Worldwide, anaemia affects over two billion people and the World Health Organization (WHO) has estimated that half of these are due to iron deficiency. Iron deficiency is not only the most prevalent but also the most neglected nutrient deficiency in the world. Iron deficiency is the most prevalent single deficiency state on a worldwide basis. Prevalence of anaemia in the South Asia is amongst the highest in the world, mirroring overall high rates of malnutrition. [1]

WHO defined anaemia as haemoglobin concentration less than 13 g/dl in adult males or hematocrit value less than 0.33. In India prevalence is 47-50% [2] while as per NFHS-4, prevalence of anaemia among MEN 15-49 YEAR AGE (<13gm/dl) is 18.5% for urban & 25.3% for rural area. Similar results are for Andhra Pradesh state as well with 17.8% & 25% in urban & rural respectively. [3]

Most of the programs for anaemia control are directed for Reproductive & Adolescent age group & mainly for females & children. Above data shows 1 in 4 men suffers from anaemia & may face the complications & consequences. Thus there is dearth of data about the male anaemia patterns. Thus present study is aimed to assess Clinical & Haematological Profile of Male anaemic patients admitted at Medical wards.

100 Male patients admitted in medical ward for anaemia at tertiary care hospital affiliated with Sri Pingali Venkaiah medical college, Machilipatnam, Andhra Pradesh during study period, who met inclusion criteria and who were willing to participate in this study were subjected for further evaluation.

Inclusion criteria included Age group- above 12 years , Haemoglobin level ≤ 10 g/dl and Exclusion criteria includes Age group < 12 years , Female patients , Haemoglobin >10mg/dl. The study participants were recruited through Simple random sampling by random number of tables. All those patients admitted in a month were line listed & based on selected random number patients were recruited till the desired sample was achieved. It took three month to complete data collection process. Sample size was calculated using proportion of 20% anaemic male patients & 8% of precision through the formula of n=3.96*p*q/l2. [4] The final product of the above calculation was arrived at 99 which were rounded to 100.

Along with clinical data, demographic information in form of age, socio-economic status was obtained. A detailed history was taken including the chief complaints, which were in form of easy fatigability, breathlessness on exertion, oedema feet, anorexia, palpitation, and jaundice, Glossitis, bleeding from any site, numbness, paraesthesia and any disturbances in gait. Past history and family history pertaining to anaemia was also recorded. Specific inquiry regarding haemolytic, haemorrhagic, hepatic or endocrine disorders were made and noted. In the personal history, details of the dietary pattern (vegetarian and mixed.), addictions (tobacco in different forms, alcohol), appetite were obtained Drug history for ingestion of any offending drug which might have caused anaemia (Aplastic, haemorrhagic or haemolytic) was also determined. Patients were classified in lower, middle and upper socio-economic class according to monthly family income as per Kuppu swami’s socioeconomic classification. [5] A thorough physical examination was performed with special emphasis on signs of anaemia on general examination like pallor in conjunctiva, tongue, palms, nails, lips and mucus membranes. Other relevant findings on general examination like icterus, mouth ulcer, cheilosis, koilonychias, oedema feet and face, neck veins, skin pigmentations, purpura, petechial, lymphadenopathy and stigmata for endocrinopathy. Vital data including temperature, pulse, blood pressure, respiratory rate were noted. Nutritional status was assessed with the help of measuring height and weight as well as by calculating the body mass index. Systemic examination included that for cardiovascular system (Water hammer pulse, signs of CCF, hemic murmur), abdomen (ascites, organomegaly) and CNS examination (higher functions, sensory system, gait disturbances, motor system, reflexes).

Ethical Approval: Prior approval of the institutional ethics committee was taken before commencing the study. Data collected from the selected subjects were internally compared and statistically analysed by using descriptive and inferential statistics through Microsoft excel & Epi info based on formulated objectives of the study.

Table 1: Socio demographic Profile & personal profile of study participants (n=100).

