*Co esponding au ho : Debanjan Saha.
Copy igh © 2025 Au ho (s) e ain he copy igh o his a icle. This a icle is published unde he e ms o he C ea i e Commons A ibu ion Liscense 4.0.
B ea hless Shadows o Silen Anemia: Un eiling he Hidden Challenge o Combined
I on and Vi amin B12 De iciency: A Case Repo
Debanjan Saha 1, *, Lakshi a Yada 1 and Subhash Baddula 2
1 Depa men o Medicine, Mili a y Hospi al, D ugmulla, India.
2 Depa men o Su ge y, Mili a y Hospi al, D ugmulla, India.
Wo ld Jou nal o Biology Pha macy and Heal h Sciences, 2025, 23(03), 383-391
Publica ion his o y: Recei ed on 15 Augus 2025; e ised on 20 Sep embe 2025; accep ed on 23 Sep embe 2025
A icle DOI: h ps://doi.o g/10.30574/wjbphs.2025.23.3.0855
Abs ac
This case epo p esen s a 44-yea -old male a my pe sonnel and animal aine who de eloped g adually p og essi e
exe ional b ea hlessness o e h ee mon hs, wi hou o he ca dio espi a o y complain s, p omp ing di e en ial
conside a ion o occupa ional and espi a o y e iologies owing o his p o essional en i onmen and exposu e o
animals. Clinical assessmen e ealed ma ked pallo , and he pa ien ’s labo a o y in es iga ions es ablished a diagnosis
o combined i on and i amin B12 de iciency anemia, a ibu able o his ecen swi ch o a ege a ian die o six mon hs.
Hema ological e alua ion showed a mic ocy ic hypoch omic blood pic u e wi h low mean co puscula olume and
signi ican ly educed se um i on and i amin B12 le els. No e idence was ound o in ec ious, ca diopulmona y, o
sys emic disease, and classical causes o anemia we e excluded h ough comp ehensi e es ing. Managemen in ol ed
in a enous and o al supplemen a ion o bo h i on and i amin B12, leading o apid esolu ion o b ea hlessness and
no maliza ion o hemoglobin alues and o he hema ological indices wi hin one week. This case highligh s he necessi y
o ho ough die a y his o y and mic onu ien e alua ion in adul s wi h unexplained dyspnea, pa icula ly in cases wi h
ecen die a y change, as dual de iciencies may obscu e classical labo a o y ea u es o anemia and delay diagnosis.
Ea ly ecogni ion and simul aneous co ec ion o bo h nu ien de ici s a e c i ical in ensu ing p omp eco e y,
p e en ing complica ions, and ein o cing he need o sys ema ic diagnos ic s a egies in simila clinical p esen a ions.
Keywo ds: I on de iciency anemia; Vi amin B12 de iciency; Mic ocy ic hypoch omic anemia; Nu i ional anemia;
Vege a ian die ; Pa en e al i amin B12
1. In oduc ion
B ea hlessness is de ined by he Ame ican Tho acic Socie y as ‘‘a subjec i e expe ience o b ea hing discom o ha
consis s o quali a i ely dis inc sensa ions ha a y in in ensi y.’’[1]
B ea hlessness has a widesp ead impac on he pa ien and hei amily. I is associa ed wi h poo quali y o li e, poo
su i al, and inc eased eme gency ca e and hospi al admissions wi h inc eased hospi al leng h o s ay and in-hospi al
ad e se e en s.[2] Recogni ion ha b ea hlessness may be pe sis en and disabling despi e op imal ea men o he
causa i e medical condi ion has led o ecen naming and de ining o ch onic b ea hlessness synd ome.[3]
Symp oms o anemia desc ibed in li e a u e a e a igue, educed cogni i e unc ion, b ea hlessness, lack o ene gy,
weakness, and dizziness [4]. These symp oms can be in e p e ed as indica i e o symp oma ic anemia and may hus
play a ole in diagnos ic and he apeu ic decisions [5].
