ORIGINAL ARTICLE
Refractory Iron-deficiency Anemia and Autoimmune Atrophic Gastritis in Pediatric Age Group: Analysis of 8 Clinical Cases Natalina Miguel, MD,* Emı´lia Costa, MD,w Marta Santalha, Jr, MD,z Rosa Lima, MD,y Jose´ Ramon Vizcaino, MD,8 Fernando Pereira, MD,y and Jose´ Barbot, MDw
Introduction: Refractory iron-deficiency anemia with no obvious etiology in pediatric age can be a puzzling problem. Screening of iron malabsorption conditions, including autoimmune atrophic gastritis (AAG), is emerging as a priority in the investigational procedure. Materials and Methods: Retrospective analysis of clinical process of children/adolescents with the diagnosis of AAG. Results: Eight patients (aged between 4.7 and 18 years old) were identified. The diagnosis was triggered on the basis of high serum gastrin levels and strong positivity of antiparietal cell antibodies. Upper endoscopy and biopsy revealed atrophic gastritis in all patients, with 2 of them with intestinal metaplasia. Four patients presented with Helicobacter pylori infection object of eradication therapy. After a medium follow-up of 36.6 months, antiparietal cell antibodies and hypergastrinemia did not show evidence of regression. Of the 3 patients who underwent endoscopic reevaluation, a similar anatomo-pathologic pattern was observed in 2 and intestinal metaplasia in 1 patient. Normalization of hematological parameters was achieved, using alternative iron formulas. Conclusions: AAG must be recognized as a pathology affecting pediatric patients. Gastric autoimmune lesion is a chronic process with potential evolution to malignancy. Management guidelines in childhood are not available. Their elaboration is important considering an important risk factor in these age group: a long life expectancy. Key Words: refractory iron-deficiency anemia, hypergastrinemia, autoimmune atrophic gastritis, Helicobacter pylori infection, ferrous glycine sulfate
(J Pediatr Hematol Oncol 2014;36:134–139)
I
ron-deficiency anemia (IDA) is the most common form of microcytic and hypochromic anemia worldwide.1–3 The age groups at a higher risk are nursing infants, teenagers, and women of childbearing age.1,3,4 Refractory iron-deficiency anemia (rIDA) is defined by the lack of response to iron ingestion treatment prescribed for at least 2 months.1 Evaluation of an rIDA condition can be complex. Inadequate ingestion, occult blood loss, Received for publication August 20, 2012; accepted October 16, 2013. From the *Department of Pediatrics, Centro Hospitalar Tra´s-osMontes e Alto Douro, Vila Real; Departments of wHematology; yPediatric Gastroenterology; 8Pathology, Centro Hospitalar do Porto, Oporto; and zDepartment of Pediatrics, Centro Hospitalar do Alto Ave, Guimara˜es, Portugal. The authors declare no conflict of interest. Reprints: Natalina Miguel, MD, Servic¸o de Pediatria do Centro Hospitalar Tra´s-os-Montes e Alto Douro, Avenida da Noruega, 5000514 Vila Real, Portugal (e-mail: [email protected]). Copyright r 2013 by Lippincott Williams & Wilkins
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absorption disorders, and, rarely, metabolic abnormalities must be considered. Investigational sequence depends on the clinical presentation and patient age. Absorption deficiency has been receiving increasing attention as a cause of rIDA. Historically, celiac disease was the main condition interfering with iron absorption investigated by pediatricians. Two other pathologies were more recently recognized: Helicobacter pylori infection (Hp) and autoimmune atrophic gastritis (AAG).1–6 In this context, Hershko proposed an algorithm for IDA diagnostic work-up. In pediatric patients, oral iron therapy can be introduced without an exhaustive diagnostic approach. Inadequate response, in the absence of an obvious cause, requires a screening of malabsorption disorders, based on noninvasive methods (antigliadin/antiendomysial antibodies, c-urea breath test, antiparietal cell antibodies, and serum gastrin levels), before endoscopic evaluation.3 AAG was, for many years, considered a disease affecting only elderly patients. The underlying hematological anomaly was pernicious anemia. Studies published until 2009 by Hershko proved that AAG is not exclusively an adult disease and that pernicious anemia is not the only hematological anomaly associated. IDA can be the hematological presentation and can precede by many years the clinical onset of pernicious anemia. The author studied 160 patients with AAG, using as diagnostic criteria hypergastrinemia and strong positivity of gastric antiparietal cell antibodies. Eighty-three (52%) of them presented with IDA. This group of patients was about 21 years younger than the other group with macrocytosis. There was a higher prevalence of female patients. Marignani et al7 compared 2 groups of patients with AAG. The group of patients with microcytic anemia was 20 years younger than the other with macrocytosis. Chlorydric acid is essential for solubilization and reduction in food iron, conditions that are critical for its normal absorption. Autoimmune process damages the parietal cells and determines atrophic gastritis (AG), resulting in deficient gastric acidity. Hp infection has been proven to be a cause of rIDA by a number of possible mechanisms such as occult blood loss, dietary iron competition, interference with gastric acid secretion and with gastric ascorbate levels and AG caused by inflammation.8,9 Eradication therapy normalizes the hematological picture. In some patients with AAG, a complete remission of AG was observed after Hp eradication.1,2,10–13 However, the Hp’s role as the trigger agent of the autoimmune process is still under discussion.1,2,4,5,9 Iron-alternative formulas bypassing duodenal absorption (intravenous iron) or gastric hypochlorhydria (ferrous glycine sulfate) proved to be effective in the resolution of
J Pediatr Hematol Oncol
Volume 36, Number 2, March 2014
J Pediatr Hematol Oncol
Volume 36, Number 2, March 2014
IDA and AAG in Pediatric Age
Oral iron challenge study with elemental iron as ferrous sulphate/hydroxide Serum iron (µg/dl) Our patients 400 350 300 250 200 150 100 50 0
Patients with IDA but normal absorption
1
2
3
4
Hours after iron load
5
FIGURE 1. Oral iron absorption (ferrous hydroxide/sulfate): after a loading dose of 2 mg of oral iron, at time 0, followed by measuring of serum iron at 1, 2, 3, and 4 hours. The expected answer in our patients was different from that observed in patients with iron-deficiency anemia but normal absorption after a load of 2 mg of oral elemental iron.
rIDA.14 However, medical literature is scarce about the management of mucosal gastric chronic immune aggression in such a young group of patients. A potential increase in the risk of gastric cancer and pernicious anemia are not yet objects of follow-up and therapeutic guidelines in pediatric age.
