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IJCRR - 7(16), August, 2015

Pages: 49-53

Date of Publication: 21-Aug-2015

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A DETAILED STUDY OF THE ROLE OF SERUM FERRITIN AS THE INDICATOR OF IRON STORES IN SEVERE HOOKWORM INFECTION DIAGNOSED BY DOING ENDOSCOPY

Author: Govindarajalu Ganesan

Category: Healthcare

Abstract:Objective: Severe anaemia is reported to occur in severe hookworm infection in many studies. But so far detailed study of the role of serum ferritin as the indicator of iron stores and iron status in patients with severe anaemia due to hookworm infection diagnosed by doing upper gastro intestinal endoscopy was not done. Hence a detailed study of the role of serum ferritin as the indicator of iron stores and iron status in patients with severe anaemia due to hookworm infection diagnosed by doing upper gastro intestinal endoscopy was done in our institute. Methods: A study of 1259 patients who had undergone upper gastro-intestinal endoscopy for a period of 5 years from May 2009 to April 2014 was carried out in our institute. In each of these 1259 patients, the first and second part of duodenum were carefully examined to find out the presence of hookworms. In all the patients found to have hookworms in duodenum, investigations were done to know about the presence of anaemia except in the very few patients who were lost for follow up. In patients with severe anaemia [haemoglobin < 7g/dl or g%] peripheral smear examination was also done in addition to haemoglobin estimation . But in one patient with severe anaemia, measurement of serum ferritin which indicate the iron stores and iron status was also done in addition to haemoglobin estimation and peripheral smear examination. The results were found as given below. Results: Of these 1259 patients, as many as 18 patients were found to have hookworms in duodenum while doing upper gastrointestinal endoscopy. Of these 18 patients, 4 patients were lost for follow up and full details about their investigations were not available. The remaining 14 patients were taken into consideration for our study. Of these14 patients, 9 patients had anaemia and 2 of these 9 patients were found to have severe anaemia [haemoglobin 3.2g%, 2.1 g%.] The peripheral smear of both the patients showed severe hypochromic anaemia. In one patient with severe anaemia [haemoglobin 3.2g%] in whom serum ferritin which indicate the iron status and iron stores was also done, serum ferritin was extremely low.
Conclusion: Hence measurement of serum ferritin could reveal iron stores and deteriorating iron status in patients with severe anaemia due to hookworm infection.

Keywords: Severe anaemia, Hookworm infection, Serum ferritin, Iron stores, Upper gastro intestinal endoscopy

Full Text:

INTRODUCTION

Severe anaemia is reported to occur in severe hookworm infection in many studies (1to17). But so far detailed study of the role of serum ferritin as the indicator of iron stores and iron status in patients with severe anaemia due to hookworm infection diagnosed by doing upper gastro intestinal endoscopy was not done. Hence a detailed study of the role of serum ferritin as the indicator of iron stores and iron status in patients with severe anaemia due to hookworm infection diagnosed by doing upper gastro intestinal endoscopy was done in our institute.

MATERIALS AND METHODS

This study was conducted in the department of general surgery, Aarupadai Veedu Medical College and Hospital, Puducherry. A study of 1259 patients who had undergone upper gastro-intestinal endoscopy in our institute for a period of 5 years from May 2009 to April 2014 was carried out. In each of these 1259 patients, the first and second part of duodenum were carefully examined to find out the presence of single or multiple hookworms. In all the patients found to have hookworms in duodenum, investigations were done to know about the presence of anaemia except in the very few patients who were lost for follow up. Anaemia is defined as haemoglobin < 12g/dl or 12g% in women and haemoglobin < 13g/dl or13g% in men. Severe anaemia is taken as haemoglobin <7g/dl or g% . In patients with severe anaemia [haemoglobin <7g/dl or g%] peripheral smear examination was also done in addition to haemoglobin estimation . But in one patient with severe anaemia, measurement of serum ferritin which indicate the iron stores and iron status was also done in addition to haemoglobin estimation and peripheral smear examination . The results were found as given below.