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I on de iciency anemia emains a majo global heal h issue, con ibu ing o app oxima ely 800,000 dea hs annually
wo ldwide.[6] While anemia is his o ically associa ed wi h women o ep oduc i e age and child en, ecen ends
indica e an inc easing isk among males, in luenced by ac o s such as e hnici y and age—wi h age being a mo e
signi ican isk ac o in men compa ed o women.[7] Absolu e i on de iciency a ises om inc eased physiological i on
equi emen s, inadequa e die a y in ake, impai ed abso p ion, o ch onic blood loss.[8] In con as , unc ional i on
de iciency desc ibes a condi ion whe e i on s o es a e su icien , bu inco po a ion in o e y h oid p ecu so s is
impai ed, o en obse ed in se ings o in ec ion, in lamma ion, o malignancy.[9] This mechanism unde lies he i on
de iciency seen in a ious ch onic diseases.
Labo a o y diagnosis is essen ial o con i ming i on de iciency anemia. Ini ially, clinical suspicion is aised by ea u es
sugges i e o anemia, including a low mean co puscula olume (≤80 μm³) and a educed mean hemoglobin
concen a ion (≤13.7 g/dL). The nex s ep in ol es assessing se um e i in le els, whe e alues ≤30 ng/mL con i m
i on de iciency anemia. I se um e i in esul s a e inconclusi e, u he in es iga ions such as o al i on-binding
capaci y, se um i on, and ans e in sa u a ion a e pe o med. In i on de iciency anemia, o al i on-binding capaci y is
ele a ed, whe eas se um i on and ans e in sa u a ion le els a e dec eased.[10] The mains ay o ea men o i on
de iciency anemia is o eplenish i on s o es. This can be done h ough he adminis a ion o o al o pa en e al i on
supplemen s. The e a e able s wi h a ying dosages a ailable o consump ion in o al o m as opposed o pa en e al
i on which is an indi idualized in usion. This disc epancy in dosing be ween he wo ou es equi es an in-dep h e iew
o how he dosages o i on supplemen s can be s anda dized.
Vi amin B12 (B12) is classi ied as a wa e -soluble i amin, and is dis inc i e among all i amins due o i s la ge size,
complexi y, and ha i con ains he me al ion cobal . I is necessa y o app op ia e ne ous sys em unc ion and o he
me abolism o ca bohyd a e, p o ein, and a . De iciencies in B12 can lead o ine icien e y h opoiesis and
megaloblas ic anemia [11] Popula ions a he highes isk o B12 de iciency include he elde ly and hose ha ollow a
ege a ian o egan die . De iciency wi hin he elde ly popula ion is o en he esul o age- ela ed gas ic a ophy. This
causes a dec ease in acid and in insic ac o p oduc ion leading o B12 malabso p ion. I should be no ed, howe e ,
ha causes such as pe nicious anemia and ood-bound malabso p ion accoun o less han hal o poo B12 s a us
among he elde ly. A high a e o de iciency among ege a ians o egans exis s because B12 is only na u ally p esen
in animal p oduc s, so hose who do no consume die s high in o i ied p oduc s a e a isk [12]
He e, we p esen a case o a young male, who p esen ed wi h b ea hlessness and was de ec ed o ha e anemia due o
combined de iciency o I on and Vi B12.
2. Case Repo
A 44-yea -old man, an a my pe sonnel, an animal aine by p o ession, p esen ed wi h b ea hlessness on exe ion.
Insidious in onse a ound 03 mon hs back, g adually p og essi e. The e was no associa ed cough/ ches pain/
palpi a ions/ o hopnoea/ Pa oxysmal Noc u nal Dyspnoea. No hemop ysis o bleeding om any o he o i ice no ed.
The di e en ial diagnoses o be conside ed a his poin a e abula ed in Table 1.
Table 1 Di e en ial Diagnoses based on p esen ing complain s
Se ial
No
B oad
Classi ica ion
Di e en ials
1
Respi a o y Causes
In e s i ial lung disease (including hype sensi i i y pneumoni is, especially
ele an o animal exposu e)
Occupa ional/en i onmen al lung disease (e.g., ch onic exposu e- ela ed lung
disease due o animal dande , hay, mold)
Ch onic obs uc i e pulmona y disease (less likely i non-smoke , bu possible wi h
p io exposu es)
Pulmona y hype ension
Subclinical o ea ly ch onic in ec ions (e.g., ube culosis)
As hma (adul onse , occupa ional, o alle gic)
Res ic i e lung disease om o he causes (e.g., sa coidosis)
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2
Ca diac Causes
Ea ly hea ailu e (dias olic dys unc ion, may occu wi hou classic symp oms)
Ischemic hea disease (occasionally p esen s wi hou ches pain)
Ca diomyopa hy o o he s uc u al hea disease
Pulmona y embolism (ch onic o subacu e o ms)
3
Hema ologic/O he
Medical Causes
Anemia ( hough bleeding no men ioned, may s ill conside )
Me hemoglobinemia o o he hemoglobinopa hies (can cause exe ional dyspnea)
Ea ly sys emic illness (e.g., hy oid diso de s)
4
Neu omuscula and
Miscellaneous
Decondi ioning (less likely in a my pe sonnel, bu possible)
Neu omuscula weakness (myas henia g a is, mo o neu on disease)
Dys unc ional b ea hing o anxie y- ela ed dyspnea
In his case, animal aine occupa ion aises he suspicion o hype sensi i i y pneumoni is and o he occupa ional
lung diseases as especially ele an di e en ials, in addi ion o common ca diopulmona y and hema ological causes.
