia and patients wit iron-deficiency anemia, serum ESF titers were found to decrease prior to any substantial rise in hemoglobin concentrations. In the patients with pernicious anemia, the lowest ESF levels were found 1 day after administration of vitamin B12, whereas in the patients with iron-deficiency anemia, the lowest ESF levels were reached in the second week of oral iron therapy. ON the basis of these data it was concluded that serum ESF titers in anemic patients are not only inversely related to the hemoglobin concentration but also to the activity of the erythroid bone marrow.

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