Sequential study on patients considered as having evidence of AAG included upper endoscopy, and gastric biopsy under general anesthesia (antrum, antrum/corpus, or antrum/corpus/fundus) was conducted and the biopsy fragments (1.5 to 2.5 mm in diameter) were placed in formalin, fixed in paraffin, and stained using hematoxylineosin and modified Giemsa. Diagnosis of Hp infection was based on identification of the bacteria in the stomach. Review of gastric biopsy plaques was conducted in a blinded manner. AG was defined as a replacement of native glands by the connective tissue or intestinal-type epithelium13,14 (Fig. 3). Gastritis staging and grading were recorded according to the Sydney criteria from 0 to 3 (absent, light, moderate, and strong16–21; Table 2). Autoimmunity of patients in whom the diagnosis of AAG was made was evaluated by the following parameters: antinuclear antibodies, antiphospholipid antibodies, antidouble-stranded DNA antibodies, antithyroid antibodies, anti-intrinsic factor antibodies, and direct antiglobulin test. Serum immunoglobulin levels were also documented. Cobalamin levels had been assessed in 62,5% of AAG patients. All patients were treated with an alternative iron formula: intravenous (IV) iron (sacarose ferrous hydroxide) and oral ferrous glycine sulfate. Those exhibiting some evidence of Hp infection received eradication therapy in accordance with the Maastricht III-2000 guidelines.22
MATERIALS AND METHODS Our retrospective study includes patients aged below 18 years, in whom the diagnosis of AAG was made in the context of investigation of rIDa of unknown etiology. Diagnosis methodology, followed by Hershko et al3 workup algorithm oral iron refractoriness, was concluded after 2 months of therapeutic failure.1 Obscure etiology was concluded after the exclusion of dietary errors, therapeutic noncompliance, gynecologic, or occult fecal blood loss. Iron malabsorption screening methodology included serologic parameters for celiac disease, respiratory or serologic test for Hp infections, antiparietal cell antibodies of AAG, and serum gastrin level as indirect markers of hypochloridria. Serum gastrin levels were measured by chemiluminescence. Hp infection was explored using the c-urea breath test and/or additional serologic investigation (ELISA, assessing Hp-IgG and IgA levels). Serum antiparietal cell antibodies titers were measured using FEIA and immunofluorescence. Iron malabsorption was suspected by an oral iron challenge study with ferrous sulfate or hydroxide-ferric polymaltose, as described by Hartman and Barker (Fig. 1).15 After a loading dose of 2 mg of oral iron, at time 0, serum iron was dosed at 1, 2, 3, and 4 hours. Hypochloridric condition was confirmed in 2 patients with a similar study with ferrous glycine sulfate, according to Hershko et al (Fig. 2).14 Strong evidence of AAG was considered on the basis of positivity of the antiparietal cell antibodies associated with high serum gastrin levels.
RESULTS We found 8 patients, aged between 4 and 18 years (average, 12.3 y), 2 male and 6 female considered as having evidence of malabsorption and laboratory and anatomopathologic criteria of AAG (Table 1). The average interval between the diagnosis of IDA and AAG was 21.4 months (range, 5 to 53 mo). The average hematologic parameters at AAG diagnosis were: hemoglobin 9.25 g/dL (8 to 11 g/dL),
Oral iron challenge study with ferrous glycine sulphate Our patients
Serum iron (µg/dl) 350
Patients with IDA but normal absorption
300 250 200 150 100 50 0
Hours after oral iron load 1
2
3
4
5
FIGURE 2. Oral iron challenge with ferrous glycine sulfate. After an iron loading in fasting of 2 mg of this formula, our patients revealed a later absorption than the observed in iron-deficient patients with normal absorption after a loading of 2 mg of ferrous sulfate. r
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15 y
6y
5 mo
4y
18 y
3
4
5
6
7
13.8
18
6
4.7
6
18
16
16
Sex
Male
Female
Male
Female
Female
Female
Female
Female
8.8 63.2 18.3 8.6 61.4 19.5 9.5 71.2 18 8.9 66 16.4 9.9 56 16.5 11 70.5 16.8 9.3 62.9 16.2 8 60 16.2
Hemoglobin (g/dL) MCV (fL) RDW (%)
8 8.3
2 2.3
7 8
3 3.8
9 2.9
8
5
10
53
5
36
15
1.5 1 12
41
Duration of Treatment With Oral Iron (mo)
5 3
Transferrin Saturation (%) Ferritin (ng/mL)
417
300
547
558
535
672
429
556
119
97.4
147.1
172
215
158.2
250
172
No
—
No
—
—
No
—
Yes Negative
Yes Negative
No
—
Yes Negative Yes Negative
Yes Negative
No
Yes Negative Yes Negative
Yes Positive
Yes Negative Yes Negative
Yes Positive
Negative
Negative
Negative
Negative
Negative
ANAs +
Negative
Negative
Autoimmunity: Breath Test Serum Gastrin ANAs, APLAS, c-Urease Hp Serology Level Antigastric Parietal Anti-ds-DNA, (n < 100 pg/ Cell Antibodies Yes/ Positive/ Yes/ Positive/ Thyroid Antibodies mL) (n < 25 U/mL) No Negative No Negative Positive/Negative
J Pediatr Hematol Oncol
r
ANAs indicate antinuclear antibodies; anti-ds-DNA, antibodies against double-stranded DNA; APLAs, antibodies against antiphospholipid; Hp, Helicobacter pylori infection.