Indi idual belonged o he s a e o Tamil Nadu, p esen ly pos ed and wo king a Jammu and Kashmi o he las one
yea . He is no addic ed o alcohol/ obacco in any o m/ any known abusi e subs ance. He consumed mixed die, hough
o a ound 06mon hs p io o p esen a ion, he had swi ched o a ege a ian die .
The e is no signi ican illness in he pas . No hospi al admissions o he pa ien in his li e hus a .
The e is no simila illness among amily membe s.
2.1. On Examina ion
Gene al condi ion – Good. Heigh – 174cm. Weigh – 86kg. BMI – 28.4kg pe squa e me e. Blood P essu e –
136/80mmHg, measu ed in igh a m and 128/82mmHg, measu ed in le a m, bo h in supine pos u e, wi h no pos u al
d op in blood p essu e no ed. Pallo p esen . No cyanosis/ clubbing/ edema/ ic e us no ed. Jugula enous p essu e
was no ele a ed. The e was no ce ical/ axilla y o inguinal lymphadenopa hy in he pa ien .
Sys emic Examina ion: Vesicula b ea h sounds app ecia ed in bo h lung ields, wi h no ad en i ious sounds. Abdominal
examina ion did no e eal any hepa osplenomegaly. Examina ion o he ca dio ascula and Neu ological sys em was
un ema kable.
The di e en ials ha would now be conside ed a e abula ed in Table 2.
Table 2 Di e en ials o be conside ed a e clinical examina ion
Se ial
No
G ade o
possibili y
De ails
1
Mos likely
Anemia-Rela ed Causes (Especially Nu i ional)
Pallo is a key inding, suppo ing anemia as a p obable cause o exe ional dyspnea. The
swi ch o a ege a ian die in he las 6 mon hs inc eases he isk o i on de iciency o
po en ially i amin B12 de iciency anemia. Nu i ional anemia is highly likely, especially
in his age g oup and con ex .
Ch onic Disease ela ed Anemia (Seconda y Anemia)
While possible, he e is no o e e idence o ch onic in ec ion, in lamma ion, o
malignancy (no lymphadenopa hy, hepa osplenomegaly, sys emic symp oms).
2
S ill Possible,
Bu Less Likely
Hype sensi i i y Pneumoni is o In e s i ial Lung Disease
Absence o ad en i ious sounds (c ackles, wheeze), no mal espi a o y examina ion,
and no signs o clubbing make signi ican in e s i ial o pa enchymal lung disease less
likely a p esen .
O he Occupa ional Lung Disease
Wo ld Jou nal o Biology Pha macy and Heal h Sciences, 2025, 23(03), 383-391
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Less likely wi h a no mal espi a o y exam and no ch onic indings.
3
Unlikely
Di e en ials
Ca diac Disease
Lack o hea ailu e signs, no mal ca dio ascula exam, and no p io symp oms make
p ima y ca diac e iology unlikely.
Ch onic In ec ions, Neoplasia, Sys emic Diseases
No sugges i e physical signs: no lymphadenopa hy, o ganomegaly, o sys emic
symp oms.
2.2. In es iga ions
On a i al: (Ini ial Blood Pic u e) Hb – 10.3g/dl; To al Leucocy e coun – 8000 pe mic oL; Pla ele coun – 2.65 lakhs
pe mic oL; Neu ophils – 67%; Lymphocy es – 21%; Monocy es – 08%; Eosinophils – 04%. Mean Co puscula Volume
– 63.8 L; Mean Co puscula Hemoglobin – 18.5pg; Mean Co puscula Hemoglobin Concen a ion – 29.0g/dL; Packed
Cell Volume – 35.7%.
