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LIFE-THREATENING ANEMIA DIAGNOSIS DUE TO MYOMA UTERI IN THE EMERGENCY DEPARTMENT: A CASE REPORT.

Introduction

Uterine myoma is a benign tumor of the uterus and clinically apparent in up to 25% of reproductive-age women. The silent uterine bleeding usually develops secondary to myoma (2,3). Bleeding, anemia, fatigue and orthostatic hypotension are common events in emergency department. Severe anemia at a level <4g/dL is rarely seen in the hospital enviroment. Two cases with such low hemoglobin levels have been published before. The first case hemoglobin level of 1.8 g / dL have been reported from a patient standing by Imaizumi et al, and this was due to chronic urinary bleeding. Other anemia was reported by Schmitt et al. as secondary to colon cancer with a hemoglobin level of 1.8 g / dL.. Our case with a hemoglobin value of 1.2 is the lowest hemoglobin value in the literature.

Case Report

A 35-year-old previously healthy woman presented to the emergency department with the orientation of the polyclinic of obstetrics and gynecology. The complaint bringing the patient to the obstetrics and gynecology was mild tiredness and occasional vaginal bleeding. The diameter of the myoma had been measured as 4.2 cm in the polyclinic by Ultrasonography. The patient's heart rate was between 95 to 105 beats per minute, and his blood pressure was 115/85 mmHg when supine but 90/40mm Hg upon standing. There was a generalized abdominal tenderness. The rhythms of the electrocardiogram were normal.

The patient had no history of hematopoietic disorders. She explained no history of hepatitis, intravenous drug use, prosthetic valves, or hemoptysis. Although the patient's fatigue and thyroid function tests were normal, there were complaints of shedding hair for 1 month. We did not define any feature other than non-irritating intermittent bleeding with not exceeding the size of a teaspoon. Based on a "diluted" sample, the initial laboratory evaluation was complicated by standard laboratory protocols rejecting the patient's complete blood count due to machine failure. After two rejected attempts, the emergency physician was asked to report the results, and then in the third specimen, a severe anemia with hemoglobin level of 1.2 g / dL was seen (Table-1). Hepatitis marker was negative. Ferritin, iron was low. Iron binding capacity high. Peripheral blood smear contained hemolysis-related changes. Fecal occult blood test is negative.

The patient was given two units of erythrocyte suspension with appropriate cross-match blood. Hemoglobin increased to 3.93 g/dL and hematocrit reached 15.4% after erythrocyte suspension was administered. The treatment was completed on the withdrawal of hemoglobin to normal levels, after making sure that your cancer screening tests are negative. She discharged 3 weeks after the admission and being followed by gynecological diseases.

Discussion

Case with severe anemia at a level lower than 4 g/dL is rarely seen in the hospital emergency. However, those indicate clinical symptoms, when they reached the emergency department. Sometimes there are complaints of dysphagia, fragile nails, relative impotence, fatigue and cramps in the calves on climbing stairs, which are disproportionate to their anemia. In contrast, our case had no noisy table indicating severe anemia. There were only complaints of shedding hair for 1 month, with no history of hepatitis, prosthetic valves, intravenous drug use, or hemoptysis.

In literature knowledge, we encountered to two cases of low hemoglobin levels, which was not low as our case. Imaizumi et al has been reported a patient with a hemoglobin level of 1.8 g / dL due to chronic urinary bleeding. And another anemia was reported by Schmitt et al, as emerged secondary to colon cancer with 1.8 g/dL. The most common source of blood loss leading to such severe anemia is the gastrointestinal system. There was no report for myoma uteri at this lowest level. The current patient adds to recent reports of patient survival with a hemoglobin level of <2 g/dL, at the lowest level in the literature.

References

(1.) Orlandi M, Inauen W. [Chronic gastrointestinal bleeding]. Therapeutische Umschau Revue therapeutique. 2006;63(5):327-332.

(2.) Kurt H, Demirkiran D. Changing of Hemoglobin A1c Affects Mean Platelet Volume in Type-2 Diabetes Mellitus. Ulutas Med J. 2016;2(1):27-35.

(3.) Padmakumar R, Pai M, Farish S, Rajeev J, Sanjeev T, Sreevalsan TV, et al. Successful bowel surgery at hemoglobin 2 g/dL without blood transfusion. World journal of gastrointestinal surgery. 2013;5(8):252-255.

(4.) Rockey DC, Hafemeister AC, Reisch JS. Acute on chronic gastrointestinal bleeding: a unique clinical entity. Journal of investigative medicine : the official publication of the American Federation for Clinical Research. 2017;65(5):892-898.

(5.) Imaizumi T, Yagi E, Ushijima K, Suzuki K, Terasaki H. A patient with a preoperative hemoglobin concentration of 1.8 g.dl1: how was the life-threatening anemia tolerated without any intensive care? Journal of anesthesia. 1999;13(2):125-126.

(6.) Schmitt RE, Buckley CJ. Extreme anemia (hemoglobin 1.8 g/dL) secondary to colon cancer. Proceedings (Baylor University Medical Center). 2016;29(4):393-4.

(7.) Zollinger A, Hager P, Singer T, Friedl HP, Pasch T, Spahn DR. Extreme hemodilution due to massive blood loss in tumor surgery. Anesthesiology. 1997;87(4):985-987.

Abdullah ALGIN (*), Ismail TAYFUR (**), Mustafa Ahmet AFACAN (**), Sahin COLAK (**), Mehmet SARIAYDIN (***), Huseyin Avni FINDIKLI (***), Hakan AYDIN (***)

(*) Department of Emergency Medicine, Adiyaman University Training and Research Hospital Adiyaman, Turkey

(**) Department of Emergency Medicine, SBU Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey

(***) Department of Internal Medicine, Adiyaman University Training and Research Hospital Adiyaman, Turkey
TABLE 1. All hematological Parameters were given with reference range

Hemotological Parameters                   Value   Reference range

Hemoglobin (g/dL)                            1,2       14-18
Hematocrit (%)                               7,7       42-52
Red Blood Cells (u/L)                        1,25       4-6,13
White Blood Cells (u/L)                      7,23       4,3-10,3
Mean corpuscular volume (fL)                60         80-97
Mean corpuscular hemoglobin (pg)             9,3       25-33,3
Mean corpuscular hemoglobin concentration
(g/dL)                                      15,8       30-35
Total iron binding capacity ([micro]g/dL)  499        241-421
Transferrin saturation (%)                   0,1       18%-48%
Transferrin (mg/dL)                        249        180-344
Blood Iron ([micro]g/dL)                    17         30-162
Haptoglobin (mg/dL)                        193         62-197
Folat (pg/mL)                               11          2,5-20
Vitamin B12 (nmol/L)                       180        180-914
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Author:Algin, Abdullah; Tayfur, Ismail; Afacan, Mustafa Ahmet; Colak, Sahin; Sariaydin, Mehmet; Findikli, H
Publication:Journal of Emergency Medicine Case Reports
Date:Jan 1, 2019
Words:1008
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