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Pallor

Specialties > Child health

Differential Diagnosis Schema 🧠

Hematological Causes

  • Iron deficiency anemia: Common cause of pallor, often associated with fatigue, shortness of breath, and spoon-shaped nails (koilonychia).
  • Vitamin B12 or folate deficiency: Leads to megaloblastic anemia, presenting with pallor, glossitis, and neurological symptoms such as peripheral neuropathy.
  • Hemolytic anemia: Pallor along with jaundice, dark urine, and splenomegaly; may be due to autoimmune conditions, infections, or hereditary disorders.
  • Aplastic anemia: Presents with pallor, fatigue, petechiae, and increased susceptibility to infections; pancytopenia on blood tests.

Cardiovascular Causes

  • Heart failure: Chronic heart failure can lead to poor perfusion and subsequent pallor; associated with dyspnea, edema, and fatigue.
  • Shock: Acute pallor due to reduced perfusion, accompanied by hypotension, tachycardia, and cool extremities; may be hypovolemic, cardiogenic, septic, or anaphylactic.
  • Severe aortic stenosis: Can cause pallor along with a slow-rising pulse, angina, and syncope.
  • Peripheral vascular disease: Pallor in the affected limb, particularly after exertion; associated with claudication and weak pulses.

Respiratory Causes

  • Chronic obstructive pulmonary disease (COPD): Chronic hypoxia can lead to pallor; associated with a chronic cough, wheezing, and use of accessory muscles for breathing.
  • Pulmonary embolism: Sudden onset of pallor with pleuritic chest pain, dyspnea, and hemoptysis; may have signs of deep vein thrombosis.
  • Pulmonary fibrosis: Progressive pallor associated with exertional dyspnea, dry cough, and fine inspiratory crackles.

Renal Causes

  • Chronic kidney disease (CKD): Pallor due to anemia of chronic disease; associated with fatigue, uremic symptoms (e.g., pruritus), and edema.
  • Acute kidney injury (AKI): Sudden pallor with oliguria, edema, and uremic symptoms; may follow severe infection, dehydration, or nephrotoxic drug use.
  • Nephrotic syndrome: Pallor due to hypoalbuminemia; associated with severe edema, proteinuria, and hyperlipidemia.

Endocrine Causes

  • Hypothyroidism: Pallor with dry skin, hair loss, weight gain, and fatigue; may have associated bradycardia and cold intolerance.
  • Cushing’s syndrome: Pallor with easy bruising, central obesity, and striae; often due to prolonged corticosteroid use or an adrenal tumor.
  • Adrenal insufficiency (Addison’s disease): Pallor with hyperpigmentation in areas of friction, fatigue, hypotension, and weight loss.

Key Points in History 🥼

Onset and Duration

  • Acute onset: Suggests conditions such as acute hemorrhage, shock, or acute hemolytic anemia.
  • Chronic onset: More consistent with chronic anemia, chronic heart failure, or chronic kidney disease.
  • Intermittent pallor: May be seen in conditions like Raynaud’s phenomenon, where pallor occurs episodically.

Associated Symptoms

  • Fatigue and weakness: Common in anemia, heart failure, and chronic disease.
  • Dyspnea: Suggests anemia, heart failure, or respiratory disease.
  • Chest pain: May indicate ischemic heart disease, severe anemia, or pulmonary embolism.
  • Weight loss: Concerning for malignancy, chronic infection (e.g., tuberculosis), or endocrine disorders.
  • Jaundice: Suggests hemolysis or liver disease.
  • Cold intolerance: Associated with hypothyroidism or severe anemia.
  • Syncope or dizziness: Common in severe anemia, hypovolemia, or cardiac causes.

Background

  • Dietary history: Poor dietary intake, especially of iron, vitamin B12, or folate, can lead to anemia.
  • Medication history: Consider drugs that cause bone marrow suppression, hemolysis, or nutrient malabsorption (e.g., methotrexate, antiretrovirals).
  • Travel history: Important for assessing the risk of hemolytic anemia due to malaria or other infections.
  • Family history: Consider hereditary causes of anemia, such as thalassemia, sickle cell disease, or hereditary spherocytosis.
  • Occupational history: Exposure to toxins or radiation that may affect bone marrow or cause hemolysis.

Possible Investigations 🌡️

Laboratory Tests

  • Full blood count (FBC): Key investigation to identify anemia; assesses hemoglobin, hematocrit, and red cell indices.
  • Iron studies: Includes serum iron, ferritin, transferrin saturation; helps differentiate between iron deficiency anemia and anemia of chronic disease.
  • Vitamin B12 and folate levels: Essential for diagnosing megaloblastic anemia.
  • Reticulocyte count: Assesses bone marrow response in anemia; elevated in hemolytic anemia, low in aplastic anemia.
  • Renal function tests: Assesses urea, creatinine, and electrolyte levels; important in chronic kidney disease.
  • Liver function tests: Helps identify liver disease or hemolysis (e.g., elevated bilirubin).
  • Thyroid function tests: Useful in suspected hypothyroidism.
  • Coagulation profile: Important in cases of suspected bleeding disorders.
  • Blood film: Morphological examination of red cells can help identify causes like hemolysis, megaloblastic anemia, or bone marrow disorders.
  • Bone marrow biopsy: Considered in cases of unexplained anemia, pancytopenia, or suspected bone marrow pathology.

Imaging

  • Chest X-ray: Useful in assessing for signs of heart failure, pulmonary fibrosis, or infections such as tuberculosis.
  • Abdominal ultrasound: Helps evaluate splenomegaly, hepatomegaly, or kidney pathology.
  • Echocardiogram: Considered in cases of heart failure or suspected severe aortic stenosis.
  • CT scan: May be necessary to assess for malignancies or systemic causes of anemia.

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Child health