A 65-year-old woman presented to the hospital with five days of intermittent hematochezia, left lower abdominal pain, weakness, fatigue, and dyspnea with minimal exertion. She also reported six months of intermittent vaginal bleeding. Her initial systolic blood pressure was 66 mmHg and laboratory studies showed a hemoglobin of 4.6 g/dL. Physical examination revealed pallor of the conjunctiva, conjunctival rim, and palms (Figs. 1 and 2). An abdominal computed tomography (CT) scan showed acute diverticulitis. A pelvic ultrasound and endometrial biopsy showed abnormal endometrial thickening but no malignancy.
Figure 1.
Conjunctival rim (arrows) and conjunctival (star) pallor.
Figure 2.
Palmar pallor.
Conjunctival rim pallor, conjunctival pallor, and palmar pallor have positive likelihood ratios (+LR) for anemia (hemoglobin < 11 g/dL) of 16.7, 4.7, and 5.6, which increase the post-test probability of anemia by 53%, 29%, and 33%, respectively1–3. These findings are helpful for the diagnosis of anemia of any severity in patients of all skin colors. The patient refused blood product transfusion due to her religious beliefs and was treated supportively with erythropoietin 20,000 units for seven days, iron infusions, and minimization of blood draws. Her hemoglobin eventually recovered to 8.2 g/dL after three weeks of observation in the hospital, and she was discharged with a follow-up colonoscopy scheduled six weeks later.
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References
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