Diagnostic clues to megaloblastic anaemia without macrocytosis

Masking of the macrocytic expression of megaloblastic anaemia (MA) by coexisting thalassaemia, iron deficiency and chronic illness has been widely reported. We described the haematological and clinical features of 20 Chinese patients with MA presenting with mean corpuscular volume (MCV) < or =99 fl, and analysed the steps leading to the final diagnosis of MA with concomitant thalassaemia trait (n = 11), thalassaemia trait and iron deficiency (n = 3), iron deficiency (n = 4) and chronic illness (n = 2). We also compared the haematological characteristics of this group of patients with a group of normocytic anaemic patients without vitamin B(12)/folate deficiency, and identified certain laboratory information useful for differentiating the two groups. Statistically significant parameters included the mean values of haemoglobin, MCV, red cell distribution width (RDW), reticulocyte index, platelet count and serum bilirubin. All provided clues to maturation disorders within the marrow. A decision flowchart for the diagnosis of MA without macrocytosis was proposed. In the studied population, by using the parameters of haemoglobin <10 g/dl, MCV 80-99 fl, RDW > or = 16% and reticulocyte index < or = 2% as indicators, there was a 58% chance that a patient had MA without macrocytosis if he/she had all the four indicators, and a 2.2% chance of having it if he/she did not have these indicators. We emphasized the importance of including peripheral blood smear examination in the diagnostic procedures for such patients, as well as the importance of paying attention to patients' medical history, racial background and previous MCV value.     

Is analysis of the reticulocyte haemoglobin equivalent a useful test for the diagnosis of iron deficiency anaemia in geriatric patients?

BackgroundIron deficiency anaemia (IDA) and anaemia of chronic disease (ACD) are common in elderly patients but there are no standard diagnostic criteria. The reticulocyte haemoglobin equivalent (Ret-He) is routinely measured by modern automated blood analysers and is an early indicator of iron deficiency. The aim of this study was to investigate whether the Ret-He level as calculated by the Sysmex XE-5000 automated blood analyser is a useful parameter for the diagnosis of IDA in a geriatric hospitalized population.MethodsIn a prospective study, blood samples were collected in 26 geriatric patients with IDA and 111 patients with ACD diagnosed according to generally accepted laboratory and clinical criteria. A blood count including Ret-He, mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC) and standard iron parameters was performed in each patient.ResultsHaemoglobin, Ret-He, MCV, MCH and MCHC levels were all significantly lower in IDA as compared to ACD patients. However, the area under the curve (AUC) was greater for MCH (0.87, 95% CI 0.78–0.95) and MCHC (0.86, 95% CI 0.76–0.96) then for Ret-He (0.828, 95% CI 0.73–0.93) and MCV (0.80, 95% CI 0.68–0.91). A Ret-He cut-off value of 26 pg had a sensitivity and specificity based on its optimal combination of 85% and 69% respectively.ConclusionAnalysis of Ret-He does not perform better than the classical red cell indices such as MCH and MCHC in differentiating IDA and ACD in geriatric patients.     

The value of the erythrocyte indices as a screening procedure in predicting nutritional deficiencies

The results of a large number of nutritional screen requests (n = 871) were compared with corresponding values of erythrocyte indices considered predictive of nutritional deficiencies to determine if such indices could be used in a prospective screening procedure to restrict the number of serum vitamin B12, folate, and ferritin assays. Low mean cell haemoglobins (MCH less than 27 pg) were found to be superior to low mean cell volumes (MCV less than 77 fl), in predicting low serum ferritin values. The occurrence of deficient ferritin values was 90% when the MCH was very low (MCH less than 23 pg). Vitamin B12 or folate deficiency could not be predicted from the MCV. A normal MCV was found in more than 55% of vitamin B12 deficient samples and some 30% of serum B12 deficients (less than 150 micrograms/l) showed no evidence of anaemia (Hb greater than 12 gm/dl) or macrocytosis (MCV less than 100 fl). It would not seem appropriate to use erythrocyte indices alone as a method of selecting samples for further investigation of folate or vitamin B12 status.     

