My Anemia

A 71-year-old retired physics professor was seen and evaluated in the Sarasota-Manatee area for anemia in early 2007.

He was initially noted to have anemia, leukocytosis, with low serum iron, but an elevated serum ferritin of over 500. A bone marrow examination was not performed per patient history. Nonetheless, a diagnosis of iron deficiency anemia with myeloproliferative syndrome was made. The patient stated that he received a total of 40 doses of IV iron on a weekly basis for iron deficiency. A bone scan done in early 2007 was interpreted as demonstrating metastatic disease. No further diagnostic or therapeutic plans were pursued despite abnormal findings. Complete medical records were requested and not received. The patient came to see me in 2008 for a second opinion stating,

“I HAVE RECEIVED 40 DOSES OF IV IRON. MY BONES HURT AND I FEEL TERRIBLE. WHY DO I FEEL SO BAD?”

[tabs tab1=”Diagnosis” tab2=”Significant Findings” tab3=”Pharmacology” tab4=”Management” tab5=”Comments” tab6=”Patient Update”]
[tab num=1]The patient, at the time of his initial patient visit, had a bone marrow examination. Marrow demonstrated markedly increased iron stores, no evidence of myeloproliferative disorder, and low grade B-cell non-Hodgkin’s Lymphoma.[/tab]
[tab num=2]Patient serum ferritin was elevated at over 1500. Marrow and serum findings taken together suggest marked iron overload in a patient who had repeatedly received IV iron. CT/PET fusion scan demonstrated stage 4 non-Hodgkins lymphoma with bone metastasis.[/tab]
[tab num=3]The patient’s lymphoma was treated with rituxan (monoclonal antibody targeting CD20+ B cells) and fludarabine. IV iron was obviously discontinued. Treatment for iron overload was initiated.[/tab]
[tab num=4]The patient had a diagnosis of stage 4 lymphoma likely present since early 2007 and was a likely contributory cause for patient’s anemia. No evidence for iron deficiency anemia or myeloproliferative disorder. Chemotherapy and Zometa started for metastatic disease to bone.[/tab]
[tab num=5]Patient’s stage 4 lymphoma has been treated and patient in Case of the month: September 2009 remission. He has significant iron overload. Treatment choices for iron overload are phlebotomy or treatment with oral exjade (deferasirox), an iron chelator. Cost of exjade is $5,734.95 per month at local retail pharmacies.[/tab]
[tab num=6]The patient co-pay for exjade is more than $2,000 per month. We are trying low intensity phlebotomy every 2 weeks.[/tab]
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