Newman's Notions | December 14, 2022 | FREE
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An intern and an attending try to iron out a misunderstanding.

Scene: The Team E workroom, a hospital near you.

Intern: We had an admission last night of a patient with too much iron.

Attending: Let me stop you right there. Too much iron? Do you mean hemochromatosis or another iron overload condition? Language is important for clarity of communication. It is almost as crucial as listening.

Intern: Actually …

Illustration by David Rosenman
Illustration by David Rosenman

Attending: Actually, hemochromatosis is a fascinating disease. It is a common hereditary disorder affecting chromosome 6. Do you know the mutation?

Intern: This patient transferred in ...

Attending: Yes, exactly. Transferrin. An HFE gene mutation is the most common form, type 1, which leads to decreased production of hepcidin, which leads to less ferroportin and increased iron absorption, which is bound to transferrin. Does the patient have abnormally colored skin?

Intern: No ….

Attending: Well that is a little unusual; 70% of patients have the true bronzed skin. Do you want to know something very interesting?

Intern: …

Attending: It's sometimes referred to as bronze diabetes, despite being an iron storage disease. And bronze is actually made of copper and tin, not iron!

Intern: Fascinating, but …

Attending: Yes, fascinating. Diabetes is only seen in half the patients, with liver fibrosis being the more common sign. You can also see impotence, cardiomyopathy, and weakness. Are these patients prone to infection?

Intern: You're …

Attending: Exactly, Yersinia, as well as Vibrio and Listeria. Glad you have been paying attention. So, how are we going to diagnose? Transferrin saturation level drawn? Genetic analysis?

Intern: No ….

Attending: You are correct, the genetic analysis does not need to be performed as an inpatient. An MRI or elastography to assess for hepatic fibrosis? So how will you treat? Chelation or phlebotomy? Please answer me in a coherent fashion. Clear communication, like I said, is a hallmark of a good case presentation.

Intern: Neither. This patient does not have hemochromatosis. I plan on a psychiatry consult. I was trying to tell you that he had too much iron because he took 300 FeSO4 tablets thinking it would make him strong like Iron Man.

Attending: Wait, no skin discoloration, normal liver function, no arrhythmia? What makes you think this is hemochromatosis at all? That makes no sense. Iron overdosage on the other hand is a very interesting topic. …