Iron Deficiency Anemia - Hypochromic Microcytic Anemia

Patient

Q: My girlfriend is 21 years old. She has been anemic for a long time. She occasionally has fainting spells. She complains of brittle nails occasionally. Recently she became very weak and was hospitalized for a week. She was given I/V iron everyday for a week. The diagnosis was Iron Deficiency Anemia, but the underlying condition was never found out.

1 MONTH AGO:

Her blood picture then (1 month ago):
Marked anisopoikilocytosis with normocytes, microcytes, ovalocytes, acanthocytes, fragmented RBCs and spherocytes. Moderate hypochromia. Polychromatic cells seen.
WBC count increased, neutrophils predominate.
Platelet count adequate, seen scattered, singly.
The report said that it was hypochromic microcytic anemia and hereditary hemolytic anemia was to be excluded.

An ultrasonography abdomen was done. Everything was normal but there was Cystitis. Urine culture was done and there was presence of bacteria in urine. She was given a course of Levofloxacin during her week of hospitalization.

She was also given i/v deriphylin and i/v iron during hospitalization.

Several tests were done and autoimmune conditions were excluded. Direct coomb’s test was negative.

She was given an endoscopy. No significant finding except Mallory Weiss tear in the esophagus. But that was probably due to trauma from the endoscope. She complained of pain in the throat during the endoscopy.

NOW:

She has chronic cough (Started a couple of months before hospitalization, it’s a lot better now) – tuberculosis was excluded by X ray as well as mantoux test and sputum culture.

She suffers from indigestion and vomiting (again a lot better now). Complains of nausea. (probable diagnosis of GERD but no one has confirmed anything so far. She is being given pantocid right now)

She complains of excessive pain during menstruation but the menstrual period lasts for only 4 days. Bleeding is not excessive according to her.

She vomited 2 days ago after lunch and had a fainting spell on the same day. She hit her head while falling. Complaining of headache now and then for the last couple of days.

I asked her to check Hb, TSH, Ferritin and LFT. Here TSH is normal -1.1 mIU/L. Ferritin levels are highly increased – 239.3 ng/ml.
Hb was around 9g/dl before hospitalization. Now it is 10.2 g/dl. Not much improvement is there?
LFT – the bilirubin levels keep increasing – it was 0.9, 1.34 and 1.70 during various points in the past month. The most recent value is 1.70 taken yesterday. 0.5 mg/dl direct bilirubin and 1.20 mg/dl indirect bilirubin. The sclera are slightly jaundiced.
This worries me.

Why isn’t her anemia improving? Why are the LFT values abnormal?
There is no tuberculosis, so why the cough?
Also the nausea and vomiting seems to be another problem. There are occasional complaints of nausea though they are much lesser than before. The thing is she was hospitalized for a week given a lot of medication and discharged. She has been on oral iron therapy thereafter. There isn’t significant improvement in hemoglobin levels. The bilirubin levels are elevated.
There is no autoimmune disease according to the tests, no H. pylori infection either.

Symptoms:  Pallor, icterus, coughing, nausea, vomiting
Doctor

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