An added value for the hemoglobin content in reticulocytes (CHr) and the mean corpuscular volume (MCV) in the diagnosis of iron deficiency in postpartum anemic women

Introduction: To evaluate the use of reticulocyte hemoglobin content (CHr) and mean corpuscular volume (MCV) to identify truly iron‐deficient women with postpartum anemia (PPA), in order to reduce unnecessary iron supplementation. Methods: Three hundred women with more than 500 mL of blood loss or clinical signs of anemia were divided in a control (Hb ≥ 10.5 g/dL, N = 150) and postpartum anemia group (PPA, Hb < 10.5 g/dL; N = 150). PPA women were given ferrous fumarate for a period of 4 weeks. Efficacy of the treatment was evaluated by comparing Hb, CHr, and MCV at baseline (T₀) and after 4 weeks (T₄). Using standard iron deficiency cut off values for MCV (80 fL) and CHr (28 pg) at T₀, we divided the PPA group of both parameters into two subgroups, one suggestive for iron deficiency and one suggestive for noniron deficiency. Results: Irrespective of the parameter or the subdivision, delta Hb concentrations (T₄–T₀) showed a similar increase in all PPA subgroups investigated. Both parameters in the PPA subgroups below their respective cut off value showed a significant improvement toward normalization, while the MCV and CHr in the PPA subgroups above their respective cut off value did not show any significant increase. Conclusion: Our data suggest that the etiology of the anemia in postpartum anemic women is not always iron deficiency. Using a combination of Hb, MCV and CHr, we increased the stringency to identify truly iron‐deficient postpartum anemic women, thereby reducing unnecessary iron supplementation in those women with sufficient iron stores.     

Causes of microcytic anaemia and evaluation of conventional laboratory parameters in the differentiation of erythrocytic microcytosis in blood donors candidates*

ABSTRACT

Context and Objective: Microcytic anaemia results from defective synthesis of haemoglobin in the erythroid precursors, causing a reduction in its mean corpuscular volume (MCV). The most common causes of microcytosis, without the increase in HbA₂ levels, are iron deficiency anaemia (IDA) and α-thalassemia. The aim of this study was to identify the causes of microcytic anaemia and evaluate the haematological parameters from blood donors deemed ineligible (due to the low haematocrit level) that would differentiate the IDA and α-thal, whether isolated or in association.

Methods: Genomic DNA was submitted to the polymerase chain reaction multiplex for the diagnosis of the most common allele deletions of α-thal and erythrogram and in order to verify haematological parameters. Iron deficiency (ID) was determined through the measurement of serum ferritin.

Results: Of the 204 samples, 82 (40.2%) were identified with ID, 24 (17.8%) with α-thal and 10 (4.9%) with ID associated with α-thal. In the α-thal with ID group haemoglobin (Hb), MCV, mean corpuscular Hb concentration (MCHC) and mean corpuscular Hb (MCH) values were significantly lower compared to the isolated α-thal. In the group with ID Hb, MCV, MCHC and MCH values were significantly lower compared to those with isolated α-thal. The α-thal with ID group, showed Hb, MCV, MCHC and MCH significantly reduced when compared to those with IDA.

Conclusions: This study showed that the values of haematological parameters, especially haematocrit, Hb, MCV, MCH, MCHC and red blood cell distribution width (RDW), are lower in patients with IDA, especially when associated with α-thal and therefore it may be useful to discriminate between the different types of microcytic anaemia.     

Serum transferrin receptor levels in patients undergoing evaluation of iron stores: correlation with other parameters and observed versus predicted results

Serum transferrin receptor (sTfR) concentrations were measured in specimens from 77 patients undergoing serum ferritin determination, and the results correlated with serum ferritin, serum iron, serum total iron-binding capacity (TIBC) saturation, erythrocyte mean corpuscular volume (MCV), and mean corpuscular haemoglobin (MCH). All parameters exhibited the expected inverse correlation with sTfR; this correlation was statistically significant for all parameters except serum iron concentration. The frequency with which iron deficiency (defined as absence of stainable marrow iron) is observed in patients with particular ferritin values in this centre was determined and used to estimate the expected number of iron deficient patients in the present study. In no setting were significantly fewer sTfR levels > 3.05 μg/ml observed than expected. However, significantly greater than expected numbers of elevated sTfR values were observed in patients with serum ferritin > 220 μg/l (P = 0.002). The results suggest that the sTfR level is probably not useful as a single test for identification of iron deficiency in unselected patients.     

