PROTEIN DEFICIENCY ANAEMIA

In experimental animals, deficiency of protein or some of the essential amino acids are known to induce anaemia which is curable with protein. In dogs, made anaemic by bleeding, haemoglobin regeneration appears to be accelerated by dietary protein.

In humans, however, protein deficiency unless its very severe may not cause any significant anaemia. Haemoglobin has got a high priority for available protein and under conditions of protein deficiency, haemoglobin formation proceeds in preference to formation of proteins in plasma and tissues. Anaemia of protein deficiency occurs mostly in the poor in association with generalised malnutrition resulting from dietary inadequacy. Though its particularly common in young children with kwashiorkor and in pregnant women, older children, adult males and non-pregnant females may also be affected. Clinically such patients show signs of protein malnutrition. Wasting, however, may not be a prominent feature as the calorie content is not always low, though the diet lacks in protein. The liver is often palpable, though the spleen is usually not.

DIMORPHIC ANAEMIA

Combined deficiency of haemopoietic factors are common particularly when the basic cause is dietary inadequacy or intestinal malabsorption. When iron deficiency is associated with deficiency of folic and/or vitamin B12, the resulting condition has been called dimorphic anaemia. Dimorphic anaemia may therefore occur whenever and wherever causes contributing to the deficiency of iron, folic acid and vitamin B12 are operative. The causative factors will thus include a combination of those discussed under iron deficiency anaemia and nutritional macrocytic anaemia. Common conditions where anaemia is dimorphic are :

(a) Dietary inadequacy, particularly during growing periods and in pregnancy.

(b) Intestinal malabsorption and post-gastrectomy syndrome.

(c) Dietary inadequacy in association with blood loss.

Clinical features will vary depending on the degree of anaemia; the relative proportion of the deficient factors, is also one of the basic cause.

The haematological findings will be determined by the relative contribution of iron on one hand and folic acid and/or vitamin B12 on the other hand. In an average case, evidences of dimorphic anaemia will be evident from the following :

Gross erythrocytic hypochromia and/or hypoferraemia in association with megaloblasts in blood and/or low serum vitamin B12 or serum folate.

When one deficiency is predominating, the expression of other deficiency may be masked. The presence of such a latent minor deficiency may be unmasked when the major deficiency has been corrected with appropriate therapy.

NUTRITIONAL MACROCYTIC ANAEMIA

First described by Wills(1930) found in Indian women; the disorder represents dietary inadequacy of folic acid and/or vitamin B12. The relative proportion of folic acid and vitamin B12 deficiency varies from one patient to another, and from one place to another depending mainly on the dietary habits of the patient concerned. It is particularly common in the poor people of tropical and sub-tropical countries. Apart from poverty, religious tenets and wrong dietary habits contribute to dietary inadequacy. Megaloblastic anaemias in infancy and pregnancy are variants of this disorder. Increased demands of the stressful periods, unmasking a latent deficiency. Adequate amount of intrinsic factor is present. In an average case, there is no significant evidence of malabsorption of vitamin B12 and folic acid, though, diarrhoea, steatorrhoea, and a flat glucose tolerance curve may be present. When prolonged deficiency has led to severe depletion, a secondary factor of intestinal malabsorption may be superimposed due to dystrophic changes of intestinal mucous membrane. The disorder is uncommon in temperate climates where occasional cases are seen in infancy, pregnancy and in association with dietary inadequacy incidental to vegetarianism.

ANAEMIA IN PREGNANCY

The term ‘anaemia in pregnancy’ refers to all forms of anaemia encountered during pregnancy. This term includes anaemias occurring independently of pregnancy and also anaemias precipitated or caused by pregnancy. The term ‘anaemia of pregnancy’ is, however, used in a more restricted sense and is applicable only to those types which appear for the first time during pregnancy and are directly precipitated or caused by the pregnancy. Thus anaemia in pregnant women may be either direct consequence of pregnancy or just an associated condition perhaps unmasked by the pregnancy.

Pregnancy is regarded as a physiological process. In normal pregnancy, a healthy woman with adequate haemopoietic reserve should not usually show any anaemia. But even under normal conditions, certain physiological adjustments regularly takes place to meet the increased metabolic demands which are consequent on or conditioned by pregnancy. These physiological adjustments do not ordinarily entail any significant strain on maternal haematopoiesis. Under unfavorable circumstances, however, these changes may not only deplete the maternal reserve but may also predispose to or precipitate anaemia.

SKIN DISEASES DURING PREGNANCY

Pruritus: Generalized or abdominal pruritus sometimes develops during pregnancy. This is attributed to endocrine, toxic, neurogenic cause or hepatic dysfunction. Prurigo gestation is a special form of generalized pruritus, appears as numerous pruritic papules with bloody crusts on the extensor surface of limbs, abdomen and chest. Other causes of pruritus viz. jaundice, diabetes or any skin disease are to be ruled out. Treatment is unsatisfactory. Lotions as described under vulval pruritus, sedatives and antihistamines can be tried for some relief. The condition disappears after delivery.

Herpes gestationis: This is considered peculiar to the pregnancy as it has a tendency to recur in the successive pregnancies. Generalized pruritus is followed by appearance of grouped erythematous papules, vesicles on abdomen, thighs, breasts, legs and forearms. Eosinophilia may be present. Corticosteroid can be given orally, and as local ointment.

Impetigo herpetiformis: This rare fatal skin disease has been described as being associated with pregnancy. The manifestations are confluent pustular eruptions on groin, thigh, breast, axillae with fever, joint pain and delirium. Oral mucosa show grayish white patches. Termination of pregnancy results in recovery. General supportive measures such as antibiotics, corticosteroids, soothing lotions are useful.