Pe iphe al Blood Smea : RBC MORPHOLOGY: P edominan ly No mocy ic No moch omic o mic ocy ic hypoch omic
RBCs wi h anisocy osis. (Figu e 1)
• WBC MORPHOLOGY: 7500/uL Neu ophils 66% Lymphocy es 24% Monocy es 03% Eosinophils 07%
• PLATELETS: Adequa e on smea
• IMPRESSION: Mic ocy ic hypoch omic blood pic u e wi h ela i e eosinophilia
• Li e Func ion es , Renal Func ion Tes , Thy oid p o ile – No mal
• ECG – No mal Sinus Rhy hm
• Ches X Ray PA iew – Wi hin No mal Limi s
Figu e 1 Pe iphe al blood smea s ained wi h W igh 's s ain unde 1000x oil imme sion mic oscope showing
hypoch omic mic ocy ic ed blood cells mos likely due o i on de iciency anemia.
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387
In iew o mic ocy ic hypoch omic pic u e, pa ien was made o unde go Blood examina ion o I on S udies and HPLC
(Table 3). In iew o his ege a ian die o e las 03 mon hs, he unde wen e alua ion o Blood le els o Vi B12. Rele an
in es iga ions a e ch onologically a anged in Table 4.
Table 3 Blood o HPLC: Tabula ed epo
Se
No
Diso de
Pa ame e
Biological e
in e al
Resul
Uni
Rema ks
1
Sickle Cell Anaemia (Hb SS)
S-Band
N.D
N.D
%
Nega i e
F-Band
<=2
0.50
%
A-Band
60 - 98
97.10
%
A2-Band
1.3 - 3.5
2.40
%
2
Be a halassemia
A2-Band
1.3 - 3.5
2.40
%
Nega i e
A-Band
60 - 98
97.10
%
F-Band
<=2
0.50
%
3
Sickle Cell Disease
S-Band
N.D
N.D
%
Nega i e
F-Band
<=2
0.50
%
D-Band
N.D
N.D
%
A-Band
60 - 98
97.10
%
A2-Band
1.3 - 3.5
2.40
%
4
Va ian hemoglobinopa hies (C, D, H, ba
band) including Hb E (Va Hb)
F-Band
<=2
0.50
%
Nega i e
C-Band
N.D
N.D
%
E-Band
N.D
N.D
%
A-Band
60 - 98
97.10
%
D-Band
N.D
N.D
%
Unknown
N.D
N.D
%
Blood o I on S udies: Se um i on – 34.21 µg/dL (65-175); TIBC – 428.25 µg/dL (250-450); T ans e in Sa u a ion – 7.99% (20-50); Se um Fe i in
– 28.3 ng/ml (Male: 30-400); Vi B12 (Cyanocobalamin) <50.00 pg/ml (180-914)
3. T ea men
Pos admission, pa ien ’s blood samples we e sen o Vi B12 le els, HPLC and I on s udies. Repo s o Vi B 12 le els
we e ecei ed a he ea lies which showed a de iciency. Supplemen a ion in he o m o inj and o al Vi B12. Two days
la e , on a i al o epo s o HPLC and I on s udies, pa ien was con i med o ha e i on de iciency as well. De iciency o
i on was calcula ed acco ding o Ganzoni’s equa ion and injec able i on in he o m o Inj Fe ic Ca boxymal ose was
adminis e ed. Table 5 gi es he imeline o e en s o he pa ien .
