Case Study: Sick And Tired, Seeing Things? You Might Have Anemia

Updated | Published
by SafetyNurse1968 SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

This is a true story about a young woman who began to hallucinate. In the 'Mystery of The Dog in a Fedora', you can read the story from the beginning. This is part two, and includes the solution to the mystery. Read on to get an in-depth review of signs, symptoms, etiology, risk factors, diagnostic tools and treatments for various types of anemia.

How do you assess anemia?

Case Study: Sick And Tired, Seeing Things? You Might Have Anemia


Read the full story HERE. A few years ago, my cousin Ruth came to live with us for the Summer and be a nanny to my four kids. While she was living with us she presented with increasing fatigue and listlessness. Eventually she admitted to having hallucinations, describing lights flashing on the ceiling as she tried to sleep, and of seeing our family dog wearing a grey fedora. She had always been pale and thin, she was a vegetarian, and she had recently stopped taking her birth control pills, which had led to intermittent bleeding for several months. In addition, she had a family history of suicide and manic depression. I suggested she try to eat more iron rich foods, and keep me posted on her fatigue level, but she didn't tell me much - typical of a teenager. Finally, we ended up taking her to the ER when she admitted to having thoughts of harming herself.

I had considered anemia as the source of her fatigue, but when I questioned her about the amount of bleeding she was having, she had denied that it was excessive. In my experience anemia doesn't cause hallucinations, so when she started telling me about seeing our dog in a hat, given her family history, I started worrying about a mental health disorder, especially schizophrenia, which typically presents in early adult-hood.


Ruth was in the psych ward for four days, and during that time they did a full history and physical, including a psychological evaluation, medication reconciliation and a wide panel of lab tests. Though they found signs of depression, that didn't explain seeing my dog in a fedora. What they did find was severe iron deficiency anemia. She had been bleeding longer and more heavily than she had previously admitted, and I could have kicked myself for not taking her to see a doctor sooner. This article is my penance for not picking up on it sooner. I review risk factors, signs and symptoms of the various types of anemia, as well as diagnostic tests and treatments, and there are great resources for further learning.

I still don't think I would have put iron deficiency anemia with hallucinations - I have looked far and wide for case studies or research discussing a link between the two. I Googled anemia and hallucinations multiple ways and got nothing. I tried hypoxia and hallucinations as well. I looked on Google Scholar, PubMed and hematological websites, but found very little linking the two. There is an article about a woman with very low iron who thought she was infested with spider eggs (Delusional parasitosis secondary to severe iron deficiency anemaia). I also found a link between mountain climbing and psychosis, but the authors haven't found a direct link between hypoxia from mountain climbing and hallucinations. There's also a link between Vitamin B-12 deficiency caused anemia and hallucinations. Some people diagnosed with dementia or Alzheimer's are actually suffering from B12 deficiency. Ruth wasn't a mountain climber, she wasn't vegan or lacking intrinsic factor or producing inadequate stomach acid. She was slowly bleeding to death.


Anemia is common and affects one-third of the world's population, and more than 3 million Americans. Anemia is defined as any pathological condition leading to significant decrease in total body erythrocyte (Red Blood Cell) mass. Red blood cells (RBCs) carry hemoglobin, an iron-rich protein that binds and carries oxygen to tissues in the body. Anemia occurs when you don't have enough red blood cells or when your red blood cells don't work correctly.


Given the prevalence of anemia, you would think it would be easy to get all the information you need to know on the internet, but not so. I found myself longing for my old nursing school Med/Surg textbook. I found a lot of information for the layperson, describing signs and symptoms, but very little information on diagnostic lab values, and how to do a work-up on someone suspected of having anemia. As a patient safety specialist, I know that multiple organizations recommend up-to-date, easily accessible information be available to healthcare providers. It is often nurses who spot valuable details: patterns in vital signs, low lab values, patient behaviors, family stories, empty vitamin bottles found in a purse (can you hear the patient's voice? "oh, I didn't think it was important to tell the doctor about my vitamins!") When we have access to knowledge, we are better detectives and have a better chance of keeping our patients safe.


