Enhanced Nickel Sensitivity in Iron Deficiency Anemia

Sir, We are writing with reference to your review article in the January–March 2017 issue on “directly observed iron supplementation for control of iron deficiency anaemia.”[1] The article is well written and the suggestion of directly observed iron supplementation may definitely prove fruitful. We, as oral diagnosticians, come across several cases with undiagnosed iron deficiency anemia. We would like to share our experience with a patient with iron deficiency anemia who also had a unique manifestation. Iron deficiency anemia continues to be the most common nutritional disorder in the world. In India, it is considered as a severe public health problem with a prevalence of ≥40%.[2] The oral diagnostician encounters cases often reporting with the complaint of burning sensation of the oral mucosa. This is attributed to the iron deficiency which affects the normal functioning and turnover of the epithelial cells causing atrophy of the oral mucosa.[3] We encountered a case of iron deficiency anemia with an infrequent history of chronic urticaria. She had a long-standing history of constantly being on and responding well to antihistamines. The frequency and severity of urticaria coincided with consumption of green leafy vegetables, chocolates, and nuts, which she restricted herself from. Previous patch testing revealed no positive results. Proper iron therapy eventually improved her hemoglobin profile and eventually reduced the episodes of urticaria. Interestingly, the foods which precipitated the episodes of urticaria are rich in nickel.[4] Nickel sensitivity is a possibility to be considered in patients with iron deficiency anemia presenting with chronic urticaria.[5] The human body retains approximately 3%–6% of the total amount of dietary nickel absorbed. This is enhanced in iron deficiency anemia. The divalent metal transporter protein presents on the surface of the intestinal enterocytes, absorbs, and transports dietary iron, in the unavailability of which, it binds to other divalent cations. This is of significance in patients with nickel allergy, developing iron deficiency anemia. Adequate iron supplementation eventually limits the absorption of nickel, which along with a low nickel diet is recommended for patients with iron deficiency anemia and nickel sensitivity.