Unrestricted growth of Plasmodium falciparum in microcytic erythrocytes in iron deficiency and thalassaemia

The mechanism(s) underlying the apparent resistance to malaria in certain inherited red cell disorders and iron deficiency anaemia remain poorly understood. The possibility that microcytic erythrocytes might inhibit parasite development, by physical restriction or reduced supply of nutrients, has been considered for many years, and never formally investigated. We sought to determine whether in vitro growth studies of P. falciparum could provide evidence to suggest that small red cell size contributes to malaria resistance in those red cell disorders in which microcytosis is a characteristic feature.
Invasion and development of P. falciparum in iron deficient red cells (mean values for mean cell volume [MCV] 66 fl, mean cell haemoglobin [MCH] 19 pg) and in the red cells of two gene deletion forms of α-thalassaemia (mean MCV 71 fl, MCH 22 pg) were normal, assessed both morphologically, and by ³H-hypoxanthine incorporation. Although parasite appearances were normal in all cell types, morphological abnormalities were noted in iron deficient and thalassaemic cells parasitized by mature stages of P. falciparum , notably cellular ballooning and extreme hypochromia of the red cell cytoplasm. Using electron microscopy, the red cell cytoplasm in parasitized thalassaemic cells showed reduced electron density and abnormal reticulation. Normal invasion rates were observed following schizogony in microcytic cells of both types.
Our findings indicate that whilst minor morphological abnormalities may be detected in parasitized iron deficiency and thalassaemic erythrocytes, development of P. falciparum in these conditions is not limited by small erythrocyte size.     

Investigation of microcytosis: a comprehensive approach

Abstract: Microcytosis is a highly prevalent finding during blood examination. This study investigates the causes of microcytosis (defined as mean corpuscular volume (MCV)<82 fl) in 466 patients referred to our laboratory for suspected hemoglobinopathy. The following data were obtained: Hb, MCV, serum iron, transferrin, ferritin, HbA2, HbF, isoelectric focusing of the Hb, gene mapping of chromosome 16 with Xba I and Bgl II and hybridization with an α- and a ζ-probe, inflammatory status. Results show that iron deficiency remains the first cause of microcytosis (35.2% of our patients), even in a selected population such as ours. Deletional α-thalassemia, probably the most frequent hemoglobinopathy throughout the world, represents the second most frequent cause of microcytosis (31.1%), followed by β-thalassemia heterozygous state (18.9%). Of our patients, 1.3% had microcytosis due to the presence of an abnormal hemoglobin (HbC, Hb S/C, HbE). Three cases (0.6%) had other possible causes of microcytosis. Of the remaining 60 cases, 28 had an inflammatory state. Finally, 32 cases (6.9%) remain unexplained; taking into consideration the origin of these cases, their hematological parameters and their family history, we postulate that these cases are at high risk for non-deletional α-thalassemia.     

Effective screening for double heterozygosity of Hb E/α0-thalassemia

One hundred and forty-one blood samples of hemoglobin E (Hb E) carriers were collected to define suitable cutoff values of Hb E level, mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH) as screening indicators for detecting individuals with double heterozygosity for Hb E/α^o-thalassemia. Based on the values that gave 100% sensitivity, Hb E < 26%, MCV < 74 fl, and MCH < 24 pg were selected. Further validation of these selected values in additional 152 heterozygous Hb E pregnant women revealed 100% sensitivity, 86.2% specificity, and a 25.9% positive predictive value (PPV) for using Hb E cutoff point only, meanwhile, 100% sensitivity, 83.4% specificity, and 22.6% PPV were achieved for the MCV cutoff point. In addition, 100% sensitivity, 86.3% specificity, and 25.9% PPV were gained for the MCH cutoff point. Combining Hb E level with either MCV or MCH cutoff points, the specificity and PPV were increased to 95.1% and 50.0%, respectively. It is concluded that Hb E level < 26%, MCV < 74 fl, and MCH < 24 pg could be used for screening α^o-thalassemia in heterozygous Hb E. However, to improve specificity and PPV of the tests, a combination of Hb E level < 26% with either MCV < 74 fl or MCH < 24 pg is recommended.     

