Revisiting Plummer Vinson Syndrome
A 49-year-old female presented with difficulty in swallowing and easy fatigability from 3 months. The dysphagia initially was mainly to solids. There was no history of malaena or hematochezia. On examination her pulse rate was regular, 98/min, and blood pressure was 110/80 mm of Hg. She had pallor and koilonychia. Systemic examination was unremarkable. Lab reports showed hemoglobin (Hb)- 8.8 g/dl, total leukocyte count (TLC)-6400/μL, platelet count-140,000/μL. Mean corpuscular volume (MCV)-60.7 fl, mean corpuscular hemoglobin (MCH)-19.2 pg/cell, mean corpuscular hemoglobin concentration (MCHC)-31.8 g/dl; serum creatinine-0.8 mg/dl, total bilirubin-0.8 mg/dl, (direct-0.11 mg/dl), SGPT-8 U/L. Fecal occult blood test was negative and stool for parasites was negative as well. Serum iron was 40 μg/dl; Total iron binding capacity was 170 μg/dl; transferrin saturation was 10% and serum ferritin was 15 ng/ml. Peripheral smear showed microcytic hypochromic picture. Ultrasonography of abdomen and pelvis was normal. Barium swallow was suggestive of a web at C5 level at anterior aspect of pharyngo-esophageal junction. Upper GI endoscopy showed a smooth, circular, whitish narrowing suggestive of a post cricoid web at the C5 vertebra-level []. There was no evidence suggestive of other causes of iron deficiency anemia such as malabsorption, malnutrition, use of NSAIDs and abnormal vaginal bleeding. Absence of iron overload, no hemolysis, no history suggestive of lead exposure, use of isoniazid or any chronic diseases make the alternative diagnoses such as sideroblastic anemias, thalassemias, warm antibody autoimmune hemolytic anemia, anemia of chronic disease, lead poisoning, and pyridoxine deficiency less likely. A diagnosis of PVS was made. Upon patient's insistence, endoscopic dilatation was deferred and the patient was discharged on oral iron supplements (ferrous ascorbate 100 mg). Patient was lost to follow up until 6 months when patient presented again with complaints of non-resolving dysphagia and that the dysphagia progressed to liquids. Work up this time showed that Hb improved to 10.8 g/dl, MCV-80.2 fl, MCH-28 pg/cell, and MCHC-33.4 g/dl. Fluoroscopy-guided dilatation of the hypopharyngeal web was done (no evidence of mass/ulceration or thickening found on fluoroscopy). Dysphagia subsided and patient's general condition improved. She was able to swallow solids and liquids at the time of discharge. Oral iron supplements were continued and she was counseled for frequent follow-ups.