As per Table:1, Anaemia was prevalent in males of all age group but highest in fifth decade which was around 23%, followed by 15% in 6th decade, 18% in 3rd decade, 12% in 7th decade and 2nd decade, 7% in 3rd decade, 9% in 8th decade. 67% males were vegetarians and 33% males were non vegetarians. 5% males were pure vegetarians who were taking various types of food from natural sources only like cereals, pulses, vegetables, fruits and nuts (no milk or dairy products, no eggs, no meat, no fish). 24% males were Lacto-vegetarian who were taking milk and Dairy products. 35% males were Lacto-ova-vegetarian who was taking cereals, pulses, fruits, vegetables, milk and milk products and eggs. 3% males were Ova-vegetarian who were taking eggs in addition to vegetarian food items but no other items. Among non-vegetarian males, their diet consists of chicken, meat, fish, eggs, milk & dairy products.

22% Males were Bidi smokers, 14% males were Alcoholic and 45% male were Tobacco chewers. This study shows anaemia was more common in lower socio economic males (67%) in comparison to middle and higher socio economic males (33%). Patients were classified in lower, middle socio-economic class according to monthly family income as per Kuppuswami’s socio-economic classification ⁽⁵⁾

Table 2: Distribution of study participants according to presenting symptoms (n=100).

                                               *= Multiple responses

The most common symptom observed in our study was weakness (85%). Second most common symptom observed in our study was easy fatigability (82%). Third most common observed in our study was breathlessness on exertion (47%). Other symptom observed in our study were palpitation (44%), anorexia(46%), upper GI blood loss (13%), lower GI blood loss(18%), dizziness(46%), abdominal distension (4%), tingling and paraesthesia (14%), sensory disturbances (4%). In our present study, male patients were admitted to hospital for various co-morbid conditions, we had focused on symptoms like breathlessness on exertion, easy fatigability, weakness, palpitation, dizziness, anorexia along with comorbid conditions. There was significant improvement in comorbid conditions after correction of anaemia done. It would help in improving quality of life of people.

Table 3: Distribution of study participants according to presenting signs on physical examination (n=100).

                                             * Multiple Responses

Out of 100 male patients, the sign associated with anaemia was Pallor of conjunctiva, nails and tongue which was present in all males, followed by Glossitis in 56 patients , Cheliosis in 45 patients ,Odem of Feet in 37 patients, Koilonychias in 27 patients, Apthous ulcers in 23 patients, Mucocutanoeus Hyper pigmentation in 21 patients, Jaundice in 20 patients, Lymphadenopathy in 24 patients, Splenomegaly in 24 patients, Hepatomegaly in 26 patients, sensory disturbance in 4 patients , Gait disturbance in 4 patients and Hemic murmur in 34 patients.

In present study, 30 male patients were having Haemoglobin between 7.1 to 10 gm. %. So 30% males were having moderate anaemia. ^[6] 70 male patients were having Haemoglobin below 7 gm. %. So 70 %males were having severe anaemia. ^[6] The intensity of anaemia was decided according to ICMR grading system.^[6]

Table 4: Types of anaemia as per peripheral smear of study participants (n=100).

In our present study, most common RBC morphology was microcytic hypochromic (50%) which was associated with iron deficiency. Dimorphic picture was found in (15%) males. It shows combined deficiency of iron, vit B12,folic acid. Macrocytosis was found in 19% males. 8% males were having normocytic normochromic pattern in peripheral smear in our present study. 3% males were having pancytopenia in peripheral smear which has correlation with aplastic crisis. 5% males were having Haemolytic pattern in peripheral smear which was associated with haemoglobinopathies like thalassemia and sickle cell anaemia.

Table 5: Distribution of various indices (MCV, MCH, MCHC) for measurement of anemia among study subjects (n=100).

                          There was vast variation among various forms of anemia & Hematological indices.

Table 6: Comparison of Age Distribution As Reported By Various Studies.