Evaluation of microcytosis using serum ferritin and red blood cell distribution width

Out of 104 patients with microcytosis (MCV less than 80 fl), 69% had an iron deficiency, 21% a chronic disease and 10% hemoglobinopathy or thalassemia trait. The absence of bone marrow iron stores or the response to iron supplementation were used to establish the diagnosis iron deficiency. On the basis of sensitivity (90%) and specificity (100%), the serum ferritin concentration is more suitable for assessment of iron deficiency than the serum iron concentration, the total iron-binding capacity or the percentual saturation of transferrin. The red cell distribution width (RDW) is the parameter with the highest sensitivity for iron deficiency (94%). An RDW value within the reference interval can be used to exclude iron deficiency in those cases in which the serum ferritin concentration does not accurately reflect the iron stores owing to severe tissue damage, as in inflammation or malignancy.     

Quantitative anisocytosis as a discriminant between iron deficiency and thalassemia minor

The coefficient of variation (CV) of red cell size, as measured by electronic red cell sizing (erythrography), was less than 14.0% in 20 normal subjects. In 22 of 25 patients with beta-thalassemia minor and microcytosis (mean corpuscular volume [MCV] less than 70 fl), CV was less than 14.0%; in the other 3, CV was 14.0%--14.9%. In 53 patients with iron deficiency anemia and MCV less than 70 fl, CV always was greater than 14.0%. In 7 patients with alpha-thalassemia minor and MCV less than 70 fl, CV was less than 14.0% in all 7. Among patients with microcytosis, erythrography appears to be an excellent technique for rapidly distinguishing between iron deficiency and alpha or beta thalassemia minor.     

Hypersegmented neutrophils and vitamin B12 deficiency. Hypersegmentation in B12 deficiency

The sensitivities and specificities of the mean cell volume (MCV), the red cell distribution width (RDW), and blood smear hypersegmentation for B12 deficiency were reviewed in 515 patients whose B12 levels were determined. 61 patients had B12 levels less than 200 pg/ml. 43 patients were defined as B12 deficient (n = 13) or non-B12 deficient (n = 30). Hypersegmentation was more sensitive (91%) than MCV greater than 95 fl (62%) or RDW greater than 15% (54%) in detecting B12 deficiency. The MCV and the RDW should not be relied on when screening for B12 deficiency; examination of the blood smear for hypersegmentation is essential.     

Microcytosis in Hodgkin disease associated with unbalanced globin chain synthesis

A review of 162 patients with Hodgkin disease disclosed 36 with microcytic anemia (mean corpuscular hemoglobin values [MCV] less than 80 fl). Three patients had iron deficiency, and one had beta-thalassemia. Of the remaining 32 patients, 24 had microcytic anemia at the time of diagnosis of Hodgkin disease, and ten, including two patients with this finding initially, developed microcytic anemia in association with recurrence of Hodgkin disease. Seven patients with Hodgkin disease and normal MCV had normal alpha-to-beta-globin chain ratios (1.0 +/- 0.14). Seven patients with Hodgkin disease and MCV less than 80 fl had significantly lower alpha-to-beta chain ratios (0.66 +/- 0.05). Twelve normal controls and four with iron-deficiency anemia and MCV less than 80 fl had normal ratios. Anemia was corrected, and MCV returned to normal in all patients who responded to therapy for Hodgkin disease. In the two patients studied sequentially, abnormal alpha-to-beta-chain ratio was corrected along with the anemia.     

Population Screening and Prevention Strategies for Thalassemias and other Hemoglobinopathies of Eastern India: Experience of 18,166 cases

Abstract

We evaluated population screening programs (1999–2011), conducted by the Thalassaemia Foundation, Kolkata, India, for the first time in Eastern India in different districts of West Bengal, for prevention of thalassemia comprising screening of heterozygotes and β-thalassemia intermedia (β-TI) cases [β⁺, β⁺⁺, β⁰/β⁺, β^E/β^E (codon 26 or HBB: c.79G?>?A), Hb-E-β-thalassemia (Hb E-β-thal)]. Among 18,166 cases, we found 2092 heterozygotes and 2245 β-TI individuals (who had no information about their disorders). Results were evaluated with standard hematological analyses including erythrocyte indices, hemoglobin (Hb) typing and quantification. Participants were divided into five groups (children, pre-marriage cases, pre-pregnancy cases, affected family members, pregnant women). The objectives of this evaluation were to fix cut-off values of red blood cells (RBCs), mean corpuscular volume (MCV), mean corpuscular Hb (MCH), red blood cell distribution width (RDW) and Hb A₂, as the standard World Health Organization (WHO) guidelines were not strictly followed in mass-scale screening programs. We have observed many dilemmas in considering the status of the thalassemia subject, due to presence of some other clinical conditions such as iron deficiency anemia, α-thalassemia (α-thal), δ-thalassemia (δ-thal), clinically silent Hb variants, and some cases of non hemoglobinopathies (such as pregnancy) along with thalassemia. The MCV values varied greatly in different conditions of hemoglobinopathies, whereas MCH provided a more stable measurement. We found an MCH value of <27.0?pg is a suitable cut-off point for screening in this population. Participants with an MCH of <27.0?pg should be investigated further to confirm or exclude a diagnosis of β-thal trait.     