13 y
15 y
2
8
13 y
1
Age at Age at Patient Diagnosis Diagnosis Number of IDA of AAG (y)
TABLE 1. Characteristics of Our Patients
Miguel et al Volume 36, Number 2, March 2014
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Volume 36, Number 2, March 2014
IDA and AAG in Pediatric Age
formulas, 3 with IV iron (#1, 4, 6) and 5 with ferrous glycine sulfate (#2, 3, 5, 7, 8; Table 3). Follow-up was lost in 2 patients. The other 6 patients have an average follow-up of 36.6 months (7 to 67 mo). Three patients were reevaluated 2, 4, and 5 years after initial diagnosis (#8, 6, and 4). The first two patients showed anatomo-pathologic pattern identical to the first study. The third patient had already a previous successful treatment with IV iron in the absence of etiological diagnosis. One year later, facing IDA recurrence, AAG diagnosis was made and a new therapeutic approach with ferrous glycine sulfate resulted again in the normalization of the hematological picture. A progressive and a 3-fold increment of serum gastrin levels led us to repeat endoscopic evaluation 60 months after the diagnosis. It was documented de novo Hp infection and the emergence of IM. FIGURE 3. PAS/Alcian blue staining of the gastric tissue ( 100). Atrophic gastritis is evident; glands are replaced by fibrotic material and a lymphomononuclear inflammatory infiltrate may be noted (inset: 200 showing intestinal tissue metaplasia).
MCV 63.9 fL (56 to 71.2 fL), and RDW 17.23%. Ferritin average was 4.18 ng/mL (1 to 8.3 ng/mL). Iron absorption tests were indicative of absorption deficiency (Fig. 1). All patients had hypergastrinemia and expressed high serum levels of antibodies against the gastric parietal cells. Four of the patients (#1, 3, 5, and 7) showed evidence of Hp infection (AAG/Hp +) at diagnosis. One patient (#7) revealed anatomo-pathologic demonstration of Hp infection, despite a normal c-urease test. The histologic pattern of gastritis was not discriminative between patients with or without Hp infection. Intestinal metaplasia (IM) was demonstrable in 2 patients (Fig. 3), 1 AAG/Hp + (#7) and 1 AAG/Hp (#8; Table 2).16–21 Gastric dysplasia was not found in any patient. One patient (#3) had an additional marker of autoimmunity at diagnosis (Table 1). Cobalamin levels, assessed in 5 patients (#1, 2, 5, 6, and 7), were normal. Normalization of hematological and iron biochemical parameters was achieved in all patients with alternative iron
DISCUSSION AAG diagnosis in this group of patients supports recent references considering that the disease can affect young people.1–4 Refractoriness to oral iron therapy, iron malabsorption, hypergastrinemia, and AG were common to all studied patients. This fact enhances the importance of including a protocol-based approach of malabsorption diseases, other than celiac disease, in all cases of pediatric rIDA. Serum gastrin levels seem to be a good indirect indicator of hypochloridria, a consequence of parietal cell loss. However, serum gastrin levels should be measured in strictly standardized conditions, namely after fasting. Additional quantification of pepsinogen I and II and the evaluation of the pepsinogen I/II ratio can increase the sensibility and specificity of the procedure.23–25 Alternative iron therapeutic approach proved to be effective in solving IDA, but it must be considered a lifelong treatment. There are 2 alternative procedures: periodical IV iron administration to load iron stores, or a daily dose of oral ferrous glycine sulfate to provide baseline requirements.
TABLE 2. Histologic Analysis of Gastric Biopsy Samples Using the Sydney Criteria10–14
Patient Number Diagnosis 1 2 3 4 5 6 7 8
AAG + / Hp + AAG + / Hp AAG + / Hp + AAG + / Hp AAG + / Hp + AAG + / Hp AAG + / Hp + AAG + / Hp
Localization
Lymphoid Lymphoid Infiltrates Aggregates
Antrum
Transepithelial Migration of Lymphocytes
Neutrophil Glandular Activity Atrophy
Intestinal Metaplasia/ Dysplasia
Hp
1
2
1
0
2
0/0
3
2/3
0
1/2
0
3
0/0
0
2
0
2
0
1
0/0
2
Antrum
2
2
1
2
1
0/0
0
Antrum and corpus Antrum
2
2
1
0
2
0/0
2
2
0
1
1
3
0/0
0
Antrum
1
0
1
1
1
1/0
1
Antrum, corpus, and fundus
2
0
2
1
1
1/0
0
Antrum and corpus Antrum
Hp indicates Helicobacter pylori infection.
r
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TABLE 3. Iron Therapy and Patient Outcomes
Patient Number
Intravenous Iron
Ferrous Glycine Sulfate
Triple Therapy for Hp
1
Yes
No
Yes
2
No
Yes
3
No
Yes
4
Yes
No
5
No
Yes
Yes
6
Yes
No
—
7
No
Yes
Yes
8
No
Yes
Final Analytical Data Hemoglobin (g/dL) Transferrin Saturation (%)/Ferritin (ng/mL) Vitamin B12 (lg/mL)/Gastrin (pg/mL) 13.6 14/11 362/383 12.6 29/30 470/ 13.4 63/23 —/— 11.9 26/23 —/1.386 11.4 25.9 —/— 10.7 26/37 360/728 13 40/21 388.7/186 13.4 8/7 —/422
Yes
Hp indicates Helicobacter pylori infection.
