ABSTRACT

TO STUDY THE FREQUENCY OF IRON DEFICIENCY ANAEMIA,IT'S CLINICAL PRESENTATIONS AND

IT'S CORRELATION WITH HAEMATOLOGICAL

AND BIOCHEMICAL PARAMETERS.

THESIS

SUBMITTED IN PARTIAL FULFILLMENT OF

THE REQUIREMENTS FOR THE DEGREE OF

DOCTOR OF MEDICINE IN PATHOLOGY

BY

DR. MANOHAR PRADHAN, MBBSMAHARAJGUNJ CAMPUS & T. U. TEACHING HOSPITAL

INSTITUTE OF MEDICINE

TRIBHUVAN UNIVERSITY

KATHMANDU, NEPAL

JANUARY 2000

Certificate

This is to certify that the work of

Dr. Manohar Pradhan on

"To study the frequency of

iron deficiency anaemia,

it's clinical presentations

and its correlation with

Haematological and

Biochemical parameters"

was conducted in

Department of Pathology

and Department of Biochemistry

under our supervision and guidance.

DR. SUSHEILA DALI MR. BHARAT JHA

Preceptor, Co-guide,

Professor and Head, Associate Professor,

Department of Pathology Department of Biochemistry

Maharajgunj Campus and T.U. Teaching Hospital

Maharajgunj, Kathmandu

Nepal

Declaration

This thesis has not been submitted in candidature for any other degrees. Reproduction or transmission of this thesis, in any form or by any means, electronic, mechanical, photocopying including inter-library loans for outside organizations has been granted.

DR. MANOHAR PRADHAN

Dedicated

To

My Parents,

Brothers,

Friends

And

Pathologist

ACKNOWLEDGEMENT

It is with sincere gratitude and pleasure that I acknowledge the invaluable assistance of many kind individuals in the completion of this thesis. Foremost among those to whom I am deeply indebted is my preceptor Professor Dr. Susheila Dali, who has been most supportive with valuable comments and corrections during the course of my work. I am also much indebted to the co-ordinator of MD Pathology and Dean of Institute of Medicine Professor Dr. Hari Govinda Shrestha for his resourceful and constructive advice to accomplish the task. I owe a great debt to my co-guide Assistant Dean and Associate Professor Bharat Jha for his kind guidance and much needed assistance in Biochemistry evaluation.

Special thanks and gratitude are due to Dr. Gita Sayami and Dr. Bidur Osti for their kind guidance and to Dr. Bijayee Shrestha for her invaluable suggestions and helping in literature searches. I also acknowledge my colleagues in Pathology Dr. Rang Bahadur Basnet, Dr. Viswa jeet Amatya, Dr. Bandana Sigdel, Dr. Ram Chandra Adhikari, Dr. Ashok Joshi, Dr. Jagat Singh Pandey and Dr. Reeta Devi Bashyal for being most gracious and resourceful in my effort.

I also acknowledge with gratitude the stimulus of all medical laboratory technologists and technicians, who have helped me in so many ways during my work. For her extra effort, I express my deepest gratitude and sincere appreciation to Mrs. Puspa Bista, without whose help my work would not have been complete. I owe many thanks to Associate Professor Shyam Sunder Malla, Head, Department of Biochemistry, for providing biochemistry lab for biochemical investigation. I am also grateful to Mr. Shree Ram Sharma, Mr. Keshab Parajuli, Mr. Ram Chandra Subedi, Mrs. Purna Maya Rana, Mr. Ram Bahadur Shrestha, Mr. Arun Bajra Bajracharya, Mrs. Jayanti Dhaubadel, Miss Krishna Shrestha, Mr. Diwas Shrestha, Mr. Sameer Jha, Mr. Pramod Raut, Mr. Sumeru Pradhan, Mr. Bijaya Jha, Miss Rushila Chitrakar, Mr. Madhav and Mr. Shiva Ram Budhathoki. In addition, I am grateful to Mr. Chinta Mani Sharma of Microbiology Department for his kind permission to use deep freezer.

I am most appreciative and grateful to Dr. Rajni Mahto, Dr. Eli Pradhan, Dr. Kanchan Koirala, Dr. Man B. KC and Dr. Anil Pahari for all their assistance in referring the associated cases to me.

I would also like to give thanks to my best friend Er. Birendra Raj Pandey, who have taught me to appreciate and apply the statistical analysis in computer. Also I sincerely appreciate the assistance of Neeraj Shrestha for his invaluable contribution in searching literature in Internet. Not to be forgotten are my brothers Er. Harihar Pradhan and Biswambhar Pradhan and my parents for being unfailing source of cheerfulness and encouragement. And finally my thanks to PGMECC for contributing the funds required to accomplish my task.

