Adolescent Anemia Evaluation

A 10-year-old of Middle Eastern ancestry , assigned female at birth, is seen for routine well child care. 

She is generally healthy and plays soccer, reporting excellent exercise tolerance, stating, “I’m the fastest midfield on the team.” Physical examination is within normal limits with Tanner stage 2. Height and weight are at 40% tile, consistent with previous measures. Laboratory evaluation reveals a mild microcytic hypochromic anemia with a NL RDW. This likely represents which of the following?

A. Vitamin B 12 deficiency

B. G6PD deficiency

C. Iron deficiency

D. Beta thalassemia minor

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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for students studying the pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Doctor Margaret Fitzgerald shares her knowledge and experience to help you 

dissect the anatomy of a test question, so you can better understand 

how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 10-year- old of Middle Eastern ancestry, assigned female at birth, is in for routine well-child care. She's generally healthy and plays soccer reporting excellent exercise tolerance, stating “I'm the fastest midfield on the team.” Physical exam is within normal limits with Tanner stage two. Height and weight are at the 40th percentile, consistent with previous measurements. 

Laboratory evaluation reveals a mild microcytic hypochromic anemia 

with a normal limit RDW. This likely represents: 

A: Vitamin B12 deficiency. 

B: G6PD deficiency. 

C: Iron deficiency. 

D: Beta thalassemia minor. 

The correct answer is D: Thalassemia minor. Where should you start with this question? First, let's determine what kind of a question this is. 

I know I've mentioned this in other podcasts, and you likely remember this from your studies. Anemia is technically not a diagnosis, but rather a clinical sign that can be caused by a variety of reasons. 

But even with that said, we're just going to call this a diagnosis question. And the other thing that I'd say for everybody pontificating that anemia is not a diagnosis. There are about a million ICD-9-I'm sorry, there are about a million ICD-10 codes for anemia as a diagnosis. 

First, as we typically do a little bit of background information, the thalassemia are genetically based blood conditions where the body produces altered hemoglobin to form. Hemoglobin is made from two proteins alpha and beta globin.  

The beta thalassemia occurs most often in people of Mediterranean, African, and Middle Eastern ancestry with some select Asian ancestry, 

and beta cell minor, aka sal minor or cell trait, and which one altered gene has been inherited. 

The result is a mild microcytic hypochromic anemia because there's no micronutrient deficiencies. The RDW or red blood cell distribution width is within normal limits, implying that new red blood cells are within normal size range when compared to the older sites. 

And in other words, with the normal limit RDW, there is no evolving 

Microcytic or macrocytic anemia. People with cell minor, whether it's 

alpha or beta, have no particular health risks. At the same time, prior to pregnancy, genetic counseling should be considered. 

With that in mind, let's take another look at the question. A 10-year-old of Middle Eastern ancestry, assigned female at birth, is seen for routine well-child care. She’s generally healthy and plays soccer reporting excellent exercise tolerance, stating “I'm the fastest midfielder on the team.” Physical exam is within normal limit. She's Tanner stage two. 

Height and weight are at the 40th percentile, consistent with previous measures. Laboratory evaluation reveals a mild microcytic hypochromic anemia with a normal limit RDW. 

This most likely represents which of the following:  

A: Vitamin B12 deficiency. This is incorrect. On hemogram, B12 deficiency presents as a macrocytic normochromic with a normal limit RDW. 

In addition, as with any other diagnosis, keep in mind who is most at risk for that condition? B12 deficiency is most often noted in adults 

over the age of 60, and commonly in with a person who has an autoimmune condition, such as type one diabetes or thyroid disease, and or is of Northern European ancestry. 

Pernicious anemia is the most common form of vitamin B12 deficiency seen in this country. Option B: G6PD deficiency. Well, she does have one possible risk for the development of G6PD deficiency, and that's Middle Eastern ancestry, one of the ethnic groups at risk for this condition. 

However, in the day to day was G6PD deficiency-this red blood cell condition does not cause any abnormalities in the immigrant. If you recall with G6PD deficiency, hemolysis is possible with exposure to certain oxidative stress is such a  

certain exposure, including trimethoprim-sulfmethoxazole-i.e., Bactrim or Nitrofurantion. 

I'll cover G6PD deficiency in another podcast. C: Iron deficiency. Now this is one of the two answers that looks possibly correct. And this is really where the crux is of answering this question correctly. But this is of course not the right answer. On hemogram iron deficiency anemia does present as a microcytic hypochromic anemia. However, the RDW is elevated that implies-with the elevated RDW that the new red blood cells are smaller and paler than the old red blood cells as the iron deficiency progresses. 

Also, iron deficiency anemia is really uncommon in children of this age. 

You might think, yes, but a 10-year-old girl can menstruate, which is a risk for developing IDA. But she's Tanner 2, and menstruation does not typically begin until 10 years. And if she had started her period, it 

probably would have been mentioned in the, history of present illness. Particular only if iron deficiency was the correct answer. 

D: Beta thalassemia minor. This is, of course, the correct answer, and cell minor, where the red blood cells are small and pale due to this genetic alteration in hemoglobin, the cells sizes are within normal limits of variability. Therefore, the RDW is normal. 

I'll cover confirmatory lab testing for this condition in an upcoming podcast. Key takeaway: knowledge of common hematologic conditions-how these present in immigrant and White groups are at greatest risk is a key component to competent practice and NP board success. 

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