An additional question is the management of Hp infection in these patients. Pathogenicity of Hp in the development of AAG was suggested but not definitively proved.1,2,9 Our short experience does not allow us to contribute to the clarification of this issue. However, considering that Hp eradication is a simple and relatively innocuous procedure, our procedure is the regular search and treatment in case of positivity.14,15 More controversial is the management of chronic gastric immunologic damage. Histologic follow-up of mucosal gastric injury can be carried out in a periodical and regular manner or punctually face indirect evidence of improvement or worsening of AG. We have followed the second alternative, and in this context 3 patients (#4, 6, 8) have been the object of endoscopic reevaluation 2, 4, and 5 years after initial diagnosis. No evidence of improvement was documented. On the contrary, one of them showed, 5 years later, worsening of the gastric lesion. It must be emphasized that, according to the Vienna classification, AG and IM are considered nondysplastic but possibly associated with gastric cancer conditions.26 In what concerns adult patients, a multidisciplinary European group of 63 experts combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions in the stomach. Final recommendations emphasize on follow-up more than on therapeutic procedures.27 Other group recommend regular endoscopic evaluation of patients with AG and IM. Its frequency depends on the lesion extension and the association with at least one of these risk factors (a first degree family history, incomplete IM, smoking habit).26,27 However, no guidelines are developed for pediatric age groups. We consider that this is a delicate question because children
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have an additional and unique risk factor: their large life expectancy.
REFERENCES 1. Hershko C, Victor Hofbrand A, Keret D, et al. Role of autoimmune gastritis, Helicobacter pylori and celiac disease in refractory or unexplained iron deficiency anemia. Haematologica. 2005;90:585–595. 2. Hershko C, Ronson A, Souroujon M, et al. Variable hematologic presentation of auto-immune gastritis: age-related progression from iron deficienc¸y to cobalamin depletion. Blood. 2006;107:1673–1679. 3. Hershko C, Lahad A, Kereth D. Gastropathic sideropenia. Best Pract Res Clin Haematol. 2005;18:363–380. 4. Hershko C, Pats J, Ronson A. The anemia of achylia gastrica revisited. Blood Cells Mol Dis. 2007;39:178–183. 5. Hershko C, Ianculovich M, Souroujon M. A hematologist´s view of unexplained iron deficiency anemia in males: impact of Helicobacter pylori eradication. Blood Cells Mol Dis. 2007;38: 45–53. 6. Ricuarte O, Gutierez O, Cardona H, et al. Atrophic gastritis in young children and adolescentes. Original article. J Clin Pathol. 2005;58:1189–1193. 7. Marignani M, Delle FG, Mecarocci S, et al. High prevalence of atrophic body gastritis in patients with unexplained microcytic and macrocytic anemia: a prospective screening study. AMJ. 1999;94:766–772. 8. Pacı´ fico L, Annia J, Osborn JF, et al. Consequences of Helicobacter pylori infection in children. World J Gastroenterol. 2010;16:5181–5194. 9. Amedei A, Bergman Mathijs P, Appelmelk Ben J, et al. Molecular mimicry between Helicobacter pylori antigens and H + , K + - adenosine triphosphatase in human gastric autoimmunity. J Exp Med. 2003;198:1147–1156. r
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10. Ricuarte O, Gutierrez O, Cardona H, et al. Atrophic gastritis in young children and adolescents. J Clin Pathol. 2005;58: 1189–1193. 11. DuBois S, Kearney DJ. Iron-deficiency anemia and Helicobacter pylori infection: a review of evidence. Am J Gastroenterol. 2005;100:453–459. 12. Huang X, Qu X, Yan W, et al. Iron deficiency anaemia can be improved after eradication of Helicobacter pylori. Postgrad Med J. 2010;86:272–278. 13. Qu XH, Huang XL, Xiong P, et al. Does Helicobacter pylori infection play a role in iron deficiency anemia? A metaanalysis. World J Gastroenterol. 2010;16:886–896. 14. Hershko C, Ianculovich M, Sourounjon M. Decrease treatment failure rates following duodenal release ferrous glycine sulphate in iron deficiency anemia associated with autoimmune gastritis and Helicobacter pylori gastritis. Acta Haematologica. 2007;118:19–26. 15. Hartman KR, Barker JA. Microcytic anemia with iron malabsorption: an inherited disorder of iron metabolism. Am J Hematol. 1996;51:267–275. 16. Ribeiro MD, Lopes C, Pereira AC, et al. A follow-up model for patients with atrophic chronic gastritis and intestinal metaplasia. J Clin Pathol. 2004;57:177–182. 17. Rugge M, Genta RM. Staging and grading of chronic gastritis. Human Pathology. 2005;36:228–233. 18. Khakoo SI, Lobo AJ, Shepherd NA, et al. Histological assessment of Sydney classification of endoscopic gastritis. Gut. 1994;35:1172–1175. 19. Langner M, Machado RS, Patrı´ cio FRS, et al. Evaluation of gastric histology in children and adolescents with Helicobacter
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20. 21. 22. 23. 24. 25. 26. 27.
