Mystery of iron deficiency anemia

Rosy Zafar

I received a call from the laboratory informing me about the results of Mr D.’s bloodwork: his hemoglobin level was 75 g/L.

I have known Mr D. since I started my practice. He is a very pleasant man with chronic kidney disease and arthritis. On his first visit his gentle demeanor reminded me of my father, who died in his early 60s from a heart attack. I was only 11 years old when my father died. I have vivid memories of my father. I remember that he never lost his temper or raised his voice when most people would have. I remember him teaching me math very patiently the night before my grade 5 annual assessment and telling me the theories about the solar system and its origin. I cannot forget those lovely evenings when we snuggled in a blanket for bedtime stories. I remember the fun we had playing “20 Questions” together while he broke peanuts and pine nuts from their shells for me. Having someone in my office like Mr D. who had some undefined resemblance to my beloved father gave me an intangible pleasure. When I heard about Mr D.’s low hemoglobin level, I advised my secretary to call him for follow-up.

Mr D. arrived the next morning. After we discussed the usual causes of anemia, further bloodwork was done, a fecal occult blood test was ordered, and a transfusion was arranged owing to his subjective complaint of shortness of breath. I called him a week later to ask how he was doing. He was feeling well and was very pleased because of the quick resolution of his symptoms. Six months later he returned to the clinic because of shortness of breath and fever. This time he was seen by one of my residents. He also reported some chest pain associated with a cough. There was no past history of asthma or chronic obstructive pulmonary disease. He was a lifetime smoker. Based on his symptoms, a presumptive diagnosis of pneumonia was made and he was immediately sent for a chest x-ray scan for confirmation of the diagnosis. The results of the x-ray scan were not what I had expected. They revealed a large lung mass occupying the lower zone of the left lung and extending to the chest wall.

I called Mr D. once more to discuss his test results and tell him the bad news. A referral was made to the regional thoracic clinic. Histologic examination revealed that the mass was a non–small cell carcinoma, and further investigations showed that it had already metastasized. He was told by the oncologist that his life expectancy was 4 months without chemotherapy and 10 months with chemotherapy.

Mr D. asked me several questions and I tried to answer them to the best of my abilities. One question he never asked me was if things would have been different had I diagnosed his lung mass earlier. I’m not sure if I know the answer, but I am sure that I will now order a chest x-ray scan for anyone who presents with new-onset anemia requiring transfusion.