A 54-year-old woman presented to the primary care clinic with fatigue and a 7-year history of intermittent hemorrhoidal bleeding. On examination, she appeared pale and had spoon-shaped nails (koilonychia) on the second and third fingers (Panel A) and the thumb (Panel B) of both hands. The laboratory evaluation showed a hemoglobin level of 7.8 g per deciliter (normal value, 12 to 15), a mean corpuscular volume of 66 fl (normal value, 80 to 95), a platelet count of 550,000 per microliter (normal value, 150,000 to 400,000), an iron level of 23 μg per deciliter (normal value, 40 to 155), a ferritin level of 3 ng per milliliter (normal value, 12 to 150), and a total iron-binding capacity of 470 μg per deciliter (normal value, 250 to 400). The findings on upper gastrointestinal endoscopy and colonoscopy were normal, except for the presence of hemorrhoids. Because bleeding from hemorrhoids does not typically cause this degree of anemia, further evaluation for other causes of iron deficiency was undertaken. Stool examination for ova and parasites and laboratory testing for celiac disease were negative, and results on abdominal ultrasonography were normal. Koilonychia is associated with iron-deficiency anemia and may also be hereditary, idiopathic, or associated with nail trauma or solvent exposure. The first three digits may be preferentially affected. The patient was treated with oral iron supplementation. At the 3-month follow-up, her fatigue had lessened, and her hemoglobin level had increased to 11.2 g per deciliter; however, her nails appeared unchanged.

一名54岁的妇女因疲劳和7年间断性痔疮出血病史来到基层医疗诊所。经检查，她显得面色苍白，双手的第二和第三根手指（面板A）和拇指（面板B）上有汤匙形的指甲（甲子甲）。实验室评估显示血红蛋白水平为每分升7.8 g（正常值，12至15），平均红细胞体积为66 fl（正常值，80至95），血小板计数为550,000每微升（正常值，150,000至400,000），每分升23μg的铁含量（正常值40至155），每毫升3 ng的铁蛋白水平（正常值12至150）和每分升470μg的总铁结合能力（正常值，即250到400）。上消化道内镜和结肠镜检查结果正常，除了痔疮的存在。由于从痔疮出血通常不会引起这种程度的贫血，因此对铁缺乏的其他原因进行了进一步评估。卵和寄生虫的粪便检查以及腹腔疾病的实验室检查均为阴性，腹部超声检查结果正常。肺泡炎与缺铁性贫血有关，也可能是遗传性，特发性的，或与指甲外伤或溶剂接触有关。前三个数字可能会受到优先影响。该患者接受口服补铁治疗。在三个月的随访中，她的疲劳减轻了，她的血红蛋白水平增加到了每分升11.2 g。然而，她的指甲似乎没有变。对铁缺乏的其他原因进行了进一步评估。卵和寄生虫的粪便检查以及腹腔疾病的实验室检查均为阴性，腹部超声检查结果正常。肺泡炎与缺铁性贫血有关，也可能是遗传性，特发性的，或与指甲外伤或溶剂接触有关。前三个数字可能会受到优先影响。该患者接受口服补铁治疗。在三个月的随访中，她的疲劳减轻了，她的血红蛋白水平增加到了每分升11.2 g。然而，她的指甲似乎没有变。对铁缺乏的其他原因进行了进一步评估。卵和寄生虫的粪便检查以及腹腔疾病的实验室检查均为阴性，腹部超声检查结果正常。肺泡炎与缺铁性贫血有关，也可能是遗传性，特发性的，或与指甲外伤或溶剂接触有关。前三个数字可能会受到优先影响。该患者接受口服补铁治疗。在三个月的随访中，她的疲劳减轻了，她的血红蛋白水平增加到了每分升11.2 g。然而，她的指甲似乎没有变。肺泡炎与缺铁性贫血有关，也可能是遗传性，特发性的，或与指甲外伤或溶剂接触有关。前三个数字可能会受到优先影响。该患者接受口服补铁治疗。在三个月的随访中，她的疲劳减轻了，她的血红蛋白水平增加到了每分升11.2 g。然而，她的指甲似乎没有变。肺泡炎与缺铁性贫血有关，也可能是遗传性，特发性的，或与指甲外伤或溶剂接触有关。前三个数字可能会受到优先影响。该患者接受口服补铁治疗。在三个月的随访中，她的疲劳减轻了，她的血红蛋白水平增加到了每分升11.2 g。然而，她的指甲似乎没有变。