pylori gastritis using the Update Sydney System. Arq Gastroenterol. 2009;46:328–332. Aydin O, Egilmez R, Karabacak T, et al. Interobserver variation in histopathological assessment of Helicobacter pylori gastritis. World J Gastroenterol. 2003;9:2232–2235. Guarner J, Herrera-Goepfert R, Mohar A, et al. Interobserver variability in application of the revised Sydney classification for gastritis. Hum Pathol. 1999;30:1431–1434. Malfeiteiner P, Megraud F, O’Morain C, et al. Current concepts in the management of Helicobacter pylori infection. The Maastricht II Consensus report. Gut. 2007;56:772–781. Burkitt MD, Varro A, Pritchard DM. Importance of gastrin in the pathogenesis and treatment of gastric tumors. World J Gastrenterol. 2009;15:1–16. Gede AI. Serum gastrin level and pepsinogen I/II ratio as biomarker of Helicobacter pylori chronic gastritis. Acta Med Indones. 2010;42:142–146. Iijima K, Abe Y, Kikuchi R, et al. Serum biomarker tests are useful in delineating between patients with gastric atrophy and normal healthy stomach. World J Gastroenterol. 2009;15:853–859. Vannella L, Lahner E, Annibale B. Risk for gastric neoplasias in patients with chronic gastritis: a critical reappraisal. World J Gastroentrol. 2012;28:1279–1285. Ribeiro MD, Areia M, De Vries AC, et al. Management of precancerous conditions and lesions in stomach (MAPS): guideline from European Society of Gastrointestinal Endoscopy of pathology (ESGE), European Helicobacter Study Group (EHSG), European Society of pathology (ESP), and the Sociedade Portuguesa de Endoscopia digestiva (SOED). Virchows Arch. 2012;460:19–46.
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Refractory Iron-deficiency Anemia and Autoimmune Atrophic Gastritis in Pediatric Age Group: Analysis of 8 Clinical Cases Natalina Miguel, MD,* Emı´lia Costa, MD,w Marta Santalha, Jr, MD,z Rosa Lima, MD,y Jose´ Ramon Vizcaino, MD,8 Fernando Pereira, MD,y and Jose´ Barbot, MDw
Introduction: Refractory iron-deficiency anemia with no obvious etiology in pediatric age can be a puzzling problem. Screening of iron malabsorption conditions, including autoimmune atrophic gastritis (AAG), is emerging as a priority in the investigational procedure. Materials and Methods: Retrospective analysis of clinical process of children/adolescents with the diagnosis of AAG. Results: Eight patients (aged between 4.7 and 18 years old) were identified. The diagnosis was triggered on the basis of high serum gastrin levels and strong positivity of antiparietal cell antibodies. Upper endoscopy and biopsy revealed atrophic gastritis in all patients, with 2 of them with intestinal metaplasia. Four patients presented with Helicobacter pylori infection object of eradication therapy. After a medium follow-up of 36.6 months, antiparietal cell antibodies and hypergastrinemia did not show evidence of regression. Of the 3 patients who underwent endoscopic reevaluation, a similar anatomo-pathologic pattern was observed in 2 and intestinal metaplasia in 1 patient. Normalization of hematological parameters was achieved, using alternative iron formulas. Conclusions: AAG must be recognized as a pathology affecting pediatric patients. Gastric autoimmune lesion is a chronic process with potential evolution to malignancy. Management guidelines in childhood are not available. Their elaboration is important considering an important risk factor in these age group: a long life expectancy. Key Words: refractory iron-deficiency anemia, hypergastrinemia, autoimmune atrophic gastritis, Helicobacter pylori infection, ferrous glycine sulfate
(J Pediatr Hematol Oncol 2014;36:134–139)
I
ron-deficiency anemia (IDA) is the most common form of microcytic and hypochromic anemia worldwide.1–3 The age groups at a higher risk are nursing infants, teenagers, and women of childbearing age.1,3,4 Refractory iron-deficiency anemia (rIDA) is defined by the lack of response to iron ingestion treatment prescribed for at least 2 months.1 Evaluation of an rIDA condition can be complex. Inadequate ingestion, occult blood loss, Received for publication August 20, 2012; accepted October 16, 2013. From the *Department of Pediatrics, Centro Hospitalar Tra´s-osMontes e Alto Douro, Vila Real; Departments of wHematology; yPediatric Gastroenterology; 8Pathology, Centro Hospitalar do Porto, Oporto; and zDepartment of Pediatrics, Centro Hospitalar do Alto Ave, Guimara˜es, Portugal. The authors declare no conflict of interest. Reprints: Natalina Miguel, MD, Servic¸o de Pediatria do Centro Hospitalar Tra´s-os-Montes e Alto Douro, Avenida da Noruega, 5000514 Vila Real, Portugal (e-mail: [email protected]). Copyright r 2013 by Lippincott Williams & Wilkins
134 | www.jpho-online.com
absorption disorders, and, rarely, metabolic abnormalities must be considered. Investigational sequence depends on the clinical presentation and patient age. Absorption deficiency has been receiving increasing attention as a cause of rIDA. Historically, celiac disease was the main condition interfering with iron absorption investigated by pediatricians. Two other pathologies were more recently recognized: Helicobacter pylori infection (Hp) and autoimmune atrophic gastritis (AAG).1–6 In this context, Hershko proposed an algorithm for IDA diagnostic work-up. In pediatric patients, oral iron therapy can be introduced without an exhaustive diagnostic approach. Inadequate response, in the absence of an obvious cause, requires a screening of malabsorption disorders, based on noninvasive methods (antigliadin/antiendomysial antibodies, c-urea breath test, antiparietal cell antibodies, and serum gastrin levels), before endoscopic evaluation.3 AAG was, for many years, considered a disease affecting only elderly patients. The underlying hematological anomaly was pernicious anemia. Studies published until 2009 by Hershko proved that AAG is not exclusively an adult disease and that pernicious anemia is not the only hematological anomaly associated. IDA can be the hematological presentation and can precede by many years the clinical onset of pernicious anemia. The author studied 160 patients with AAG, using as diagnostic criteria hypergastrinemia and strong positivity of gastric antiparietal cell antibodies. Eighty-three (52%) of them presented with IDA. This group of patients was about 21 years younger than the other group with macrocytosis. There was a higher prevalence of female patients. Marignani et al7 compared 2 groups of patients with AAG. The group of patients with microcytic anemia was 20 years younger than the other with macrocytosis. Chlorydric acid is essential for solubilization and reduction in food iron, conditions that are critical for its normal absorption. Autoimmune process damages the parietal cells and determines atrophic gastritis (AG), resulting in deficient gastric acidity. Hp infection has been proven to be a cause of rIDA by a number of possible mechanisms such as occult blood loss, dietary iron competition, interference with gastric acid secretion and with gastric ascorbate levels and AG caused by inflammation.8,9 Eradication therapy normalizes the hematological picture. In some patients with AAG, a complete remission of AG was observed after Hp eradication.1,2,10–13 However, the Hp’s role as the trigger agent of the autoimmune process is still under discussion.1,2,4,5,9 Iron-alternative formulas bypassing duodenal absorption (intravenous iron) or gastric hypochlorhydria (ferrous glycine sulfate) proved to be effective in the resolution of
J Pediatr Hematol Oncol
Volume 36, Number 2, March 2014
J Pediatr Hematol Oncol
Volume 36, Number 2, March 2014
IDA and AAG in Pediatric Age
Oral iron challenge study with elemental iron as ferrous sulphate/hydroxide Serum iron (µg/dl) Our patients 400 350 300 250 200 150 100 50 0
Patients with IDA but normal absorption
1
2
3
4
Hours after iron load
5
FIGURE 1. Oral iron absorption (ferrous hydroxide/sulfate): after a loading dose of 2 mg of oral iron, at time 0, followed by measuring of serum iron at 1, 2, 3, and 4 hours. The expected answer in our patients was different from that observed in patients with iron-deficiency anemia but normal absorption after a load of 2 mg of oral elemental iron.
