Hematology/Paradoxical Anemia


QUESTION: Hi Dr. Kulkarni,

I have a very interesting case that I can't figure out what's happening.

I have a client who had low iron in January (I don't know her iron status before that). So she started taking iron supplementation, and when she was re-tested in June, her iron was actually even lower. So her doctor prescribed her an even higher dose of iron. So she had her iron levels re-tested last week, and her iron levels were even lower than before.

Any clue as to what's happening here?

You said your 'client', so what profession do you pursue? :) Anyway I want to know whether the iron supplements were given orally or parenterally(like IV or IM injections). If oral iron therapy is failing then it means she isnt absorbing it. May be its indicating pernicious anemia. Better to screen her for pernicious anemia(of course atrophic gastritis). Also sometimes vit C deficiency can reduce iron absorption. So that needs to be screened. They can try whether IV/IM injections improve iron levels. A peripheral blood smear test would give some more diagnostic values. If everything fails then its better to visit nearby heamatologist and gastroenterologist(to rule out any other malabsorption syndormes).

Thanking you!

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QUESTION: Hi Dr. Kulkarni,

Thank you very much for your fast response.

I'm a personal trainer.

In regards to absorption, my client said that at the higher dose, her stool turned a dark color. Would that indicate good absorption? The very first time, we also tried combining the iron with vitamin C, but that didn't work.

So does that rule out absorption, and the most likely culprit is pernicious anemia? Or is malabsorption still a possibility?

Stool color can not predict the level of absorption. Most of the iron supplements produce dark colored stool. But in case if the stool is dark without iron supplements then its matter of concern. It could indicate Upper GI bleeding like ulcers. It seems to be pernicious anemia to me. She should be put on IM/IV iron supplements immediately. And see how she responds. Prior to that a peripheral blood smear test would be recommended. If there is suspicion of anemia due to blood loss, then an stool test for occult blood could be necessary to rule out any parasitic infestation.(In any case peripheral blood smear test is the key test which will guide which way the diagnosis should go) After she recovers she can meet a good gastroenterologist for any problems with malabsorption or atrophic gastritis.

Thanking you!


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Dr.Shrinidhi Kulkarni


I can answer all questions related to hematology. RBC, WBC, Platelet and blood forming organs etc and related questions. hematology also includes blood proteins, hemoglobin and disorders related to clotting abnormalities. So questions about all aspects of hematology are welcome!


Working as a Doctor in Primary Health care Centre.

KIMS Banglore

MBBS, Internship in Internal Medicine

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