SIGNS AND SYMPTOMS Of IRON OVERLOAD Again, iron overload may be asymptomatic, which is why rou-tine screening is a very wise idea before any permanent dam-age occurs. Watch for such signs as cardiac dysfunction, liver damage, abnormal blood glucose or diabetes, and/or symptoms such as endocrine disorders, increased infections, chronic ab-dominal pain, neurological symptoms and musculoskeletal dis-orders. These clinical presentations should make you consider evaluating your patient’s serum ferritin levels. As many of our patients present with joint pain, this article will focus on joint arthropathy presentation Many of these pa-tients may have undetected hemochromatosis. Joint manifesta-tions present in over 80 per cent of people with hemochroma-tosis. Any patient presenting with polyarthropathy, including osteoarthritis (OA), calcium pyrophosphate dihydrate deposi-tion disease, pseudogout, rheumatoid arthritis (RA), ankylosing spondylitis – related to early calcification of the intravertebral disk (IVD) and ligaments – should be screened for iron overload. I think it is important to emphasize that, while many of the noted signs may seem ubiquitous to many conditions, the radiographic of feature of hook-like osteophytes that point proxi-mally rather than distally, as seen with RA, may be considered pathognomonic to iron overload. fEATURES Of IRON OVERLOAD Possible musculoskeletal manifestations: joint and bone pain; swelling; loss of motion; subcutaneous nodules; bursitis; ten-donitis; tenosynovitis. Sites of involvement: metacarpophalangeal joints; wrist; hip; knee; shoulder; ankle; metatarsophalangeal joints; elbow; spine; symphysis pubis; Achilles tendon; plantar fascia. Radiographic findings: joint space narrowing; sclerosis; cysts; pseudocysts; osteophytes; hook-like osteophytes that point proximally at the metacarpal heads (high specificity for he-mochromatosis); flattened or “squared-off” metacarpal heads; generalized osteopenia; chondrocalcinosis; subchondrial cysts; carpal erosions; calcific tendonitis. List from: Vasquez A. Integrative Rheumatology: Concepts, Per-spectives, Algorithms, and Therapeutics. The art of creating well-ness while effectively managing acute and chronic musculoskeletal disorders. Volume 1: Autoimmune Disorders. Fort Worth, TX; In-tegrative and Biological Medicine Research and Consulting, LLC: 2007. LABS Serum Ferritin Females: Less than 15 mcg/L = iron deficient, 30-70 mcg/L = health iron status; greater than 200 mcg/L = iron overload refer to GP for phlebotomy treatments Males: Less than 20 mcg/L = iron deficient, 30-70 mcg/L = health iron status; greater than 300 mcg/L = iron overload refer to GP for phlebotomy treatments Transferrin Saturation Anything greater than 40 per cent with high serum ferritin should be suspect of genetic hemochromatosis. CRP If CRP is high and serum ferritin is high, one should refer for evaluation of inflammatory process and liver disease – possibly cancer, hepatitis or alcoholic liver disease. Typically, CRP will not be elevated in just iron overload, but when both are elevated fur-ther evaluation is needed. Normal CRP should be below 2 mg/L. TREATMENT Of course, the best treatment of hemochromatosis is early detec-tion and preventing irreversible damage. Those who do test posi-tive should be referred for regular phlebotomy to reduce iron levels and be counselled on nutritional advice to reduce dietary intake of iron such as beef, pork, liver and spinach. Supplements with iron should be avoided as should vitamin C supplements that will increase iron absorption. Foods that reduce iron absorp-tion include tannins from tea, phytates in grains, soy protein and calcium supplements. Use of nutritional supplements to reduce the oxidative stress induced by high iron would be recommended, excluding vitamin C. Silymarin has a protective role at the liver and CoQ10, which also possesses antioxidant activity, with the heart and hence, these would be good strategies to implement. As one of the most common genetic disorders that can be as-ymptomatic, or present with advanced organ/joint damage, he-mochromatosis is a condition that can, with early detection, be managed. Considering the low-cost, low-invasive testing of serum ferritin, it would make sense to suggest all patients be screened rou-tinely and more so those who exhibit symptoms that could be a result of iron overload. A special note of mention of Dr. Vasquez, whose unrelenting desire to improve the health of many and dedicated work with practitioners was a reminder of this particular condition and its relevance to the doctor of chiropractic. • SOURCES Ly J., Beall D, Ahluwalia J. Hemochromatosis Arthropathy. Appl Radiol. 2006;35 (8). McCurdie I, Perry J David. Haemochromatosis and exercise related joint pain. BMJ 1999 Feb 13;318. (7181):449-451. Vasquez A. Integrative Rheumatology: Concepts, Perspectives, Algorithms, and Therapeutics. The art of creating wellness while effectively managing acute and chronic musculoskeletal disorders. Volume 1: Autoimmune Disorders. Fort Worth, TX; Integrative and Biological Medicine Research and Consulting, LLC: 2007. Vasquez A. Musculoskeletal disorders and iron overload disease: comment on the American College of Rheumatology guidelines for the initial evaluation of the adult patient with acute musculoskeletal symp-toms. Arthritis Rheum 1996 Oct;39(10):1767-8. www.canadianchiropractor.ca TESTING The best test that correlates with body iron stores is serum fer-ritin. Considering how prevalent this condition is, the low cost of this screening test and the fact that many people are asymp-tomatic until organ damage is severe and irreversible, having just about everyone ensure they have their serum ferritin tested seems justifiable. One may also combine a C-reactive Protein (CRP) test to evaluate whether there is an inflammatory role in elevating the serum ferritin, as this can happen in acute cases or infection, inflammation, and a transferrin saturation. The transferrin saturation is a good marker, along with serum fer-ritin, to pick up the genetic causation to hemochromatosis be-fore damage ensues. 36 • CANADiAN CHiROPRACTOR | APRiL 2013
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