rIDA.14 However, medical literature is scarce about the management of mucosal gastric chronic immune aggression in such a young group of patients. A potential increase in the risk of gastric cancer and pernicious anemia are not yet objects of follow-up and therapeutic guidelines in pediatric age.
Sequential study on patients considered as having evidence of AAG included upper endoscopy, and gastric biopsy under general anesthesia (antrum, antrum/corpus, or antrum/corpus/fundus) was conducted and the biopsy fragments (1.5 to 2.5 mm in diameter) were placed in formalin, fixed in paraffin, and stained using hematoxylineosin and modified Giemsa. Diagnosis of Hp infection was based on identification of the bacteria in the stomach. Review of gastric biopsy plaques was conducted in a blinded manner. AG was defined as a replacement of native glands by the connective tissue or intestinal-type epithelium13,14 (Fig. 3). Gastritis staging and grading were recorded according to the Sydney criteria from 0 to 3 (absent, light, moderate, and strong16–21; Table 2). Autoimmunity of patients in whom the diagnosis of AAG was made was evaluated by the following parameters: antinuclear antibodies, antiphospholipid antibodies, antidouble-stranded DNA antibodies, antithyroid antibodies, anti-intrinsic factor antibodies, and direct antiglobulin test. Serum immunoglobulin levels were also documented. Cobalamin levels had been assessed in 62,5% of AAG patients. All patients were treated with an alternative iron formula: intravenous (IV) iron (sacarose ferrous hydroxide) and oral ferrous glycine sulfate. Those exhibiting some evidence of Hp infection received eradication therapy in accordance with the Maastricht III-2000 guidelines.22
MATERIALS AND METHODS Our retrospective study includes patients aged below 18 years, in whom the diagnosis of AAG was made in the context of investigation of rIDa of unknown etiology. Diagnosis methodology, followed by Hershko et al3 workup algorithm oral iron refractoriness, was concluded after 2 months of therapeutic failure.1 Obscure etiology was concluded after the exclusion of dietary errors, therapeutic noncompliance, gynecologic, or occult fecal blood loss. Iron malabsorption screening methodology included serologic parameters for celiac disease, respiratory or serologic test for Hp infections, antiparietal cell antibodies of AAG, and serum gastrin level as indirect markers of hypochloridria. Serum gastrin levels were measured by chemiluminescence. Hp infection was explored using the c-urea breath test and/or additional serologic investigation (ELISA, assessing Hp-IgG and IgA levels). Serum antiparietal cell antibodies titers were measured using FEIA and immunofluorescence. Iron malabsorption was suspected by an oral iron challenge study with ferrous sulfate or hydroxide-ferric polymaltose, as described by Hartman and Barker (Fig. 1).15 After a loading dose of 2 mg of oral iron, at time 0, serum iron was dosed at 1, 2, 3, and 4 hours. Hypochloridric condition was confirmed in 2 patients with a similar study with ferrous glycine sulfate, according to Hershko et al (Fig. 2).14 Strong evidence of AAG was considered on the basis of positivity of the antiparietal cell antibodies associated with high serum gastrin levels.
