Therapeutic Oral Iron Supplementation Associated Mucosal Injury of the Upper and Lower Respiratory Tract
A Cimino, PB Illei. Johns Hopkins Medical Institutions, Baltimore, MD
Background: Mucosal injury of the upper gastrointestinal tract due to therapeutic oral iron supplementation is a well-described yet under-recognized entity. Although iron pill aspiration is well documented to cause massive necrosis and stricture of the airways, injury to the bronchial/upper respiratory tract mucosa secondary to aspiration of therapeutic oral iron ingestion has rarely been described.
Design: We describe the mucosal injury pattern in bronchial and hypopharyngeal biopsies of two elderly patients (84 y.o. woman and 8.4 y.o man) who were both receiving therapeutic oral iron supplementation. The patients had no known aspiration events. Patient 1 is an 84 y.o. woman with iron-deficient anemia who developed hemoptysis. Patient 2 is an 84 y.o man with past medical history of prostate cancer and basal cell carcinoma who presented to with an ulcerated and protuberant hypopharyngeal mass suspicious for a neoplasm.
Results: Endoscopy demonstrated friable mucosa and maculopapular lesions in the right mainstem bronchus and in the hypopharynx, respectively. Biopsies of both lesions showed mucosal ulceration with deposits of brown fibrillar material in the epithelium and submucosa with associated fibrohistiocytic reaction. Both patients had been confirmed to be taking oral iron supplements during the weeks prior their presentation. Following modifications in their medications both patients remained asymptomatic. Bronchial washings were also availble in one of the cases and demonstrated numerous crystalline particles within macrophages or free floating. Iron stains were positive in both the biopsy materials and the washings.
Conclusions: Aspiration of therapeutic oral iron supplements result in mucosal injuries that are histologically similar to the mucosal injury seen in the upper gastrointestinal tract with "iron pill" gastritis, which is an under-recognized pathologic diagnosis with important therapeutic implications for patients. These lesions can mimic neoplastic processes in the airways, particularly due to their ulcerative, friable and occasionally protuberant gross appearance. The presence of extracellular crystalline iron in the airway lumen as well as in the mucosa, associated with varying degrees of ulceration and inflammation, confirms the diagnosis of iron-induced injury even in patients with no known aspiration events.
Monday, March 22, 2010 9:30 AM
Poster Session I Stowell-Orbison/Surgical Pathology/Autopsy Awards Poster Session # 230, Monday Morning