Catastrophic Hemorrhoids
Madina Mohammadi, MD
University of California, Davis Medical Center, Sacramento, CA
INTRODUCTION
DISCUSSION
We present an unusual case of profound anemia due to
chronic bleeding from hemorrhoids. In this clinical vignette
we present the common clinical manifestations of anemia
such as tachycardia, cardiomyopathy, hypoxia,
thrombocytosis and rare manifestations such as
thrombocytopenia and lactic acidosis.
• Untreated severe iron deficiency anemia can cause
high output heart failure as seen in this case.
• Cardiomyopathy of iron deficiency anemia is
reversible with iron supplementation.
• Inadequate tissue oxygenation in these patients can
cause hypoxia and lactic acidosis.
• Although iron deficiency anemia is commonly
associated with reactive thrombocytosis;
thrombocytopenia can be a rare presentation.
• Review of case reports show that thrombocytopenia is
only seen in severe iron deficiency anemia.
• Most patients with thrombocytopenia have normal
bone marrow aspirate. Decreased number of
megakaryocytes have been reported which resolved
with iron supplementation.
CLINICAL CASE
History of Present Illness
A 27 year old African American male presented with acute on
chronic fatigue, dyspnea on exertion, chest pain, light
headedness, palpitations and rectal bleed. He was admitted 3
years ago with similar presentation. His hemoglobin was
2.5g/dl on admission and he was diagnosed with severe iron
deficiency anemia.
Physical Exam
Table 1: CBC on prior admission
Figure 1:Hemoglobin recovery and platelet
“overshoot” after initiation of iron
Table 2:CBC on current admission;
before and after transfusion and
iron supplementation
Figure 2: Chest radiograph
showed cardiomegaly and
pulmonary congestion
Vitals were notable for heart rate of 110, respiratory rate of 25
and oxygen saturation of 88% on room air.
Exam was significant for tired, pale appearing man, grade 3/6
systolic flow murmur, guaiac positive stool.
Laboratory Studies
CBC as seen in Table 2; Ferritin 7ng/ml; Lactic acid 3.4mEq/ml
Clinical Course
The patient received packed red blood cells and iron infusion
which resolved his symptoms. On echocardiogram he was
found to have dilated cardiomyopathy. Extensive
gastrointestinal evaluation only revealed internal hemorrhoids.
Hematology evaluation revealed iron deficiency anemia. Bone
marrow biopsy was unremarkable. His symptoms, hypoxia and
lactic acidosis resolved with treatment.
Clinical Pearls
• Thrombocytopenia is a rare manifestation of severe
iron deficiency anemia.
• Bone marrow dysfunction should be ruled out in
patients with iron deficiency anemia and
thrombocytopenia.
• Platelet “overshoot” can occur prior to normalization
of platelets after iron supplementation.
• Dilated cardiomyopathy due to anemia is reversible.
• Follow up echocardiogram is recommended to
confirm resolution of cardiomyopathy.
REFERENCES
1. Van K. Morris, MD, Holly L. Spraker, MD, Thrombocytopenia with iron deficiency anemia. Pediatr Hematol Oncol, August 2010
2. Mahendra K. Gupta, MD, Gardith Joseph, MD, Severe thrombocytopenia associated with iron deficiency anemia. Hospital Physician, August 2001
3. Nikita, Hegde, MD, Michael W. Rich, MD, The cardiomyopathy of iron deficiency. Texas Heart Institute Journal. November 2006
4. L.M. Sanghvi, K.C. Kotia, S.K. Sharma, L. Circulatory dynamics after blood transfusion in chronic severe anemia. British Heart Journal, 1968
5. Alvares JF, Oak JL, Pathare AV, Evaluation of cardiac function in iron deficiency anemia before and after total dose iron therapy. Journal of the Association of physicians of India. February 2000.