An Iron Deficiency Anemia With the Normocytosis of Red Blood Cells: A Case Report

In most diagnostic approaches of anemia, iron deficiency anemia is usually categorized in the group of microcytic anemia. But in this report, we found a patient who had no microcytosis although she had definite iron deficiency anemia. She was a 73-year-old Thai patient who complained gradual fatigue and anorexia without fever for 2 weeks. Her concurrent diseases included diabetes mellitus, hypertension and hypercholesterolemia. Only marked pallor was found on the physical examination, the pulse rate was 88 beats/min, regularly. Blood tests showed hemoglobin (Hb) 7.0 mmol/L, white blood cell (WBC) 10 080/mm3, platelet 529 000/mm3, mean corpuscular volume (MCV) 81.5 fL, mean corpuscular hemoglobin (MCH) 25.5 pg, red blood cell distribution width (RDW) 14.4%, serum ferritin 6.5 µg/L, serum iron 3.94 µmol/L, total iron binding capacity (TIBC) 77.33 µmol/L, transferrin saturation 5.0%, creatinine 53 µmol/L, direct antiglobulin test-negative, and fasting blood sugar (FBS) 124 mmol/L. She was definitely diagnosed as having iron deficiency anemia and continuously treated with ferrous fumarate 200 mg, 2 tablets a day. Her endoscopy revealed one large ulcer at gastric antrum and she accepted subtotal gastrectomy. The pathology was moderately well differentiated adenocarcinoma of the stomach. Three months later, her blood was tested: Hb 11.1 mmol/L, MCV 83.7 fL, MCH 27.4 pg. Our case suggested that normocytic anemia in the elderly must not preclude investigations for the diagnosis of iron deficiency anemia. Otherwise not only the proper diagnosis of anemia such as iron deficiency might be missed but the serious underlying diseases of iron deficiency anemia such as malignancy will be overlooked also.