PALLOR OF THE FACE, NAILS, OR CONJUNCTIVA
Pallor is almost invariably caused by anemia and is best analyzed with
the application of pathophysiology.Anemia may be caused by
decreased production of blood, increased destruction of blood, or loss of
blood. Decreased production results from poor nutrition
particularly, poor absorption or intake of B12 (pernicious anemia),
iron (iron deficiency anemia), and folic
acid (malabsorption syndrome). It may also result from suppressed bone
marrow (aplastic anemia) or infiltrated bone marrow (leukemia or metastatic
carcinoma). Increased destruction is caused by hemolysis from
intrinsic defects in the red cells (e.g., sickle cell anemia and
thalassemia) or extrinsic defects in the circulation (autoimmune hemolytic
anemia of many disorders). Blood loss may result from peptic ulcers
and carcinomas of the gastrointestinal (GI) tract, excessive menstruation or
metrorrhagia from tumors of the uterus, or dysfunctional uterine bleeding.
These are the principal causes of anemia, but the reader will be able to
think of several more. What is important here is to have a systematic method
to recall them.
If anemia is ruled out, the less frequent causes of pallor should be
considered. Shock, congestive heart failure (CHF), and arteriosclerosis
cause pallor by poor circulation of blood to the skin. Patients who have
hypertension may be pale from reflex vasomotor spasms of the arterioles
supplying the skin. Aortic regurgitation and stenosis, as well as mitral
stenosis, cause pallor for the same reasons, but the malar flush of mitral
stenosis may negate this. The reason that tuberculosis, rheumatoid
arthritis, carcinomatosis, and glomerulonephritis cause pallor even when
their victims are not anemic or hypertensive is not known.
Approach to the Diagnosis
The approach to the diagnosis of pallor is obviously to check for
anemia first; then to examine for the other chronic disorders. Chest x-ray,
electrocardiogram (ECG), sedimentation
rate, and a check for rheumatoid factor are all appropriate in specific
cases.
Other Useful Tests
-
Complete blood count (CBC) (anemia)
-
Sedimentation rate (chronic infection)
-
Chemistry panel (anemia of liver and kidney disease)
-
Serum B12 level (pernicious anemia)
-
Serum folic acid level (folic acid deficiency)
-
Serum iron and ferritin levels (iron deficiency anemia)
-
Stool for occult blood (GI bleeding)
-
Stool for ova and parasites (anemia due to parasite infestation)
-
Serum haptoglobins (hemolytic anemia)
-
Antinuclear antibody (ANA) analysis (collagen disease)
-
Bone marrow examination (aplastic anemia)
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
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