in a female patient who has thrush, high ESR (above 100) and is slightly anemic ( hgb=11)?
Salam Dr Najla,
More clinical data? High serum ferritin can happen in many conditions including obesity, metabolic syndrome, diabetes, hemochromatosis........ and even malignancy
Thank you so much Niklas and Yazan for your prompt response. The clinical scenario is as follows: the woman is in her mid-thirties, she comes for routine dental treatment, a neglected mouth with pseudomembranous candidiasis particularly on the tongue. Her medical history is unremarkable except for multiple child birth and removal of a neck lump (??), but among the investigations requested the following were abnormal: low ALT, high total protein, high ESR. CBC results showed that lymphocyte count is high but neutrophils are low. Also RBC, hgb and HCT are slightly below normal, MCV is normal but MPV is high. We plan to request HIV as well as swab for candida culture.
Please Niklas note that all of the above results were evaluated based on the laboratory reference range.
Ferritin is the main protein that stores the iron inside the cell.
It is also an acute phase reactant.
High level of ferritin may indicate various pathologies of iron metabolism.
It is also high in inflammation , infection or malignancy since it is an acute phase reactant.
· 1. Diseases causing iron accumulation
Hemochromatosis. Hemosiderosis. Iron poisoning. Multiple red blood cells transfusions. Hemolytic anaemia.
· 2. Liver diseases: the liver is the main organ of iron storage.
Alcoholic hepatitis, Viral hepatitis
· 3. Inflammation:
Rheumatoid arthritis, systemic lupus erythematosus, Still’s disease, Macrophage activation syndrome.
· 4. Malignancies.
With such a high ESR, investigation for inflammatory disease or malignancy is mandatory.
Thank you Niklas. Immunoglobulins are not checked yet. HbA1c also not investigated but FBS is within normal range. I totally agree with you that immunosuppression is likely to be the cause of oral thrush.
Thank you Majda for your informative answer. Although the patient's past medical history is not that clear, she reported that she had been given antibiotics for a long period of time to treat chronic respiratory tract infection that caused her chronic cough. Could this cough be attributed to oropharyngeal candidiasis and that antiobiotics just worsened the condition?
What set of investigations we can do to confirm inflammatory or malignant background?
Thank you Niklas; you summed up the management quite beautifully. And yes I am not medically qualified but I know about oral diseases as a part of systemic diseases more than most physicians. Eventually the patient will be referred to a colleague physician.
I agree with you Betul Tas
We found high level of ferritin in any acute parasitic infection
Dear Najla, the picture you are suggesting seems like Anemia of Chronic Disease. Would be worthwhile doing serum iron studies of this patient.
Also, as it is an Acute Phase Reactant, could be elevated as part of inflammation as well. If the ferritin is extremely high, say, in the thousands, consider Adult-onset Still's disease as well.
Thank you Betul, Ishag and Preet. The patient has the following results: Hgb=11, ferritin=214 ng/ml which is high considering the normal range of up to 150 according to the lab range, normal B12, and normal MCV. With such results do you think that she has anemia?
Dear Najla Saeed Dar-Odeh
I do not think the patient is anemic
I would be grateful if you provide us with albumin, CRP
Thank you Ishag. Besides albumin ad CRP, should the patient do other necessary tests?
I agree with Prof Ishag and Preet Shah we need to exclude chronic infection
Dear Najla Saeed Dar-Odeh
Yes we need to see CBC
If CRP and Albumin are high then the high ferritin level was of inflammatory origin
Dear Najla,Inflammatory marker "Procalcitonin" levels increase dramatically in patients with sepsis,and detected within 3 hours of induction of onset-at leaat 20 hours earlier than CRP.,Wassalam..Murtaza
I agree with you Murtaza Mustafa
However it is not apart of the routine work
Dear Ishaq Adam,No doubt Procalcitonin not a routine diagnostic test,but in critical cases its sensitive test.Wslm.Assoc.Prof.Murtaza Mustafa
Have you checked HIV ? Is the patient on steroids ? If ferritin is up in the thousands, or patient is febrile, consider admitting patient for further workup, urgently. HLH is a late diagnosis with ferritin extremely high >2,000 and fevers, many times lethal.
Antibiotic use would explain thrush but not cough, therefore patient should have medical evaluation soon. And I agree that you probably know about oral manifestations of systemic diseases more than most medical people, one more reason to work in cooperation, don't delay further evaluation. Good luck.
Thank you all for your advice. I reassure you that the patient will get the proper medical treatment. I don't believe in solo performance in patient care, but providing the ideal treatment plan may be complicated by some non-clinical factors like patient compliance, social factors and access to care.
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