A spry and alert patient — a woman who was still working as a pianist and piano teacher at age 92 — came to see Marvin M. Lipman, Consumer Reports’ chief medical adviser, for a preoperative exam before having shoulder surgery. Her shoulder pain was seriously interfering with her musical activities.
She had been his patient for many years and had always enjoyed excellent health, but to the surprise of them both, a blood count done as part of the workup showed severe anemia. The surgery had to be canceled until Lipman could find a cause.
The most likely suspect was some sort of bleeding, possibly caused by the ibuprofen she had been taking for her sore shoulder. Even though her stools were negative for the presence of occult blood, Lipman had her undergo an upper endoscopy (the passage of a flexible lighted tube into the stomach), thinking that there might be an ulcer or irritation causing intermittent bleeding. Nothing was found. Perplexed, he referred her to a hematologist, or blood specialist.
Anemia is not a disease but a sign of one, and its causes are many. Under normal circumstances, our bone marrow incorporates iron into the protein hemoglobin (Hgb), the major component of red blood cells. Normal Hgb ranges from 13 to 15 grams percent (gms%) for men and 12 to 14 for women. The mature red blood cell is released to perform its oxygen-carrying work throughout the body and, like all our cells, ages and dies after about three months. Its iron is reused by the bone marrow to make new blood cells. Anemia occurs when the number of red blood cells drops below normal. And since the daily loss of iron (the major component of hemoglobin) is minimal, except with menstruation, anemia should always be regarded as abnormal. Unfortunately, the cause may go unidentified.
In the lab, anemia can be measured in three ways: by actually counting the red cells, by measuring the amount of hemoglobin in the blood serum, and by noting the hematocrit, or what percentage of the blood is made up of cells.
Though there are hundreds of causes, there are only three pathways by which anemia can develop. One is a problem in the bone marrow that impairs production of red blood cells. The second is a problem, called hemolysis, that shortens the life span of red blood cells. The third is a problem that leads to the loss of red blood cells from the body, of which the most obvious and common is blood loss.
Mild anemia is common, but moderate and severe anemia are less so. In an analysis by the National Center for Health Statistics, only 3 percent of women and 1.6 percent of men had a Hgb of less than 11. In one-third of them, a bone-marrow nutrient such as iron, Vitamin B12 or folate was lacking; in another third, the anemia was due to chronic kidney disease or chronic inflammation or infection; and for the rest, the cause was unknown.
The most common cause of anemia is iron deficiency due to blood loss. Excessive menstrual bleeding occurs in about 9 to 14 percent of pre-menopausal women. In men and post-menopausal women, bleeding from the gastrointestinal tract is the leading source. Internal bleeding can be caused by too-frequent use of nonsteroidal painkillers such as ibuprofen (Advil, Motrin and their generics), ulcerations and growths, including intestinal cancer. Iron deficiency also can result from poor intestinal absorption, as in celiac disease, or from inadequate dietary iron, although that is uncommon except among some people who are vegans.
Vitamin B12 deficiency is another common cause of anemia. B12 absorption is impaired in pernicious anemia, an autoimmune disorder; in gastrointestinal disorders, such as Crohn’s disease; and in about one-third of people older than 60. Red blood cell formation can also be affected when chronic kidney disease results in the decreased formation of erythropoietin, a bone-marrow stimulant made in the kidneys. Chronic infection also can cause bone-marrow depression, although it’s not as well understood.
Cancer can infiltrate the marrow and crowd out the normal blood-forming cells. And sometimes the red blood cells become coated with an antibody that causes them to hemolyze, or burst, in the bloodstream.
After a workup that included a bone-marrow biopsy, the pianist turned out to have low-grade lymphoma. With treatment, including transfusions, she improved, had shoulder surgery and resumed her beloved musical activities.
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