Table 4 Rele an in es iga ions ch onologically a anged
Day
03 days P io o
admission
On Day o
Admission
02 days la e
04
days
la e
08 days la e
E en s
Nil
Inj Vi B12 s a ed –
1000mic og i daily
Inj FCM gi en (Blood
sampling done jus
p io )
07 doses o daily Vi
B12 inj comple ed
Hb (g/dl)
9.7
10.3
10.9
11.1
12.8
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TLC (pe
mic oL)
9100
8000
9300
7200
8700
Pla ele (lakhs
pe mic oL)
2.51
2.65
2.31
2.10
2.22
MCV ( L)
58
63.8
64.6
64.6
66.2
MCH (pg)
19
18.5
18.7
19.3
20.4
MCHC
(gm/dl)S
33
29
29
29.9
30.8
Table 5 Timeline o e en s
Occu ence o e en
Ac ion Taken
03 days p io o
admission
Pa ien de ec ed o ha e anemia
elsewhe e
Pa ien e e ed o ou hospi al
On Day o admission
Anemia con i med in pa ien
PBS shows mic ocy ic hypoch omic
anemia
Samples o Vi B12, I on s udies and HPLC
sen
On Day 1 o admission
Vi B12 de iciency con i med
Inj Vi B12 1000µg i q24h x 07 days s a ed
On Day 2 o admission
De iciency o I on con i med
No hemoglobinopa hies de ec ed
Inj FCM 1000mg i on Day 2
On Day 3 o admission
Inj FCM 500mg i on Day 3
On Day 8 o admission
Pa ien asymp oma ic
Discha ged om hospi al
Ganzoni equa ion: I on De iciency
= [2.4 x (Ta ge Hb – Ac ual Hb) x Body Weigh + I on S o es] mg
= [2.4 x (15 – 10.3) x 86 + 500] mg
= 1470.08mg
4. Follow up and Ou comes
Pa ien esponded well o ea men . Symp oma ic imp o emen was no ed. B ea hlessness esol ed g adually o e s
01 week. Lab pa ame e s imp o ed in he o m o inc ease in Hemoglobin le els (Figu e 2), Se um Fe i in le els
(>1000ng/ml) and MCV.
Pa ien was gi en inj I on p epa a ion x 02 days, ollowed by O al I on supplemen a ion.
Inj Vi B12 was supplemen ed on daily basis o 01 week ollowed by weekly doses o 04 weeks ollowed by plan o
mon hly injec ions.
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Figu e 2 G aphical ep esen a ion o imp o emen in Hemoglobin le els a e s a ing injec able i amin B12 and
in a enous i on ea men
5. Discussion
This case highligh s he impo ance o conside ing nu i ional de iciencies as a cause o exe ional dyspnea in o he wise
heal hy indi iduals, pa icula ly when die a y habi s ha e ecen ly changed. Al hough he ini ial suspicion a o ed
ca diopulmona y o occupa ional lung diseases due o he pa ien ’s p o ession and en i onmen , he clinical inding o
pallo and subsequen in es iga ions es ablished a dual de iciency o Vi amin B12 and i on as he unde lying e iology.
The coexis ence o hese de iciencies explained he mixed ed cell mo phology and symp om se e i y, while imely
co ec ion wi h pa en e al supplemen a ion esul ed in apid clinical and hema ological imp o emen . This case
unde lines he need o a comp ehensi e ye s epwise diagnos ic app oach, whe e b oad di e en ials a e me hodically
na owed, ensu ing p omp iden i ica ion and managemen o e e sible causes o anemia.
Anemia is a condi ion cha ac e ized by a educ ion in he numbe o ed blood cells (RBCs) o he concen a ion o
hemoglobin wi hin hem, leading o dec eased oxygen-ca ying capaci y o he blood. I may mani es clinically wi h
symp oms such as a igue, palpi a ions, headache, and sho ness o b ea h. Physical signs like conjunc i al and palma
pallo , al hough ha ing limi ed sensi i i y and mode a e speci ici y o diagnosing anemia, emain use ul pa icula ly
when labo a o y esou ces a e una ailable. In bo h clinical p ac ice and public heal h se ings, hemoglobin
concen a ion measu emen is he mos widely used and eliable indica o o diagnosing anemia.
Anemia can be ca ego ized based on i s unde lying e iology, such as inc eased ed blood cell loss o dec eased
p oduc ion. I may p esen as mic ocy ic anemia—commonly caused by i on de iciency o halassemia; no mocy ic
anemia—which is o en associa ed wi h in lamma o y condi ions; o mac ocy ic anemia— ypically esul ing om
i amin B12 o ola e de iciencies, li e disease, myelodysplasia, o hypo hy oidism.[13]
The Wo ld Heal h O ganiza ion (WHO) iden i ies se e al de e minan s o anemia, including biological ac o s (such as
nu ien de iciencies and malnu i ion, g ow h, physiological s a e, sex, age, and ace); in ec ions and in lamma ion
(including soil- ansmi ed helmin h in ec ions, schis osomiasis, mala ia, HIV, ube culosis, and low-g ade
in lamma ion); gene ic hemoglobin diso de s; blood loss and con acep i e use; as well as social, beha io al, and
en i onmen al ac o s.[13] I on de iciency is he mos p e alen mic onu ien de iciency associa ed wi h anemia.
