Unusual etiology for a common problem

Introduction: Diagnosing the etiology of iron deficiency anemia can be very challenging.Hypothesis: Etiology of iron deficiency anemia is not always straightforwardStudy design: Case ReportResults: 2-year-old female presented with fever, cough, pallor for 4 days. CXR showed diffuse pulmonary opacities. CRP 3.45, ESR 21, WBC 6, platelet of 361, Hgb of 4 gm/dl, MCV 54, developed hemoptysis and was transferred to the PICU with respiratory failure. Bronchiolar lavage and lung biopsy showed extensive hemosiderin-laden macrophages. Iron deficiency anemia, progressive cough, dyspnea, and infiltrates on CXR was consistent with idiopathic pulmonary hemosiderosis. Pneumocystis, HIV, histoplasma, SLE, vasculitides were negative. Patient responded to a burst of steroid with normalization of breathing and Hgb level during follow up.16 y/o female marathon runner with iron deficiency anemia refractory to iron supplementation, Hgb 7.4gm/dl over 6 month period despite taking iron supplements. MVC was 68, ferritin of 2, transferrin/TIBC levels were elevated. Hemoccult stool negative. Combination of intense physical exercise, refractory iron deficiency anemia, and lack of GI blood loss led to consideration of march hemoglobinuria. Urinalysis positive for blood, confirming the diagnosis. With IV iron and reduction of intensity of running, Hgb was up to 14.1.Conclusion: These two cases of uncommon causes of blood loss highlight the importance of considering rare causes for iron deficiency anemia especially when it is not responding to iron supplement. Without treatment of underlying cause, anemia would persist