RESULTS
Of these 1259 patients, as many as 18 patients were found to have hookworms in duodenum while doing upper gastro-intestinal endoscopy. Of these 18 patients, 4 patients were lost for follow up and full details about their investigations were not available. The remaining 14 patients were taken into consideration for our study. Of these14 patients, 9 patients had anaemia and 2 of these 9 patients were found to have severe anaemia [haemoglobin 3.2g%, 2.1 g%].

a. Investigations done in the patient with haemoglobin 2.1 g%.

In addition to haemoglobin estimation, peripheral smear examination was also done in the patient with haemoglobin 2.1 g% which showed severe hypochromic anaemia.

b. Measurement of serum ferritin which indicate the iron stores and iron status in the patient with haemoglobin 3.2g%

In this patient with severe anaemia (haemoglobin 3.2g%) , serum ferritin which indicate the iron status and iron stores was also done in addition to haemoglobin estimation and peripheral smear examination.

Serum ferritin[ stored iron].

Normally much of the stored iron in the body (about 1 g in men and less in pre-menstrual women and children) is present as ferritin. When iron is present in adequate amounts, ferritin synthesis is promoted and iron storage occurs. Ferritin concentration is an important indicator of total body iron stores.

The function of ferritin

Ferritin is an iron storage protein that keeps iron in a soluble and non-toxic form. The major function of ferritin is clearly to provide a store of iron which may be used for haem synthesis when required. The range of normal serum ferritin is18-160 ng/ ml or μg/l and a concentration of <12–15 ng/ml or μg/l is taken to indicate deficient iron stores.

Decreased serum ferritin[deficient iron stores] in hookworm infection.

Since serum ferritin level measures the total amount of iron stored in the body, low level of serum ferritin [serum ferritin<12 μg/L or ng/ml] indicates exhausted iron stores (21). Thus iron stores and iron status is assessed by serum ferritin concentration and hookworm infection is associated with the worst iron status (21). Many studies have also shown low level of serum ferritin indicating exhausted and low iron stores due to depletion of iron resulting from loss of blood in severe hookworm infection (18-22).

Decreased serum ferritin [deficient iron stores] in our patient.

In our patient also with severe anaemia due to severe hookworm infection diagnosed by doing upper gastro intestinal endoscopy, serum ferritin is very low-1.4 ng/ ml [normal range 18-160 ng/ ml] indicating exhausted iron stores and very poor iron status. Other studies have also shown low level of serum ferritin in patients with severe anaemia due to severe hookworm infection diagnosed by doing endoscopy (1, 10).

Decreased serum ferritin [indicator of deteriorating iron status].

Measurement of serum ferritin concentration could reveal deteriorating iron status even before the haemoglobin concentration had fallen below the normal value (20). In a very important study, among patients with hookworm infection as many as 42 patients had low level of serum ferritin but with normal blood haemoglobin concentration (20).

DISCUSSION

Iron has the capacity to accept and donate electrons readily, interconverting between ferric (Fe3+) and ferrous(Fe2+) forms. This capability makes it a useful component of cytochromes, oxygen-binding molecules (ie, hemoglobin and myoglobin), and many enzymes.

Total body iron and stored iron

Total body iron is about 3.5 gm in healthy men and 2.5 gm in women. About1.5 to 2 gm of this total iron is found in red blood cells as heme in hemoglobin and 0.5 to 1 gm occur as storage iron [mainly ferritin], in bone marrow, spleen, and liver mainly, with the remainder in myoglobin and in enzymes that require iron. Normally much of the stored iron in the body (about 1 gm in men and less in pre-menstrual women and children) is present as ferritin. Thus in pre-menstrual women body iron stores or body iron of >or=500 mg is normal. This is shown in many studies conducted by Milman in Scandinavia.

Studies conducted by Milman in Scandinavia.

These studies have shown that

1. The recommended dietary iron intake is 15 mg/ day(12- 18 mg/day) . But majority of women have an intake below this level .

2. Serum ferritin levels >70 microg/l corresponds to body iron of >or=500 mg.

3. Serum ferritin levels

First study conducted by Milman in Scandinavia.

More than 90% of Scandinavian women of reproductive age have a dietary iron intake below the recommended 15 mg/ day (23). An adequate iron status during pregnancy implies body iron stores or reserves ≥500 mg at conception, but only 15-20% of Scandinavian women have iron reserves of such a magnitude in a study conducted by Milman in Scandinavia (23). Among nonpregnant women of reproductive age, ∼40% have plasma ferritin ≤30 μg/l, i.e. an unfavorable iron status with respect to pregnancy (23).

