MR, a well-appearing 21-year-old White woman, presents to her student health clinic with a complaint of general fatigue despite being treated with iron supplementation for iron deficiency. Three years earlier, the patient was diagnosed with iron-deficiency anemia after presenting to her primary care provider with complaints of hair thinning and undergoing confirmatory complete blood count (CBC) and iron studies. MR was prescribed iron supplements daily and has continued that regimen for 3 years.

Despite treatment, the patient’s hemoglobin and ferritin levels remain low at 10 g/dL (normal=12.1-15.1 g/dL) and 5 ng/L (normal=12-150 ng/mL), respectively. Thus, the patient presents for further workup of the cause of her anemia.

History and Examination

MR reports fatigue, headaches, and hair loss. She also reports diarrhea, constipation, abdominal pain, and intolerance to milk. She denies any palpitations, shortness of breath, hematemesis, hematochezia, or hemorrhoids. Patient denies a history of heavy menstrual bleeding and reports her last period was 2 weeks before the appointment. The patient has no pertinent past medical history.

The patient takes 325-mg ferrous sulfate by mouth daily with a glass of orange juice. She also takes 500-mg extra-strength acetaminophen as needed for headaches and migraines. The patient denies taking any herbal supplements or vitamins, and denies any drug allergies.


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MR is a junior in college where she is studying public health. She has never smoked or used illicit drugs. She drinks 1 to 2 glasses of wine per week. She states that she loves to exercise, at least 5 days per week, and likes to eat a healthy diet comprising plenty of fruits and vegetables.

MR is single with no children. Her mother has a history of psoriasis and gastroesophageal reflux disease. Her father has a history of stroke, hypertension, and chronic kidney disease. She has a sister who is healthy. The patient denies any family history of gastrointestinal (GI)/nutritional disorders.

The patient appears to be without apparent distress. MR is dressed appropriately, well-groomed, and alert and oriented x4. Her vital signs are shown in Table 1.

Table 1. Patient Vital Signs

MeasurementResult
Height5’8″
Weight140 lb
Body mass index21.3
Blood pressure110/75 mm Hg
Respiratory rate12 bpm
Temperature98.6°F

On follow-up, MR’s laboratory results are indicative of celiac disease (Table 2). The provider deferred a confirmatory duodenal biopsy because of the extremely high antibody results. The patient is prescribed a gluten-free diet and advised to continue taking oral iron supplementation. MR also is instructed to follow up in 3 months to repeat CBC and iron studies.

Table 2. Fecal Occult Blood Test and Celiac Panel Results

TestResultNormal Reference Range
FOBTNegativeNegative
TG2-IgA134 U/mL0 to 3 U/mL
TG2-IgA9 U/mL  0 to 5 U/mL
Deamidated gliadin Ab, IgA139 U0 to 19 U
Deamidated gliadin Ab, IgG120 U0 to 19 U
Endomysial Ab IgAPositiveNegative
Ab = antibody; FOBT = fecal occult blood test; IgA = immunoglobulin A; IgG = immunoglobulin G; TG2-IgA = tissue transglutaminase immuoglobulin A.