DR. MANOHAR PRADHAN

ABSTRACT

Iron deficiency Anaemia (IDA) is the most common cause of anaemia not only in Nepal but even worldwide. A prospective study was conducted in Tribhuvan University Teaching Hospital from April 1998 to March 1999 to determine the frequency of iron deficiency anaemia in anaemic patients. Blood samples from 100 anaemic patients (58 men and 42 women) and 12 controls were analyzed. Haematological parameters like Haemoglobin, MCV (mean corpuscular volume), MCH (mean corpuscular haemoglobin), MCHC (mean corpuscular haemoglobin concentration), and other routine haemogram were studied. Biochemical parameters like serum iron, serum ferritin and percentage saturation of transferrin were also determined. Out of 100 anaemic patients 36 had all the three biochemical parameters decreased and were diagnosed as iron deficiency anaemia. In IDA, the mean Haemoglobin was 6.42 gm/dl, MCV was 76.44 fl, MCH was 20.43 pg, MCHC was 27.34%. The mean serum iron was 21.85 (g/dl, mean serum ferritin was 8.94, mean percentage saturation of transferrin was 5.83% and mean total iron binding capacity was 406.47 (g/dl. Bone marrow examination was performed in 37 patients. 22 patients had grade 0 and 15 patients had grade 1+ iron in the bone marrow as demonstrated by Prussian blue stain. Significant correlation was observed between haemoglobin level with MCHC, percentage saturation of transferrin and total iron binding capacity. ANOVA (Analysis of variance) showed significant p value in IDA and control in all haematological parameters and three biochemical parameters. Analysis between IDA and anaemia with no biochemical parameters decreased showed significant difference in all the haematological and biochemical parameters. ANOVA showed significant stastical difference in all the haematological and biochemical parameters except serum ferritin and TIBC between anaemic patients with decreased any two of the three biochemical parameters and control. Analysis of variance test between anaemia with only one of three biochemical parameter decreased and control showed that this group does not have iron deficiency. ANOVA between bone marrow with and without iron granules showed statistical significance in all biochemical parameters, Haemoglobin, MCH and MCV emphasizing reliability of bone marrow iron staining for diagnosing iron deficiency anaemia.

CONTENTS

Cover pagei

Certificateii

Declarationiii

Dedicationiv

Acknowledgev

Abstractvii

Contentsix

Abbreviationx

List of Tablexi

List of figurexiii

Introduction1

Historical Background 3

Epidemiology5

Etiology8

Clinical Manifestations14

Laboratory Evaluation of Iron Deficiency Anaemia19

Aims and Objectives25

Materials and Methods26

Results37

Discussion51

Conclusion56

Index

I. Proforma58

II. Photographs61

Bibliography66

ABBREVIATIONS

IDA Iron deficiency anaemia

Non-IDA Non iron deficiency anaemia

MCV

Mean corpuscular volume

MCH

Mean corpuscular haemoglobin

MCHC Mean corpuscular haemoglobin concentration

TLC

Total leukocyte count

TRBC

Total red blood cell count

PCV

Packed cell volume

Hb

Haemoglobin

ELISA

Enzyme linked immunosorbent assay

TIBC

Total iron binding capacity

MPO

Myeloperoxidase stain

PAS

Periodic acid schiff stain

sTfR

Serum transferrin receptor

% S. Tra.Percentage saturation of transferrin

EZP

Erothrocyte zinc protoporphyrin

EP

Eyrthrocyte protoporphyrin

LIST OF TABLES

TABLE 1 Age Distribution of IDA, Non IDA and Control Patient.

TABLE 2Sex Distribution of IDA, Non-IDA and Control Patients.

TABLE 3 Showing Ethnic origin of IDA, Non-IDA and Control Patients.

TABLE 4 Occupation of the IDA, Non-IDA and Control Patients.

Table 5 The frequency of clinical features of IDA, Non-IDA and Control.

TABLE 6 Showing decreased haematological and biochemical parameters in control and study group

Table 7 Mean Haematological parameters of IDA, Non-IDA and Control.

TABLE 8Mean Biochemical parameters of IDA, Non-IDA and Control

TABLE 9 Showing haematological values in the patients with iron deficiency anaemia

TABLE 10 Showing Red cell morphology in Iron deficiency anaemia.

TABLE 11 Showing Grade of Iron in Bone marrow aspirates.

TABLE 12 Showing the finding of bone marrow examination in iron deficiency anaemia patients.

TABLE 13 Showing correlation of haemoglobin with haematological parameters

TABLE 14 Showing correlation of haemoglobin with biochemical parameters

TABLE 15 Analysis of Variance test showing p value of Biochemical & Haematological parameters between Control and all three biochemical parameters decreased

TABLE 16 Analysis of Variance test showing p value of Biochemical & Haematological parameters between All three