Iron deficiency anemia (IDA)

Vignette says a 35 year old woman presents to her primary care physician with a history of fatigue and generalized weakness over the past 6 months; She also complains of shortness of breath with mild physical exertion; Over the last few weeks, she has also developed cravings for ice and eats ice frequently; She is vegetarian by diet; Additionally, she has been experiencing rectal bleeding for the past several months and describes blood being present on the toilet paper after bowel movements and also on the surface of the stool; She denies any pain during bowel movements but has occasional anal itching and discomfort; She has a history of chronic constipation and has been straining during bowel movements for years; Per rectal examination (PRE) shows external hemorrhoids with mild rectal tenderness; Examination shows pallor in the skin and conjunctiva; There are no signs of lymphadenopathy or hepatosplenomegaly; CBC shows low hemoglobin and low MCV; Iron studies show ↓ferritin, ↑TIBC, ↓serum iron, ↓% saturation; Diagnosis?

Diagnosis is Iron deficiency anemia (IDA).

Iron deficiency anemia is defined as hemoglobin below two standard deviations of the mean for the age and gender of the patient.

Pathogenesis:- ↓iron →↓heme →↓hemoglobin → microcytic anemia

Etiologies are insufficient iron intake, decreased absorption, increased requirement or blood

loss.

Presents with features of anemia (i.e. pallor, fatigue, SOB, palpitations), koilonychia, and

pica; Associated with Plummer vinson triad (i.e. IDA, esophageal webs and dysphagia,

glossitis).

Diagnosis:-

1. CBC shows low hemoglobin, microcytic and hypochromic RBCs with ↑red cell distribution

width and MCV < 80.

2. Iron profiling shows ↓ferritin, ↑TIBC, ↓serum iron, ↓% saturation. ↑Soluble transferrin

receptor (STFR) is elevated in IDA as in IDA there is an increased number of transferrin

receptors as they try to acquire more iron to compensate for deficiency.

3. ↑ Free erythrocyte protoporphyrin.

4. Mentzer index >13 suggests IDA; Mentzer index is MCV/RBC (million/uL).

Management:-

1. Iron supplementation (e.g. oral, intravenous); oral iron (e.g. Ferrous sulfate) is given along

with vitamin C to facilitate iron absorption; Reticulocytes are the first of improvement in iron

deficiency anemia.

2. Treat the underlying cause.

Kawasaki disease

Vignette says a 5 year old female child presents to the emergency department with history of high grade fever and red eyes for 6 days; Examination shows red, cracked tongue, red lips, and a faint maculopapular rash initially on the trunk that has now spread to her limbs; Her palms and soles are red and swollen, and she has enlarged bilateral cervical lymph nodes; Laboratory studies show elevated inflammatory markers (i.e. elevated CRP and ESR); Echocardiography shows coronary artery aneurysms; Diagnosis?

Diagnosis is Kawasaki disease. 

Kawasaki disease (aka mucocutaneous lymph node syndrome) is an acute, self-limited medium vessel vasculitis of an unknown etiology commonly affecting children.

Fever for at least 5 days with any 4 out of the 5 “CRASH” features.
Conjunctivitis
Rash (polymorphous, non vesicular on trunk and extremities)
Adenopathy (i.e. bilateral non-suppurative cervical lymphadenopathy)
Strawberry tongue
Hands/Feet edema and erythema 

Diagnosis:-
1. CBC shows leukocytosis.
2. Inflammatory markers (e.g. CRP, ESR) are elevated.
3. Echocardiography shows coronary artery aneurysms.

Treatment:- Aspirin + IVIG is the mainstay of treatment and should be initiated within the first 10 days of fever onset; IVIG is given at 2 g/kg in a single infusion and high dose aspirin is given at 80–100 mg/kg/day during the acute phase of the disease; The dose is gradually reduced to 3–5 mg/kg/day when the patient has been afebrile for over 48-72 hours.

Complication:- Coronary artery aneurysms and Myocardial infarction.

Atrial fibrillation

Vignette says a 55 year old female presents to the emergency department with a sudden onset of palpitations that started 30 minutes ago; She describes the sensation as her "heart racing" and feels lightheaded and dizziness but denies chest pain, shortness of breath or syncope; She states that she had similar episodes in the past that resolved spontaneously; She has a history of coronary artery disease; Vital signs show pulse rate of 180 beats/min, blood pressure of 110/70 mm of Hg, respiratory rate of 16 breaths/min, oxygen saturation of 96% in RA and temperature of 98.2 F; Laboratory studies show CBC, serum electrolytes, BMP, TSH and HbA1C within normal limits; ECG shows absent P waves, irregularly irregular rhythm (i.e. irregular R-R interval) and narrow QRS complexes; Transesophageal echocardiography shows thrombus in the left atrium; Diagnosis?