Absolu e i on de iciency occu s when body i on s o es a e insu icien o mee physiological needs, whe eas unc ional
i on de iciency a ises when i on s o es a e adequa e bu canno be u ilized due o impai ed mobiliza ion and abso p ion,
o en o limi i on a ailabili y o pa hogens. Bo h o ms may coexis wi hin indi iduals o popula ions. Ra e
mic onu ien de iciencies implica ed in anemia include i amins A, B2, B6, B9, B12, C, D, and E, as well as coppe and
zinc. These de iciencies may de elop when in ake ails o mee he body's demands o e ime, owing o ac o s such as
Wo ld Jou nal o Biology Pha macy and Heal h Sciences, 2025, 23(03), 383-391
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low consump ion, poo bioa ailabili y, p esence o abso p ion inhibi o s, inc eased physiological needs du ing pe iods
like in ancy, adolescence, o p egnancy, o enhanced losses.
Hemoglobin (Hb) measu emen in blood is he mos common me hod o diagnose anemia. Howe e , hema oc i (packed
cell olume) is also used. Fo mo e de ailed (causal) insigh s, ed blood cell pa ame e s—such as mean cell olume
(MCV), mean cell hemoglobin concen a ion (MCHC), and e iculocy e coun —can be in o ma i e. Addi ional es s
include examina ion o a pe iphe al blood smea , hemoglobin elec opho esis (o high-pe o mance liquid
ch oma og aphy), measu ing mic onu ien bioma ke s, using Hb colo scales, o obse ing clinical signs. Depending
on which indica o is used, di e en indi iduals may be iden i ied as anemic, since each es e lec s di e en unde lying
me aboli es o physiological p ocesses.
Combined i on and i amin B12 de iciency is an impo an bu o en unde - ecognized cause o anemia, as he wo
de iciencies may mask o modi y each o he ’s hema ological ea u es. While i on de iciency ypically p oduces a
mic ocy ic, hypoch omic anemia and i amin B12 de iciency esul in a mac ocy ic, megaloblas ic pic u e, hei
coexis ence can yield a mixed o no mocy ic mo phology, making diagnosis challenging on pe iphe al smea alone.
Mac ocy osis, he hallma k o cobalamin/ ola e de iciency anemia, is equen ly absen . Clinicians ha e o be awa e o
coexis ing condi ions ha can mask he mac ocy osis exp ession o megaloblas ic anemia, especially i on de iciency.
The clinical p esen a ion o en includes nonspeci ic symp oms such as exe ional b ea hlessness, a igue, and pallo , bu
neu ological mani es a ions o B12 de iciency may be a enua ed o o e looked in he p esence o i on de iciency.
Die a y ac o s, pa icula ly ege a ianism, ch onic blood loss, and malabso p ion synd omes, a e majo con ibu o s.
Recogni ion o his dual de iciency equi es comp ehensi e e alua ion wi h comple e blood coun s, i on s udies, and
i amin B12 le els, as ea ing only one componen may lead o subop imal eco e y o pe sis en symp oms. Ea ly
iden i ica ion and combined supplemen a ion a e c ucial o apid hema ological co ec ion and p e en ion o long-
e m complica ions
Indi iduals wi h ch onic anemia equen ly exhibi ew o no symp oms, and he condi ion is o en de ec ed inciden ally
du ing ou ine labo a o y assessmen s. Al hough anemia has been linked o educed quali y o li e and a ious ad e se
heal h ou comes, hese associa ions a e no necessa ily causal and may be in luenced by con ounding ac o s. In p ima y
and ou pa ien ca e se ings, clinicians commonly ely on pa ien his o y and epo ed symp oms o guide hei
diagnos ic e alua ion.
App op ia e ea men esul s in d ama ic clinical and labo a o y esponses in mos pa ien s. Ou pa ien showed apid
and signi ican imp o emen in symp oma ic eco e y a e cobalamin and i on supplemen a ion.
Compliance wi h e hical s anda ds
Disclosu e o con lic o in e es
No con lic o in e es .
S a emen o in o med consen
In o med consen was ob ained om all indi idual pa icipan s included in he s udy.
Re e ences
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