RESULTS We found 8 patients, aged between 4 and 18 years (average, 12.3 y), 2 male and 6 female considered as having evidence of malabsorption and laboratory and anatomopathologic criteria of AAG (Table 1). The average interval between the diagnosis of IDA and AAG was 21.4 months (range, 5 to 53 mo). The average hematologic parameters at AAG diagnosis were: hemoglobin 9.25 g/dL (8 to 11 g/dL),
Oral iron challenge study with ferrous glycine sulphate Our patients
Serum iron (µg/dl) 350
Patients with IDA but normal absorption
300 250 200 150 100 50 0
Hours after oral iron load 1
2
3
4
5
FIGURE 2. Oral iron challenge with ferrous glycine sulfate. After an iron loading in fasting of 2 mg of this formula, our patients revealed a later absorption than the observed in iron-deficient patients with normal absorption after a loading of 2 mg of ferrous sulfate. r
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15 y
6y
5 mo
4y
18 y
3
4
5
6
7
13.8
18
6
4.7
6
18
16
16
Sex
Male
Female
Male
Female
Female
Female
Female
Female
8.8 63.2 18.3 8.6 61.4 19.5 9.5 71.2 18 8.9 66 16.4 9.9 56 16.5 11 70.5 16.8 9.3 62.9 16.2 8 60 16.2
Hemoglobin (g/dL) MCV (fL) RDW (%)
8 8.3
2 2.3
7 8
3 3.8
9 2.9
8
5
10
53
5
36
15
1.5 1 12
41
Duration of Treatment With Oral Iron (mo)
5 3
Transferrin Saturation (%) Ferritin (ng/mL)
417
300
547
558
535
672
429
556
119
97.4
147.1
172
215
158.2
250
172
No
—
No
—
—
No
—
Yes Negative
Yes Negative
No
—
Yes Negative Yes Negative
Yes Negative
No
Yes Negative Yes Negative
Yes Positive
Yes Negative Yes Negative
Yes Positive
Negative
Negative
Negative
Negative
Negative
ANAs +
Negative
Negative
Autoimmunity: Breath Test Serum Gastrin ANAs, APLAS, c-Urease Hp Serology Level Antigastric Parietal Anti-ds-DNA, (n < 100 pg/ Cell Antibodies Yes/ Positive/ Yes/ Positive/ Thyroid Antibodies mL) (n < 25 U/mL) No Negative No Negative Positive/Negative
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ANAs indicate antinuclear antibodies; anti-ds-DNA, antibodies against double-stranded DNA; APLAs, antibodies against antiphospholipid; Hp, Helicobacter pylori infection.
13 y
15 y
2
8
13 y
1
Age at Age at Patient Diagnosis Diagnosis Number of IDA of AAG (y)
TABLE 1. Characteristics of Our Patients
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IDA and AAG in Pediatric Age
formulas, 3 with IV iron (#1, 4, 6) and 5 with ferrous glycine sulfate (#2, 3, 5, 7, 8; Table 3). Follow-up was lost in 2 patients. The other 6 patients have an average follow-up of 36.6 months (7 to 67 mo). Three patients were reevaluated 2, 4, and 5 years after initial diagnosis (#8, 6, and 4). The first two patients showed anatomo-pathologic pattern identical to the first study. The third patient had already a previous successful treatment with IV iron in the absence of etiological diagnosis. One year later, facing IDA recurrence, AAG diagnosis was made and a new therapeutic approach with ferrous glycine sulfate resulted again in the normalization of the hematological picture. A progressive and a 3-fold increment of serum gastrin levels led us to repeat endoscopic evaluation 60 months after the diagnosis. It was documented de novo Hp infection and the emergence of IM. FIGURE 3. PAS/Alcian blue staining of the gastric tissue ( 100). Atrophic gastritis is evident; glands are replaced by fibrotic material and a lymphomononuclear inflammatory infiltrate may be noted (inset: 200 showing intestinal tissue metaplasia).
MCV 63.9 fL (56 to 71.2 fL), and RDW 17.23%. Ferritin average was 4.18 ng/mL (1 to 8.3 ng/mL). Iron absorption tests were indicative of absorption deficiency (Fig. 1). All patients had hypergastrinemia and expressed high serum levels of antibodies against the gastric parietal cells. Four of the patients (#1, 3, 5, and 7) showed evidence of Hp infection (AAG/Hp +) at diagnosis. One patient (#7) revealed anatomo-pathologic demonstration of Hp infection, despite a normal c-urease test. The histologic pattern of gastritis was not discriminative between patients with or without Hp infection. Intestinal metaplasia (IM) was demonstrable in 2 patients (Fig. 3), 1 AAG/Hp + (#7) and 1 AAG/Hp (#8; Table 2).16–21 Gastric dysplasia was not found in any patient. One patient (#3) had an additional marker of autoimmunity at diagnosis (Table 1). Cobalamin levels, assessed in 5 patients (#1, 2, 5, 6, and 7), were normal. Normalization of hematological and iron biochemical parameters was achieved in all patients with alternative iron
DISCUSSION AAG diagnosis in this group of patients supports recent references considering that the disease can affect young people.1–4 Refractoriness to oral iron therapy, iron malabsorption, hypergastrinemia, and AG were common to all studied patients. This fact enhances the importance of including a protocol-based approach of malabsorption diseases, other than celiac disease, in all cases of pediatric rIDA. Serum gastrin levels seem to be a good indirect indicator of hypochloridria, a consequence of parietal cell loss. However, serum gastrin levels should be measured in strictly standardized conditions, namely after fasting. Additional quantification of pepsinogen I and II and the evaluation of the pepsinogen I/II ratio can increase the sensibility and specificity of the procedure.23–25 Alternative iron therapeutic approach proved to be effective in solving IDA, but it must be considered a lifelong treatment. There are 2 alternative procedures: periodical IV iron administration to load iron stores, or a daily dose of oral ferrous glycine sulfate to provide baseline requirements.
TABLE 2. Histologic Analysis of Gastric Biopsy Samples Using the Sydney Criteria10–14
Patient Number Diagnosis 1 2 3 4 5 6 7 8
AAG + / Hp + AAG + / Hp AAG + / Hp + AAG + / Hp AAG + / Hp + AAG + / Hp AAG + / Hp + AAG + / Hp
Localization
Lymphoid Lymphoid Infiltrates Aggregates
Antrum
Transepithelial Migration of Lymphocytes
Neutrophil Glandular Activity Atrophy
Intestinal Metaplasia/ Dysplasia
Hp
1
2
1
0
2
0/0
3
2/3
0
1/2
0
3
0/0
0
2
0
2
0
1
0/0
2
Antrum
2
2
1
2
1
0/0
0
Antrum and corpus Antrum
2
2
1
0
2
0/0
2
2
0
1
1
3
0/0
0
Antrum
1
0
1
1
1
1/0
1
Antrum, corpus, and fundus
2
0
2
1
1
1/0
0
Antrum and corpus Antrum
Hp indicates Helicobacter pylori infection.
r
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TABLE 3. Iron Therapy and Patient Outcomes
Patient Number
Intravenous Iron
Ferrous Glycine Sulfate
Triple Therapy for Hp
1
Yes
No
Yes
2
No
Yes
3
No
Yes
4
Yes
No
5
No
Yes
Yes
6
Yes
No
—
7
No
Yes
Yes
8
No
Yes
Final Analytical Data Hemoglobin (g/dL) Transferrin Saturation (%)/Ferritin (ng/mL) Vitamin B12 (lg/mL)/Gastrin (pg/mL) 13.6 14/11 362/383 12.6 29/30 470/ 13.4 63/23 —/— 11.9 26/23 —/1.386 11.4 25.9 —/— 10.7 26/37 360/728 13 40/21 388.7/186 13.4 8/7 —/422
Yes
Hp indicates Helicobacter pylori infection.