Second study conducted by Milman in Scandinavia.

Dietary iron intake in fertile women is median 9 mg/day. i.e. the majority of women have an intake below the estimated allowance of 12- 18 mg/day(24) . Among fertile women, 20% have iron reserves of >500 mg, which is the required minimum during pregnancy; 40% have iron stores of 100- 500 mg, and 40% have virtually no iron stores in another study conducted by Milman et al. in Scandinavia (24).

Third study conducted by Milman in Scandinavia.

42% of non-pregnant women have serum ferritin levels 70 microg/l corresponding to body iron of >or=500 mg. Non-pregnant women have a low iron status (25). Thus iron status and body iron can be monitored using serum ferritin(25) .

Fourth study conducted by Milman in Scandinavia.

Iron deficiency was defined by serum ferritin <12 microg/l in pregnancy and <15 microg/l postpartum in another study conducted by Milman in Scandinavia (26).

Study conducted by Hallberg et al.

In clinical practice the gold standard to estimate iron stores is to stain a bone marrow aspirate for iron, but this is not practical to do during population surveys, so alternative methods have been sought(27). Hallberg et al. determined the serum ferritin concentration of 203 women aged 38 years who had undergone bone marrow examination(27) .They concluded that a value of <15 μg/l was the best predictor of iron deficiency (confirmed by an absence of stainable iron in the bone marrow) (27).

Serum ferritin levels closely correlate with total body iron stores.

Ferritin concentration is an important indicator of total body iron stores and a concentration of 100 μg/l indicate the presence of storage iron (27).

World Health Organization recommendation

The range of normal serum ferritin is30–300 ng/mL (=μg/L) for males, and 15–200 ng/mL (=μg/L) for females and the mean is 88 ng/mL(=μg/L) in men and 49 ng/mL(=μg/L) in women. The World Health Organization recommends that a serum ferritin concentration 5 years of age (27).

Decreased serum ferritin in hookworm infection in 3 studies.

Serum ferritin was a valuable indicator of iron stores in populations infected with the helminths(27). Iron deficiency has generally been defined as an absence of iron stores [ferritin]. In many regions where iron deficiency is of great public health importance malaria, hookworm and other parasitic infections are endemic (27). In adults with hookworm infection serum ferritin concentrations is inversely correlated with the intensity of infection (27).

First study conducted by Albonico M et al

In the study conducted byAlbonico M et al, 492 children with hookworm positive faecal cultures, ferritin concentrations decreased with increasing proportions of Ancylostoma duodenale. Among children with only Necator americanus larvae, the prevalence of ferritin or =50% Ancylostoma duodenale larvae, the prevalence of ferritin <12 microg/l was 58.9 % (28).

Second study conducted by Bakta I. M et al

In the study conducted by Bakta I. M et al, there was a significant negative correlation between serum ferritin level and hookworm egg count(28).

Third study conducted by Pritchard DI et al

There was also a significant negative correlation between plasma ferritin level and hookworm burden in the study conducted by Pritchard DI et al (19).

Decreased serum ferritin in relation to number of hookworms

Up to a burden of 100-200 worms there is rather little effect on blood iron or serum iron, whereas there is a much larger effect on the stored iron (serum ferritin) in the study conducted by Crompton DW et al (20).

Decreased serum ferritin associated with worse iron status in hookworm infection.

Infection with malaria, Trichuris trichiura, Ascaris lumbricoides, and hookworms were all associated with worse iron status; the association with hookworms was strongest by far. In multivariate analyses, hookworm infection intensity was the strongest explanatory variable for serum ferritin (21).

CONCLUSION

Hence measurement of serum ferritin could reveal iron stores and deteriorating iron status in patients with severe anaemia due to hookworm infection.

ACKNOWLEDGEMENT

The author acknowledges the immense help received from the scholars whose articles are cited and included in references of this manuscript. The author is also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. The author is extremely grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.

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A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR.
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award

A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award

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A DETAILED STUDY OF THE ROLE OF SERUM FERRITIN AS THE INDICATOR OF IRON STORES IN SEVERE HOOKWORM INFECTION DIAGNOSED BY DOING ENDOSCOPY

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