Case 074: Folic Acid Deficiency Anemia

PATIENT PRESENTATION

Chief Complaint

“Where am I? I just want to go home.”

History of Present Illness

Kirby Owens is a 31-year-old black male brought to the Emergency Department by a friend after she found him weak and fatigued at his apartment. He endorses a headache and admits he drank more than usual last night at a party.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What symptoms of anemia are present in this patient?

   Hint: See Epidemiology and Etiology and Treatment in PPP

2. What laboratory findings would confirm this patient’s type of anemia?

   Hint: See Treatment and Figure 69-4 in PPP

3. What is the likely etiology of this patient’s anemia?

   Hint: See Treatment and Figure 69-4 in PPP

4. How should this patient’s anemia be treated?

   Hint: See Treatment in PPP

5. How soon after initiating the therapy should the anemia resolve?

   Hint: See Treatment in PPP

FOLLOW-UP

The patient returns to the Emergency Department in a month with an abscess on his left ankle after scraping it while hiking. The medical resident in the Emergency Department prescribes trimethoprim-sulfamethoxazole (TMP-SMX) DS tablets (160/800 mg) orally twice daily for 5 days. What impact may the patient’s antimicrobial therapy have on his anemia?

Question Hint: See Problematic Drug Classes and Treatment Options in PPP and review common adverse drug events for sulfamethoxazole-trimethoprim in package insert and drug references

CASE SUMMARY

Global Perspective

Folic acid deficiency develops in all populations in which malnutrition is apparent making macrocytic anemia a global health concern. Due to the association between low folic acid levels during pregnancy and neural tube birth defects, the FDA previously mandated the addition of folic acid to many grain products, including bread, pasta, and cereals. In addition to the U.S., many other countries require fortification of milled wheat flour with folic acid. The folic acid food fortification program in the US and increased awareness regarding the need for prenatal folic acid supplementation has reduced the incidence of neural tube defects by 28%.

The effect of folic acid supplementation on cancer is unclear. Low folate diets have been associated with an increased risk of many cancers including breast, pancreatic, and colon cancer. However, the incidence of some cancers has increased since folic acid fortification efforts, and data suggest that high folic acid ingestion may increase the risk of colon, breast, and prostate cancers.

In addition, low dietary folate intake been associated with an increase in the risk of coronary events, perhaps due to increases ...