A strange case of normocytic anemia

Abstract

This case-report underlines the difficulties of a correct diagnosis in a complex vitamin malnutrition that is seldom suspected in patients living in developed Countries with a good social and economic situation. A 79-year-old woman was admitted to hospital with progressive fatigue, dyspnea till orthopnea, pallor and lumbar pain. On physical examination the patient was awake, conscious and pale with severe dyspnea and the laboratory findings revealed severe anemia normochromic and normocytic; chest radiography shows cardiomegaly. An abdomen echography showed hepatomegaly and an increased gallbladder volume with multiple gallstones and “biliary mud”. The patients received infusion of 4 Units of blood and started terapy for secondary congestive heart failure. The third day the temperature increased till 39°C and the urine of the patient shown clear hematuria; considering the hypothesis of hemolytic anemia was started methylprednisolone EV. Blood analysis was made in order to clarify anemia etiology: low blood levels of Vit B12, hypersideremia and very low Unsatured Iron Binding Capacity. A further investigation revealed that her diet had exclusively consisted of potatoes and fresh cheese since years. We started therapy with VitB12 and Folate and the patient was discharge fourteen days after admission. We feel that the importance of this clinical case lies in the diagnostic investigation for the cause of anemia, often more difficult than generally perceived.