Khalid Serraj

Update of nutrient-deficiency anemia in elderly patients

Anemia, defined as a hemoglobin level < 13 g/dL in men and < 12 g/dL in women, is an important healthcare concern among the elderly. Nutrient-deficiency anemia represents one third of all anemias in elderly patients. About two thirds of nutrient-deficiency anemia is associated with iron deficiency and most of those cases are the result of chronic blood loss from gastrointestinal lesions. The remaining cases of nutrient-deficiency anemia are usually associated with vitamin B12, most frequently related to food-cobalamin malabsorption, and/or folate deficiency and are easily treated (nutrient-deficiency replacement).

The pathophysiology of elevated vitamin B12 in clinical practice

Hypercobalaminemia (high serum vitamin B12 levels) is a frequent and underestimated anomaly. Clinically, it can be paradoxically accompanied by signs of deficiency, reflecting a functional deficiency linked to qualitative abnormalities, which are related to defects in tissue uptake and action of vitamin B12. The aetiological profile of high serum cobalamin predominantly encompasses severe disease entities for which early diagnosis is critical for prognosis. These entities are essentially comprised of solid neoplasms, haematological malignancies and liver and kidney diseases. This review reflects the potential importance of the vitamin B12 assay as an early diagnostic marker of these diseases. A codified approach is needed to determine the potential indications of a search for high serum cobalamin and the practical clinical strategy to adopt upon discovery of elevated cobalamin levels. While low serum cobalamin levels do not necessarily imply deficiency, an abnormally high serum cobalamin level forms a warning sign requiring exclusion of a number of serious underlying pathologies. Functional cobalamin deficiency can thus occur at any serum level.

Anemia in elderly patients: New insight into an old disorder

Anemia is an important healthcare concern among the elderly. In these patients, the anemia is often mild, with a hemoglobin level >10u2009g/dL. It is usually well tolerated, but might be responsible for several proteiform and/or atypical presenting complaints. In the elderly, anemia is usually of multifactorial origin, including chronic inflammation, chronic kidney disease, nutrient deficiencies and iron deficiency (approximately two‐thirds of all cases). The remaining cases are unexplained (unknown etiology). In the elderly, the classic diagnosis of anemia, which is based on the mean corpuscular volume associated with a low hemoglobin level, might not be accurate. A predefined standardized diagnostic procedure should be followed. In the common case of frail elderly patients, all investigations should be carefully considered and invasive examinations undertaken where justified (risk–benefit balance). Nevertheless, most cases of anemia require further investigation and the underlying cause should be identified and treated whenever possible. Geriatr Gerontol Int 2013; 13: 519–527.

Idiopathic thrombocytopenic purpura in elderly patients: A study of 47 cases from a single reference center

BACKGROUNDnIdiopathic thrombocytopenic purpura (ITP) is often diagnosed in the elderly, but no specific guidelines exist for such patients. We describe our experience with ITP management in elderly patients and analyze the therapeutic response.nnnMETHODSnWe retrospectively reviewed a cohort of 47 consecutive elderly ITP patients (> or =60 years old) followed in a single reference center. We specifically analyzed the clinical characteristics, therapies used, patient response rates, and side effects.nnnRESULTSnThe mean age of the 47 patients was 66 (range 60-82) years; 31 patients were female. Their initial presentation included bleeding limited to the skin (n=10, 21%) and bleeding at one or more other sites (n=26, 56%); 11 patients (23%) were asymptomatic. The mean platelet count was 52 x 10(9)/L (range 1-120 x 10(9)/L). After 1 and 6 months, the overall response rate was: 61% and 33% with corticosteroids (n=43), 80% and 50% with splenectomy (n=10), and 14% and 60% with danazol (n=15), respectively. Side effects of these therapies were reported in 100% of these elderly ITP patients, 60% and 50% with these drugs, respectively. No response was reported using IVIg. One case of fatal sepsis was noted after splenectomy.nnnCONCLUSIONSnThe results confirm (1) that age influences the hemorrhagic pattern of ITP expression, response, and adverse effects of conventional ITP therapies, and (2) that danazol has the potential to be an effective therapeutic alternative to splenectomy in elderly ITP patients.

Optimal management of pernicious anemia

Pernicious anemia (also known as Biermer’s disease) is an autoimmune atrophic gastritis, predominantly of the fundus, and is responsible for a deficiency in vitamin B12 (cobalamin) due to its malabsorption. Its prevalence is 0.1% in the general population and 1.9% in subjects over the age of 60 years. Pernicious anemia represents 20%–50% of the causes of vitamin B12 deficiency in adults. Given its polymorphism and broad spectrum of clinical manifestations, pernicious anemia is a great pretender. Its diagnosis must therefore be evoked and considered in the presence of neurological and hematological manifestations of undetermined origin. Biologically, it is characterized by the presence of anti-intrinsic factor antibodies. Treatment is based on the administration of parenteral vitamin B12, although other routes of administration (eg, oral) are currently under study. In the present update, these various aspects are discussed with special emphasis on data of interest to the clinician.

