A 48 Year Old Lady Presents With Difficulty Swallowing And Fatigue

A 48 year old woman who has a long history of weakness and fatigue come to see her physician because she has been feeling difficulty in swallowing for the last few weeks. This dysphagia was intermittent and is limited to solids. She denies any history of weight loss. The patient was previously prescribed iron supplements to correct her anemia and resulting fatigue but she never took the supplement
On Examination the patient is a middle aged lady looking pale and a bit anxious. On general physical the following features were seen in the nails and the tongue.

Spoon shaped nails known as Koilonychia seen in chronic long standing Iron deficiency anemia.

Smooth, red tongue with loss of lingual papillae (Atrophic glossitis)

On lab work There was microcytic hypochromic anemia and a barium swallow revealed esophageal webs on the anterior esophageal wall.

What is the most probable diagnosis?

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Plummer Vinson Syndrome  (triad of difficulty swallowing, iron deficiency anemia & esophageal webs)

Case Discussion:
 Plummer vinson syndrome is a condition that most commonly occurs in patients with long standing iron deficiency anemia. The exact cause is unknown but genetic factors and underlying nutritional deficiencies may play a role. It is more common in woman. Sometime patients may go on to develop esophageal cancer.

Clinical features: may include:

• Difficulty in swallowing
• Painful swallowing
• Weakness
• Fatigue
• Atrophic glossitis
• Angular stomatitis.

Diagnosis : is clinical based on the triad of difficulty in swallowing, iron deficiency anemia and esophageal webs. Following workup is done:

• Complete blood count with peripheral smear. 
• Iron studies ( including serum ferritin and TIBC)
• Barium esophagogram
• Video fluroscopy

Treatment; includes iron supplements and widening of the web tissue during upper endoscopy to help swallowing the food. 

Differential Diagnosis:

• Esophageal cancer
• Isolated esophageal webs and rings
• Iron deficiency anemia
• Hypopharangeal cancer