Screening and Diagnosis of Hb Quong Sze [HBA2: c.377T > C (or HBA1)] in a Prenatal Control Program for Thalassemia

Hb Quong Sze [Hb QS, HBA2: c.377T?>?C (or HBA1)] is a common nondeletional thalassemia in southern China. It is one of the major alleles causing nondeletional Hb H (β4) disease in the Chinese population. There is no strategy currently in place that aims to screen using hematological index cutoffs for this variant. This study was carried out to evaluate whether it is effective to use mean corpuscular hemoglobin (MCH) <27.0?pg as a screening test in the first step of screening for Hb QS carriers in southern China. The data of hematological testing in the Hb QS carriers obtained from couples who underwent prenatal thalassemia screening, regardless of the red blood cell (RBC) indices, were retrospectively reviewed. A total of 51 Hb QS carriers were identified, giving a prevalence rate of 0.2%; among these, 45 were Hb QS heterozygotes. The values of hemoglobin (Hb), MCV and mean corpuscular Hb (MCH) in the 45 Hb QS heterozygotes were 13.2?±?1.8?g/dL, 75.2?±?3.3?fL and 24.5?±?0.5?pg, respectively. Eight heterozygotes (17.8%) had an MCV value of >80.0?fL, ranging from 80.9 to 84.1?fL, and would not be detected using the cutoff value of MCV <80.0?fL as a criterion for thalassemia screening. However, if screening had been based on the MCH <27.0?pg value, all 45 Hb QS heterozygotes would have been detected. Using a cutoff value of MCH <27.0?pg in nondeletional thalassemia screening would greatly decrease the DNA diagnosis burden.     

Proposed Screening Criteria for β-Thalassemia Trait During Early Pregnancy in Southern China

This study was carried out to evaluate whether it is effective to use mean corpuscular volume (MCV) <80 fL as a screening test in the first step of screening for β-thalassemia (β-thal) trait in southern China. The data of hematological testing in the first or early second trimester of gestation of 449 pregnant women who underwent prenatal diagnosis for β-thal were retrospectively reviewed. Of these, six (1.3%) had an MCV value >80 fL, ranging from 80.3 to 83.4 fL. This meant that six at-risk pregnancies would have been missed if only an MCV cut-off value of <80 fL had been used for screening. All subjects having a normal MCV value carried the same ?28 (A>G) mutation, accounting for 9.8% (6/61) of the total number of mother with this mutation. If screening had been based on the mean corpuscular hemoglobin (MCH) <27 pg, all 449 pregnant women with β-thal trait would have been detected. We suggest that all pregnant women presenting at an antenatal clinic with an MCH of <27 pg rather than an MCV of <80 fL should be investigated further to confirm or exclude a diagnosis of β-thal trait in our region.     

α0-Thalassemia Trait with Normal Red Cell Indices: A Report of Two Cases

Thalassemia screening usually involves cut-off values based on a mean corpuscular volume (MCV) of less than 80 fL or a mean corpuscular hemoglobin (MCH) of less than 27 pg. These strategies are able to detect almost all heterozygous carriers of the α-thalassemia (α-thal) (– –^SEA) deletion in the Chinese population. However, an exception can occur. We describe an α⁰-thal trait with normal red cell indices in two Chinese individuals.     

Significance of Large Red Blood Cells

S ummary . Two observers examining marrow films from 81 patients for the presence of normoblastic and megaloblastic haemopoiesis obtained good agreement when the underlying disorder gave rise to definite vitamin B₁₂ or folate deficiency confirmed by microbiological assay. When microbiological assay of serum vitamin B₁₂ and red cell folate excluded vitamin B₁₂ or folate deficiency, the marrow changes were often too minor in degree for decisive diagnosis despite the presence in many cases of large red cells.
The normal mean corpuscular volume (MCV) set in relation to a PCV excluding trapped plasma was 80–90 fl. The MCV of red cells was often elevated above 90 fl in patients without a megaloblastic anaemia and in this series was often above 100 fl in patients with aplastic anaemia, sideroblastic anaemia, myxoedema, and neoplasia. The larger the red cells, however, the more probable was the presence of megaloblastic haemopoiesis in the marrow.     