Diagnosis is Atrial fibrillation. 

Atrial fibrillation

Types:- 
1. Paroxysmal AFib:- Episodes of AFib shorter than 7 days, either self terminated or cardioverted (usually self terminated within 48 hours, often triggered in pulmonary veins). 2. Persistent AFib:- Episodes of AFib longer than 7 days, either self terminated or cardioverted. 
3. Long standing persistent AFib:- AFib lasting more than 1 year and rhythm control strategy is being adopted. 
4. Permanent AFib:- Episodes of AFib where no more rhythm strategy is adopted (i.e. as the rhythm is unresponsive). 

Presents with palpitations, SOB, syncope, and features of underlying conditions (e.g. stroke, sepsis, thyrotoxicosis). 

Causes:- 
1. Ischemic heart disease 
2. HTN 
3. Thyrotoxicosis 
4. Mitral stenosis or mitral regurgitation 
5. Alcohol 
6. OSA 

Diagnosis:- 
1. ECG shows absent P waves, irregularly irregular rhythm (i.e. irregular R-R interval), narrow QRS complex and tachycardia. 
2. Echocardiography (TEE or TTE) is done prior to cardioversion to prevent embolic stroke. 
3. Cardiac Monitor
4. EPS

Management:- 
1. Rate control:- Beta blockers (e.g. metoprolol, carvedilol, atenolol), non-dihydropyridine CCBs (e.g. verapamil, diltiazem) and Digoxin (in patients with CHF).
2. Rhythm control:- Pharmacological cardioversion (e.g. ibutilide, amiodarone, flecainide) or electrical cardioversion (DC 200J biphasic); It helps to return to sinus rhythm; Immediate cardioversion is deployed if the AFib has been present for less than 48 hours or the patient are hemodynamically unstable whereas delayed cardioversion is deployed if the AFib has been present for more than 48 hours and the patient are hemodynamically stable. 

What are the options for cardioversion for new-onset atrial fibrillation or atrial fibrillation of uncertain duration? 
· TEE prior to cardioversion while on effective anticoagulation with at least 4 weeks of therapeutic anticoagulation to follow (continue indefinitely if suggested by stroke risk).
· Alternatively, may therapeutically anticoagulate for at least 3 weeks prior to cardioversion and continue for at least 4 weeks afterwards, in lieu of TEE.

3. Anticoagulation:- Warfarin, DOACs (e.g. apixaban, rivaroxaban); CHA2DS2VASc is a clinical tool for prescribing anticoagulants in patients with nonvalvular atrial fibrillation; Congestive heart failure (1), Hypertension (1), Age ≥75 years (2), Diabetes (1), Stroke/TIA (2), Vascular disease e.g. previous myocardial infarction or peripheral arterial disease (1), Age 65-74 years (1), Sex category female (1). In non-valvular AFib, warfarin or Novel oral anticoagulants (NOACs) is indicated when CHA2DS2-VASc score ≥2 in men and ≥3 in women and should be considered CHA2DS2-VASc score >1 and >2 in men and women respectively. In valvular AFib, warfarin should be considered and targeted INR should be 2-3. 

4. Percutaneous ablation of pulmonary veins (i.e. pulmonary vein isolation) is first line for symptomatic paroxysmal atrial fibrillation. Catheter ablation for atrial fibrillation in patients with heart failure was associated with a significantly lower rate of a composite end point of death from any cause or hospitalization for worsening heart failure than was medical therapy (i.e. CASTLE HTx TRIAL).

5. Percutaneous left atrial appendage occlusion (if patients are contraindicated for long term anticoagulation therapy) i.e. Watchman, Watchman-FLX and Amlet devices. Percutaneous left atrial appendage occlusion is recommended in AF patients with a risk of stroke who have contraindications to long term anticoagulation. For high bleeding risk (HAS-BLED is greater than or equal to 3 if DOAC contraindicated.

6. Surgical ablation in patients with concomitant plan for cardiac surgery (e.g.maze procedure).
HAS-BLED score monitors a patient’s risk of major bleeding whilst on anticoagulation (i.e. Bleeding risk associated with anticoagulation); H - Hypertension, A - Abnormal renal and liver function, S - Stroke, B - Bleeding, L - Labile INRs (whilst on warfarin), E - Elderly, D - Drugs or alcohol; HAS-BLED score ≥ 3 (indicates high risk of bleeding).

Figure:- Management Guidelines of Atrial Fibrillation