Ruth had iron deficiency anemia, the most common type of anemia worldwide, affecting 10-30% of world population; in the U.S. 11% of women and of 4% men have iron deficiency anemia, but there are many other types of anemia.

Iron deficiency anemia caused by a shortage of iron in your body. Your bone marrow needs iron to make hemoglobin. Without adequate iron, your body can't produce enough hemoglobin for red blood cells. It occurs in many pregnant women and is also caused by blood loss - like Ruth's, from heavy bleeding. Ulcers, cancer and regular use of aspirin can cause it as well.

Vitamin B12 Deficiency caused by a lack of folate and vitamin B-12. Both are needed to produce healthy red blood cells. A diet lacking in these nutrients can cause decreased RBC production. In addition, if your body doesn't make intrinsic factor, you can't process the vitamin - leading to pernicious anemia.

Chronic diseases Cancer, HIV/AIDS, rheumatoid arthritis, kidney disease and Crohn's can interfere with production of red blood cells.

Aplastic anemia Caused by underproduction of red blood cells due to infection, medication, autoimmune disease and exposure to toxic chemicals.

Bone Marrow Diseases leukemia and myelofibrosis can cause anemia by affecting blood production in the bone marrow

Hemolytic Anemia when RBCs are destroyed faster than bone marrow can replace them. It can be inherited or develop later in life, includes Sickle cell Anemia which is an inherited defective form of hemoglobin that causes RBCs to form a crescent or sickle shape - they die prematurely.

Thalassemia A rare inherited blood disorder in which the body makes an abnormal form of hemoglobin


When you have anemia, your body tissues lack oxygen, so you may have one or more of the following symptoms:

  • Tiredness
  • Dizziness
  • Weakness
  • Headaches
  • Pale skin
  • Fast heartbeat
  • Shortness of breath
  • Pounding or whooshing in ears
  • Craving for ice or clay (picophagia)
  • Sore or smooth tongue
  • Brittle nails
  • Hair loss
  • Difficulty concentrating
  • Grumpiness
  • Poor cold tolerance
  • Decline in renal function
  • Osteoporosis
  • Sarcopenia (loss of muscle tissue)


There are many risk factors for anemia: major surgery or trauma, menstruation (especially if periods are heavy) recently given birth, pregnant or breast feeding, GI disease like celiac, IBD, ulcerative colitis or Crohn disease, peptic ulcer, bariatric or gastric bypass, vegetarians, people who don't each iron-rich foods.


Diagnosis of anemia involves asking many questions. You will want to know: severity; rate of onset; the patient's overall health and oxygen demand; past medical history (menstruation, duration, frequency, flow, pregnancy, blood in stool, blood loss - acute vs. chronic); family history. You will also do a complete physical exam (Pallor, conjunctiva, oral mucosa, nail beds, palmar creases, orthostatic BP changes - intravascular volume shift), lab workup and medication reconciliation.


Diagnosing iron deficiency anemia is simple. Start with the CBC and look at the RBC count, and Hematocrit and Hemoglobin levels. If those are low, get an order for TIBC, iron and ferritin. A comprehensive list of lab values related to anemia is included, and where it's applicable I have included Ruth's values as well as normal values in parenthesis.

Red blood cell size and color: with iron deficiency anemia, RBCs are smaller and paler in color

Red Blood Cell count: how many RBCs you have. It's also known as an erythrocyte count. The test is important because RBCs contain hemoglobin, which carries oxygen to your body's tissues. Your tissues need oxygen to function.

Ruth: 3.1x1012/L (3.9-5.2x1012/L)

Hematocrit: the percentage of blood volume made up by RBCs.

Ruth: 23.1% (34.9-44.5 % women; 38.8 - 50.0 % men).

Hemoglobin: the oxygen-carrying molecule found in RBCs. Lower than normal hemoglobin levels indicate anemia.

