Atiq Saad, Mobley James M, Atiq Osman O, Atiq Mohammad O, Meena Nikhil
Miscellaneous, University of Arkansas for Medical Sciences, Little Rock, USA.
Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA.
Cureus. 2018 Nov 26;10(11):e3636. doi: 10.7759/cureus.3636.
Anemia is a frequently encountered problem in the healthcare system. Common causes of anemia include blood loss, followed by impaired red blood cell production and red blood cell destruction. This case demonstrates the need for cognizance of the less frequent causes of anemia. A 27-year-old male with a history of traumatic brain injury and quadriplegia with chronic respiratory failure on home ventilator support presented to the emergency department with dyspnea and no bowel movements for three days. The patient received nutrition via percutaneous endoscopic gastostromy (PEG) tube. He was hypotensive with a mean arterial pressure (MAP) of 54 mm/Hg. There was no evidence of acute or ongoing blood loss. Initial lab data revealed hyperkalemia (K+ 6.1), severe anemia (Hb 1.5 g/dL), leukopenia (2.53 K/uL), neutropenia (ANC 700), and normal platelets. Peripheral smear revealed leukopenia with absolute neutropenia, marked anemia with anisopoikilocytosis with rare dacrocytes but no evidence of schistocytes. He responded to transfusion with improvement in hemoglobin from 1.5 to 9.1 within 24 hours. There was no evidence of hemolysis or vitamin deficiency. Ferritin and triglyceride levels were ordered to rule out hemophagocytic lymphohistiocytosis (HLH). Ferritin was elevated at 6506 ng/mL and triglycerides were 123 mg/dL. Soluble IL-2 receptor level was sent and found to be significantly elevated; however, this was felt to be more likely secondary to infection and inflammation, as the patient had no other clinical features of HLH, apart from cytopenias. Zinc supplementation was part of his wound care regimen. Copper levels were <10 ug/dL (normal: 70-140). Zinc supplements were stopped, and the patient was started on copper supplementation. At his three month follow-up clinic appointment, his anemia and leukopenia had resolved. Micronutrient deficiency is a potential cause of anemia, especially in a risk population and must be considered, as it is often easily correctible.
贫血是医疗系统中经常遇到的问题。贫血的常见原因包括失血，其次是红细胞生成受损和红细胞破坏。本病例表明需要认识到贫血的罕见原因。一名27岁男性，有创伤性脑损伤和四肢瘫痪病史，在家用呼吸机支持下患有慢性呼吸衰竭，因呼吸困难和三天未排便而就诊于急诊科。患者通过经皮内镜下胃造瘘术（PEG）管接受营养。他血压低，平均动脉压（MAP）为54mmHg。没有急性或持续失血的证据。初始实验室数据显示高钾血症（血钾6.1）、严重贫血（血红蛋白1.5g/dL）、白细胞减少（2.53K/μL）、中性粒细胞减少（中性粒细胞绝对值700）和血小板正常。外周血涂片显示白细胞减少伴绝对中性粒细胞减少，明显贫血伴异形红细胞增多，罕见泪滴状红细胞，但无裂体细胞证据。他对输血有反应，血红蛋白在24小时内从1.5升至9.1。没有溶血或维生素缺乏的证据。检测铁蛋白和甘油三酯水平以排除噬血细胞性淋巴组织细胞增生症（HLH）。铁蛋白升高至6506ng/mL，甘油三酯为123mg/dL。检测可溶性白细胞介素-2受体水平，发现其显著升高；然而，由于患者除血细胞减少外没有HLH的其他临床特征，则认为这更可能是继发于感染和炎症。补锌是他伤口护理方案的一部分。铜水平<10μg/dL（正常：70-140）。停止补锌，并开始给患者补充铜。在他三个月的随访门诊预约中，他的贫血和白细胞减少已经缓解。微量营养素缺乏是贫血的一个潜在原因，尤其是在高危人群中，必须予以考虑，因为它通常很容易纠正。