Clinical and haematological features in a compound heterozygote (HBB:c.92 + 5G > C/HBB:c.93-2A > C) case of thalassaemia major

An Indian Muslim boy was diagnosed with thalassaemia major at 3 months of age. His blood investigations revealed haemoglobin: 5.3 gm%, MCV: 68 fl, MCH 26.6 pg, MCHC: 39%, haemoglobin variant analysis: HbA₂: 2.8%, HbF: 20.3% and HbA: 75.2% (post-transfusion). His fathers’ haemoglobin was 10.2 gm%, MCV: 68 fl, MCH: 23.9 pg, MCHC: 35% HbA₂: 4.7%, HbF: 0.7% and HbA: 85.2% and his mothers’ haemoglobin was 10.9 gm%, MCV: 67.4 fl, MCH 22.6 pg, MCHC: 33.5%, HbA₂: 5.3%, HbF: 0% and HbA: 85.4%. The boy was found to be compound heterozygote for beta globin gene mutations (HBB:c.92 + 5G > C/HBB:c.93-2A > C). The mutation HBB:c.93-2A > C was inherited from his father. This report confirms the presence of HBB:c.93-2A > C in the Indian subcontinent and has important implications for screening and prenatal diagnosis of beta thalassaemia. This report also supports inclusion of this mutation in the beta globin gene mutation database.     

Prevalence of hematinics deficiency amongst female students and its correction

Background

Nutritional anemia (NA) is common in India. While iron deficiency (ID) is a well recognized cause of NA, prevalence of deficiencies of other hematinics is not systematically investigated.

Setting

Seventy students of a junior class of a polytechnic and 202 inmates of girl students home were taken up for study.

Methods

Students were given a questionnaire to elicit anemia related symptoms. Blood was collected for complete blood count (CBC), serum ferritin, folic acid and vitamin B12. Students of polytechnic received hematinic at bed time during their menstrual periods whereas inmates of students home received hematinic at bed time, 3 days in a week. After 6 months blood tests were repeated in those who completed the treatment. CBC was done on Coulter counter and ferritin, folic acid and vitamin B12 were assayed by chemiluminescence. Students were divided into three groups-(1) Control group with Hb 12.0 g/dl or more and ferritin 15.0 ng/ml or more; (2) ID Group with Hb 12.0 g/dl or more and ferritin less than 15.0 ng/ml; and (3) Iron Deficiency Anemia (IDA) group with Hb less tha 12.0 g/dl and ferritin less than 15.0 ng/ml.

Statistics

Basal parameters of three groups were compared using students t test. Change in parameters with treatment was compared using paired students t test.

Results

Median age-16 years (range 10–25). Anemia ( Hb < 12.0 g/dl)-94 (34.6%); MCV < 80 fl-153 (56.3%); MCH < 27 pg-167 (61.4%); Ferritin < 15.0 ng/ml-161 (59.2%); Folic acid < 3.5 ng/ml-34 (12.5%); Vitamin B12 < 258 pg/ml-133 (48.9%) Pre-therapy: (1) Hb, MCV, MCH and ferritin significantly lower in ID and IDA Groups compared to control group. (2) Hb, MCV, MCH and Ferritin significantly lower in IDA Group as compared to ID Group.

Post-therapy

(1) IDA group showed significant increase in Hb, MCV, MCH, ferritin, folic acid and vitamin B12. (2) final Hb (11.26+1.07) and ferritin (7.46+4.81) in IDA Group were subnormal. (3) MCV, MCH, ferritin, folic acid and vitamin B12 increased significantly in ID Group and control group.

Conclusions

(1) Nutritional anemia is common amongst asymptomatic young female students. (2) Deficiencies of iron, folic acid and vitamin B12 are common and coexist. (3) 105 mg elemental iron for 3 days in a week for 6 months is not adequate to correct IDA. (4) 105 mg iron for 3 days in a week is enough to correct ID. (5) Non-anemic individuals with ID have iron deficient erythropoiesis. (6) Non-anemic individuals without ID, in this cohort, also had iron deficient eryhtropoiesis.