Ruth: 7.0 g/dL (13.5-17.5 g/dL men; 12.0-15.5 g/dL women).

Mean corpuscular volume(MCV): the average volume of red cells. It can be directly measured by automated hematology analyzer, or it can be calculated from hematocrit (Hct) and the red blood cell count (RBC) as follows: MCV in fl = (Hct [in L/L]/RBC [in x1012/L]) x 1000.

Ruth 73 fL (78-102fL)

Ferritin: a protein that contains iron and is the primary form of iron stored inside cells. The amount released and circulating in the blood reflects the amount of iron stored in the body. When your iron level is low, your body will pull iron out of storage to use it. A low level of ferritin usually indicates a low level of stored iron.

Ruth: 4 ng/mL (12-156 ng/mL)

Total iron-binding capacity (TIBC): tells how much transferrin (a protein) is free to carry iron through the blood. If TIBC is high, more transferrin is free because there is less iron.

Ruth: 550 mcg/dL (200-450 ng/mL).

Serum Iron: The amount of iron in your blood may be normal, even if the total amount of iron in your body is low - which is why other tests are needed (like the TIBC and Ferritin levels).

Ruth: 10 umol/L (10-30 umol/L)

If it's not iron deficiency anemia, further tests are needed. Click on THIS link for more lab values and images of blood smears. And check out this Powerpoint based on Hazzard's Geriatric Medicine and Gerontology. It has flow charts for diagnosis, case studies, and a discussion of microcytic vs. macrocytic anemia (too much for this article!)


Iron deficiency anemia: taking iron supplements (take on an empty stomach to increase absorption, don't take with antacids, take with Vitamin C, watch out for constipation) and making changes to your diet (red meats, leafy-dark green vegetables, beans, molasses, liver, grains). If the underlying cause of iron deficiency is loss of blood, the source of the bleeding must be located and stopped. In Ruth's case, she had to get back on contraceptives to lighten her heavy menstrual flow. She also had to take iron, and it takes a long time to get iron levels up to normal, unfortunately, they can't be corrected overnight, and may take months to replenish.

Vitamin deficiency anemia: Dietary supplements and increasing these nutrients in your diet. If your digestive system has trouble absorbing vitamin B-12 from the food you eat, you may need vitamin B-12 shots. At first, you may receive the shots every other day. Eventually, you'll need shots just once a month, which may continue for life, depending on your situation.

Anemia of chronic disease: No specific treatment for this type of anemia. You have to treat the underlying disease. If symptoms become severe, a blood transfusion or injections of synthetic erythropoietin, a hormone normally produced by your kidneys, may help stimulate red blood cell production and ease fatigue.

Aplastic anemia: Blood transfusions to boost levels of red blood cells. You may need a bone marrow transplant if your bone marrow is diseased and can't make healthy blood cells.

Anemia associated with bone marrow disease: Medication, chemotherapy or bone marrow transplantation.

Hemolytic anemias: Avoiding suspect medications, treating related infections and taking drugs that suppress your immune system, which may be attacking your red blood cells. Depending on the severity of your anemia, a blood transfusion or plasmapheresis may be necessary. Plasmapheresis is a type of blood-filtering procedure. In certain cases, removal of the spleen can be helpful.

Sickle cell anemia: Administration of oxygen, pain-relieving drugs, and oral and intravenous fluids to reduce pain and prevent complications. Doctors also may recommend blood transfusions, folic acid supplements and antibiotics. A bone marrow transplant may be an effective treatment in some circumstances. A cancer drug called hydroxyurea (Droxia, Hydrea) also is used to treat sickle cell anemia.

Thalassemia: Blood transfusions, folic acid supplements, medication, removal of the spleen (splenectomy), or a blood and bone marrow stem cell transplant.


