Case Study: Coexistent Vitamin D and Iron Deficiency in a Child

Summary

Iron deficiency is the most common nutritional deficiency worldwide, and vitamin D deficiency is a major global health issue. We present here the case of an 11-year-old boy with coexistent iron and vitamin D deficiency manifested as tiredness, leg cramps and a lack of visible weight gain over the last year. Laboratory tests revealed iron deficiency anaemia. Treatment for three months with oral iron tablets showed improvement in serum iron and vitamin D levels, although hemoglobin levels were still unchanged.

Background

Deficiency of iron and vitamin D in children may have long-lasting effects, even if the child is clinically asymptomatic. Documentary evidence is available of vitamin D deficiency in sickle cell anaemia. However, our patient had a normal hemoglobin HPLC report, thus excluding abnormal hemoglobins.

Case Presentation

An 11-year-old boy was brought to the pediatrician with complaints of tiredness, frequent leg cramps, white marks on nails and a lack of visible weight gain. On examination, the boy weighed 37 kg, and he was alert and jovial. The child was the only child of his parents and [s2If !is_user_logged_in()]…

[/s2If][s2If is_user_logged_in()] a good student at school. General examination and systemic examination (respiratory, cardiac, neurological and gastrointestinal systems) did not reveal any obvious abnormality.

Investigations

Laboratory tests were as follows (with reference ranges in parentheses) :

  • Hemoglobin 10.8 g/dl (13-17)
  • Mean corpuscular volume 78 fl (83-101)
  • Mean corpuscular hemoglobin 24.3 pg (27-31)
  • Mean corpuscular hemoglobin concentration 31.2% (31.5-34.5)
  • Iron 23.6 ng/dl (45-182)
  • Total iron binding capacity 335.9 µg/dl (250-450)
  • Transferrin saturation 7% (20-50)
  • Ferritin 26.7 ng/ml (30-300)
  • 25-hydroxy vitamin D 13.72 ng/ml (30-100)

Results were all within the reference ranges for total leucocyte count, erythrocyte count, platelet count, liver, kidney and lipid profiles of tests, calcium, phosphorus, intact parathyroid hormone, and magnesium. HPLC was done to rule out abnormal hemoglobins, and results were normal: adult hemoglobin 3% (2.4-3.6) and fetal hemoglobin

Treatment, Outcome and Follow Up

The patient was treated with iron and vitamin D tablets for 3 months and showed a significant improvement of iron and vitamin D levels. The cramps had disappeared, and tiredness was reduced significantly.

Discussion

Several studies have suggested a role for vitamin D in erythropoiesis. Treatment with vitamin D in hemodialysis patients has resulted in reduced dosage requirements of erythrocyte stimulating agents and an increase in reticulocytosis. (1) Vitamin D has also been shown to affect bone marrow function. 25-hydroxy vitamin D deficient subjects have a lower mean hemoglobin level and significantly higher incidence of anemia compared with those with normal D25 levels. (2) It is important to note that breastfed infants are more susceptible to iron and vitamin D deficiency. (3)

Vitamin D deficiency is also associated with increased risk of anemia in healthy US children. (4) In another study, it has been seen that about 6.3% of Brazilian school children were anemic and 33% of them had multiple nutritional deficiencies, all due to inadequate fruit and vegetable consumption. (5)

Vitamin D receptors have been discovered in the bone marrow. Significantly higher levels of 25 hydroxy and 1,25 hydroxy vitamin D have been found in the buffy coat of bone marrow containing erythroid precursors, fibroblast, endothelial cells, lipid laden cells, and macrophages, compared to the levels present in bone marrow plasma. Thus the higher local concentration of 1,25 hydroxy vitamin D may directly activate the erythroid precursor cells. (2) Iron deficiency impairs vitamin D absorption (6), so vitamin D supplements alone given to infants with iron-deficiency anemia may not necessarily prevent vitamin D deficiency. Complete cure of these children is possible by treatment with calcium, magnesium, vitamin D, iron, and antibiotics. (7)

Learning Points/Take Home Messages

  1. Anemic patients, because of the associated fatigue, may feel less interested to stay outside and get enough sun exposure. This may easily predispose the patient to vitamin D deficiency.
  2. Doctors should routinely measure the vitamin D levels in iron-deficient patients, for early diagnosis and treatment options.
  3. If it can be proved conclusively that vitamin D improves erythropoiesis, then correction of vitamin D deficiency will lead to improvement in anemic patients, with or without chronic kidney disease.

About The Author

M LodhDr. Moushumi Lodh, M.B.B.S, M.D Biochemistry. Laboratory Services, The Mission Hospital, Durgapur.

 

 

References (click to show/hide)

  1. Saab G, Young DO, Gincherman Y, Giles K, Norwood K, Coyne DW. Prevalence of vitamin D deficiency and the safety and effectiveness of monthly ergocalciferol in hemodialysis patients. NephronClin Pract.2007; 105:c132–c138.
  2. Sim JJ, Lac PT, LiuILA. Vitamin D deficiency and anemia: a cross-sectional study. Meguerditchian SO, Kumar VA, Kujubu DA, Rasgon SA. Ann Hematol. 2010; 89:447-452.
  3. Jin HJ, Lee JH, Kim MK. The prevalence of vitamin D deficiency in iron-deficient and normal children under the age of 24 months Blood Res. 2013;48(1):40-5.
  4. Atkinson MA, Melamed ML, Kumar J, Roy CN, Miller ER 3rd, Furth SL, FadrowskiJJ. Vitamin D, race, and risk for anemia in children. JPediatr. 2014; 164(1):153-158.
  5. Augusto RA, Cobayashi F, Cardoso MA. Associations between low consumption of fruits and vegetables and nutritional deficiencies in Brazilian schoolchildren. Public Health Nutr. 2014; Jun 25:1-10. [Epub ahead of print].
  6. Heldenberg D, Tenenbaum G, Yosef W. Effect of iron on serum 25-hydroxyvitamin D and 24,25-dihydroxyvitamin D, Am J ClinNutr.1992;56 (3): 533-536.
  7. Wallis K. Severe vitamin D deficiency presenting as hypocalcaemic seizures in a black infant at 45.5 degrees south: a case report. Cases Journal 2008; 1:12.doi:10.1186/1757-1626-1-12.


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