Recognition and management of drug-induced cytopenias: the example of idiosyncratic drug-induced thrombocytopenia

Background: Several hundred drugs, toxins and herbs have been reported to cause blood abnormalities, and drugs account for 20 – 40% of all instances of cytopenias. Objective: In the present paper, we report and discuss the recognition and management of moderate to severe idiosyncratic drug-induced thrombocytopenia. Methods: A bibliographic search was performed on the PubMed database of the US National Library of Medicine for articles published from January 1990 to November 2008. Results/conclusions: Moderate to severe idiosyncratic drug-induced thrombocytopenia (platelet count < 100 × 109/l) is a relatively rare and potentially serious disorder. The origin may be myelosuppression or peripheral, owing to either the consumption of platelets or their immune-mediated destruction. The most common molecules responsible are heparins, quinidine, sulfonamides and gold salts. Clinically, the most classical symptom is a typical pattern of bleeding of variable intensity depending on the severity of thrombocytopenia and the molecule involved. Immune-mediated thrombocytopenia induced by heparin (type II) is more often associated with thrombotic events. The diagnosis is based on medical history and a set of clinical criteria, which also specify the level of imputability. Although the role of serological tests is not well established, they seem particularly valuable in some situations in which differential diagnosis is difficult or in type II heparin-induced thrombocytopenia. The treatment includes discontinuation of the suspected drug, and symptomatic measures that depend on the severity of clinical symptoms.

The Syndrome of Food-Cobalamin Malabsorption: A Personal View in a Perspective of Clinical Practice

This article presents recent findings on cobalamin deficiencies due to food-cobalamin malabsorption or nondissociation of vitamin B12 from its carrier proteins syndrome. These findings might be of interest to medical practitioners. This disorder, for which a definitive consensus on the criteria for diagnosis is not yet available, is the leading cause of cobalamin deficiency in the elderly. In practice, food-cobalamin malabsorption is a diagnosis of exclusion, and requires the deductive elimination of all other causes of cobalamin deficiencies, particularly pernicious anaemia. The causes or associated disorders of food-cobalamin malabsorption are multiple and include gastric pathologies, Helicobacter pylori infections and certain drugs (biguanides and proton pump inhibitors). Depending on the disease aetiology, treatment of food-cobalamin malabsorption involves oral supplementation of doses lower than those required for pernicious anaemia.

Drug-Induced Agranulocytosis in Elderly Patients: Diagnosis and Management of Life-Threatening Infections and Septic Shock

In this paper, we discuss the diagnosis and management of life-threatening infections including septic shock, in elderly patients presenting with acute drug-induced neutropenia (neutrophil count of 65 years), septicemia or septic shock, metabolic disorders such as renal failure and a neutrophil count below 0.1 × 109/L. In this potentially life-threatening disorder, modern management with broad-spectrum antibiotics and hematopoietic growth factors (particularly G-CSF), is likely to improve the prognosis, even in elderly patients.

Anémies carentielles du sujet âgé

Nutritional deficiencies cause one third of the cases of anemia in the elderly. The urgency of anemia management in elderly patients depends on tolerance and repercussions, rather than only on the hemoglobin level. Iron, vitamin B12 and folate are the most common deficiencies, and their levels should be tested. Chronic gastrointestinal bleeding is the principal cause of iron-deficiency anemia. Management is based on supplementation combined with effective etiological treatment.

Idiopathic Thrombocytopenic Purpura in Elderly Patients: A Two-center Retrospective Study of 41 Cases

Objective: This work aimed to report our observations on idiopathic or immune thrombocytopenic purpura (ITP) in elderly patients. nPatients and Methods: We retrospectively reviewed a cohort of 41 consecutive elderly ITP patients (≥65 years old) in two ITP reference centers, namely the university hospital groups of Strasbourg and Reims, France. We particularly analyzed patient clinical characteristics, along with the therapies used and side-effects, and patient response rates. nResults: The mean age of the 41 patients was 76.7 years (range: 65-91), 21 (51%) were older than 75 years and 27 were female. Initial presentations included the following: thrombocytopenia revealed by routine blood count or bleeding limited to the skin in 27 cases (66%); severe cutaneous bleeding or visceral bleeding in one or more other sites in 14 (34%). The mean platelet count was 34.4 x 109/L (range: 1-120). Spontaneous remission and complete response under therapy were reported in eight patients (20%) and 33 (80%) still exhibited chronic ITP at time of writing. There were three deaths during long-term follow-up. After 6 months, the response rate was 35% with corticosteroids, 50% with splenectomy, and 40% with danazol. Side-effects were reported in 100% of elderly ITP patients, with 60% and 50% corresponding to corticosteroids and danazol, respectively. The response rate to biological agents, namely rituximab and thrombopoietin (TPO) receptor agonists, was 80%, with no adverse effects observed. nConclusions: Our results confirm that age influences the hemorrhagic pattern of ITP expression as well as responses to and adverse effects of conventional ITP therapies.