Schizophrenia Facts and Statistics

Delusional parasitosis secondary to severe iron deficiency anemia

Mountain Climbing Can Actually Cause Psychosis, And We Don't Know Why

Iron deficiency anemia - Diagnosis and treatment - Mayo Clinic

Iron-Deficiency Anemia | National Heart, Lung, and Blood Institute (NHLBI)

Laboratory Evaluation of Anemia

Dr. Kristi Miller, aka Safety Nurse is a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes at the word processor. She is obsessed with patient safety. Please read her blog, Safety Rules! on You can also get free Continuing Education at In the guise of Safety Nurse, she is sending a young Haitian woman to nursing school and you can learn more about that adventure:

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8 Comment(s)

Rocknurse, MSN, APRN, NP

Specializes in Critical Care and ED. Has 33 years experience. 1,367 Posts

Last year I was feeling particularly run down. I was exhausted and slow and no matter how much sleep I got I was dragging each and every day. I got a full work up and found that both my vitamin D levels and my ferritin were in the toilet. After treatment I started to feel much better a few weeks later. I was amazed how sick I felt with those two values being low. I was literally unable to function. Now whenever anyone tells me they're tired, I tell them to get blood work first thing.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 522 Posts

Rocknurse said:
Last year I was feeling particularly run down. I was exhausted and slow and no matter how much sleep I got I was dragging each and every day. I got a full work up and found that both my vitamin D levels and my ferritin were in the toilet. After treatment I started to feel much better a few weeks later. I was amazed how sick I felt with those two values being low. I was literally unable to function. Now whenever anyone tells me they're tired, I tell them to get blood work first thing.

It's so much more debilitating than I ever realized. I think the stories of those who have been there really help it hit home - anemia is a big deal.



472 Posts

Thank you for posting and updating. It was a pretty interesting case, and anyway I always enjoy open ended medical case studies like this.

I am curious though how the hallucinations can be reliably attributed to anemia when you also have a diagnosis of depression, which is also known to manifest hallucinations at times.

Either way, thanks for the thread and glad to hear that your family member is doing better.


6,267 Posts

Cowboyardee said:
I am curious though how the hallucinations can be reliably attributed to anemia when you also have a diagnosis of depression, which is also known to manifest hallucinations at times.

In the case presented in the OP's second reference, the patient was believed to have a primary psychiatric illness but when routine labs were done severe anemia was found. It was treated with transfusion and the delusions and hallucinations also resolved. If it had been treatment of a primary psychiatric condition that caused resolution of the hallucinations, it would point to that as a direct cause, rather than the anemia.

In general this is why patients who present with new seemingly-psychiatric symptoms are screened or ruled out for medical causes of their condition first (or simultaneously with psychiatric assessment).


ETA: OP, thank you for the case presentation.

CharleeFoxtrot, BSN, RN

Has 11 years experience. 836 Posts

Thank you for sharing! Great exercise in thought!


BeenThere2012, ASN, RN

Specializes in PICU, Pediatrics, Trauma. 1 Article; 850 Posts

I thoroughly enjoyed this article. You are a clever mystery writer! More importantly, I learned a lot here and a great update for this old nurse on RBC function etc...Thank you for the in depth educational story.

nursej22, MSN, RN

Specializes in Public Health, TB. Has 37 years experience. 2,478 Posts

I experienced iron-deficiency anemia as a result of heavy periods/fibroids. My hemoglobin/hematocrit was 9/27 and I can testify to the overall feeling of exhaustion. I was almost breathless with just a brisk walk, and I was cold all the time.

Another often overlooked symptom is pica, especially a fondness of ice.

Thank you for both articles!



4 Posts

I thought the 2 part presentation was very effective; the case popped into my mind several times over the past few days while I waited for part 2! I graduate from nursing school this December and appreciate what effort you must have put into these articles. Thank you for writing and I hope you have more cases up your sleeve.

walkingrock, ADN

Specializes in Retired NICU. Has 43 years experience. 178 Posts

Wow! Very interesting and informative! Wouldn't have thought this would be the cause of her hallucinations! Thanks for sharing. Well written article.