An additional question is the management of Hp infection in these patients. Pathogenicity of Hp in the development of AAG was suggested but not definitively proved.1,2,9 Our short experience does not allow us to contribute to the clarification of this issue. However, considering that Hp eradication is a simple and relatively innocuous procedure, our procedure is the regular search and treatment in case of positivity.14,15 More controversial is the management of chronic gastric immunologic damage. Histologic follow-up of mucosal gastric injury can be carried out in a periodical and regular manner or punctually face indirect evidence of improvement or worsening of AG. We have followed the second alternative, and in this context 3 patients (#4, 6, 8) have been the object of endoscopic reevaluation 2, 4, and 5 years after initial diagnosis. No evidence of improvement was documented. On the contrary, one of them showed, 5 years later, worsening of the gastric lesion. It must be emphasized that, according to the Vienna classification, AG and IM are considered nondysplastic but possibly associated with gastric cancer conditions.26 In what concerns adult patients, a multidisciplinary European group of 63 experts combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions in the stomach. Final recommendations emphasize on follow-up more than on therapeutic procedures.27 Other group recommend regular endoscopic evaluation of patients with AG and IM. Its frequency depends on the lesion extension and the association with at least one of these risk factors (a first degree family history, incomplete IM, smoking habit).26,27 However, no guidelines are developed for pediatric age groups. We consider that this is a delicate question because children
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have an additional and unique risk factor: their large life expectancy.
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10. Ricuarte O, Gutierrez O, Cardona H, et al. Atrophic gastritis in young children and adolescents. J Clin Pathol. 2005;58: 1189–1193. 11. DuBois S, Kearney DJ. Iron-deficiency anemia and Helicobacter pylori infection: a review of evidence. Am J Gastroenterol. 2005;100:453–459. 12. Huang X, Qu X, Yan W, et al. Iron deficiency anaemia can be improved after eradication of Helicobacter pylori. Postgrad Med J. 2010;86:272–278. 13. Qu XH, Huang XL, Xiong P, et al. Does Helicobacter pylori infection play a role in iron deficiency anemia? A metaanalysis. World J Gastroenterol. 2010;16:886–896. 14. Hershko C, Ianculovich M, Sourounjon M. Decrease treatment failure rates following duodenal release ferrous glycine sulphate in iron deficiency anemia associated with autoimmune gastritis and Helicobacter pylori gastritis. Acta Haematologica. 2007;118:19–26. 15. Hartman KR, Barker JA. Microcytic anemia with iron malabsorption: an inherited disorder of iron metabolism. Am J Hematol. 1996;51:267–275. 16. Ribeiro MD, Lopes C, Pereira AC, et al. A follow-up model for patients with atrophic chronic gastritis and intestinal metaplasia. J Clin Pathol. 2004;57:177–182. 17. Rugge M, Genta RM. Staging and grading of chronic gastritis. Human Pathology. 2005;36:228–233. 18. Khakoo SI, Lobo AJ, Shepherd NA, et al. Histological assessment of Sydney classification of endoscopic gastritis. Gut. 1994;35:1172–1175. 19. Langner M, Machado RS, Patrı´ cio FRS, et al. Evaluation of gastric histology in children and adolescents with Helicobacter
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pylori gastritis using the Update Sydney System. Arq Gastroenterol. 2009;46:328–332. Aydin O, Egilmez R, Karabacak T, et al. Interobserver variation in histopathological assessment of Helicobacter pylori gastritis. World J Gastroenterol. 2003;9:2232–2235. Guarner J, Herrera-Goepfert R, Mohar A, et al. Interobserver variability in application of the revised Sydney classification for gastritis. Hum Pathol. 1999;30:1431–1434. Malfeiteiner P, Megraud F, O’Morain C, et al. Current concepts in the management of Helicobacter pylori infection. The Maastricht II Consensus report. Gut. 2007;56:772–781. Burkitt MD, Varro A, Pritchard DM. Importance of gastrin in the pathogenesis and treatment of gastric tumors. World J Gastrenterol. 2009;15:1–16. Gede AI. Serum gastrin level and pepsinogen I/II ratio as biomarker of Helicobacter pylori chronic gastritis. Acta Med Indones. 2010;42:142–146. Iijima K, Abe Y, Kikuchi R, et al. Serum biomarker tests are useful in delineating between patients with gastric atrophy and normal healthy stomach. World J Gastroenterol. 2009;15:853–859. Vannella L, Lahner E, Annibale B. Risk for gastric neoplasias in patients with chronic gastritis: a critical reappraisal. World J Gastroentrol. 2012;28:1279–1285. Ribeiro MD, Areia M, De Vries AC, et al. Management of precancerous conditions and lesions in stomach (MAPS): guideline from European Society of Gastrointestinal Endoscopy of pathology (ESGE), European Helicobacter Study Group (EHSG), European Society of pathology (ESP), and the Sociedade Portuguesa de Endoscopia digestiva (SOED). Virchows Arch. 2012;460:19–46.
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