Table 6 compares age distribution of anaemia among present study with Milind Chandurkar teal(2017)^[8] Mark Ruth Prassana et al. (2017)^[7],Reena Kouli et al.(2016)^[9]and Nasrin Qureshi et al. (2015)[10].In present study, Anaemia was more common in age group 41-50 years with mean age of 43 years which was consisted with all above mentioned studies except Reena Kouli et al. (2016)^[9] in which maximum incidence was seen in 20-30 year age. In present study, 63% males were above 40 years and 37% males were below 40 years .So our present study shows that we need to be alert in male patients above 40 years regarding screening of anaemia so that we can treat it and avoid complications. In present study, 67% males were coming from lower socio-economic class. These findings were comparable with Mehta B.c.et al. ^[11] (60%). Unbalanced diet with deficiency of nutrients like iron, Vit-B12, Folic acid and protein was responsible for anaemia in lower socio-economic class. In present study, 33% males were coming from Middle and higher Socio-economic class. These findings were comparable with Mehta B.c.etal ^[11] (40%) Habit of junk food consumption may because of anaemia in middle and higher socio-economic class.

Anaemia is more prevalent in lower socio economic group due to the following possible reasons: 1. More prevalence of nutritional deficiencies, 2.Delay in seeking health care facilities and medical help, 3. More prevalence of worm infestations 4. Lack of knowledge about nutrition, hygiene and the availability of facilities. 5. Ignorance.

Table 7: Comparison of Hemoglobin level As Reported by Various Studies.

Severe anaemic males are more prone to suffer from community acquired infections and heart failure .This shows that when anaemia present in the males, it is usually severe and so it should be vigorously treated.

Table 8: Comparison of clinical symptoms & various signs of anaemia with other study.

Table 9: Percentage distribution of participants as per RBC morphology in peripheral smear in various studies

So the present study emphasizes that in male patients, we should not ignore signs and symptoms of anaemia even in the presence of other comorbid conditions. Rather even in male patients, we should vigilantly look for anaemia. There was significant improvement even in co morbid conditions after correction of anaemia done. It will help in improving quality of life of people. Pallor was commonest sign found in present study (100%) which was comparable with Milind Chandurkar et al.(94%) ^[8] and Mehta B. Cetal(100%) ^[11] Koilonychias as was found in 27% in present study which was comparable with Milind Chandurkar et al. (20%)^[8] and Mehta B.c.etal al (100%)^[11] Hemic murmur was found in 34% in present study which was Comparable with Milind Chandurkar et al. (22%) ^[8]. It was present in severe anemic males whose HB below 6 gm. /dl.

Anaemia was prevalent in males of all age group but highest incidence (23%) seen in 5thdecade (41-50yearage) with mean age of 43 years. Hence in male patients, anaemia should be screened vigilantly so that we can treat it and avoid complications. Nutritional deficiency is the most common etiology found in Iron deficiency anaemia as well as Megaloblastic anaemia. Anaemia was more prevalent in strict vegetarian males (67%) as compare to non-vegetarians (33%).Lower socio economic status was responsible for high incidence of nutritional anaemia. BMI per se does not have much correlation with anaemia. Diet, Alcohol addiction, worm Infestations, personal hygiene, drugs like phenytoin, anticancer drugs, Low socio economic status are considered as modifiable risk factors of anaemia. Risk factors should be corrected by patient education, proper sanitation, removal of offending agent and proper balanced diet. The most common symptom observed were weakness (85%) Followed by easy fatigability (82%) and breathlessness on exertion (47%). so any male patient presenting with such symptoms should be vigilantly investigated for anaemia. There is significant improvement even in co morbid conditions after correction of anaemia done. It will help in improving quality of life of people. Pallor of skin and mucus membrane was the most common sign present in 100 % cases followed by Glossitis in 56% cases. So it suggests that habitual inclusion of these in examination of all male patients will assure not missing anaemia in male patients even in presence of co morbid condition. In peripheral smear examination, 50% males were having microcytic hypochromic anaemia. Most common type of anaemia was Iron deficiency anaemia observed in 50% patients. Those in male anemic patients, thorough evaluation for type of anaemia will make etiology specific treatment more effective.

LIMITATIONS OF THE STUDY

As it is a hospital based study, these results cannot be extrapolated to the general population. Many patients could not produce previous imaging studies and laboratory investigations. VitB12, serum folate level, serum iron level, TIBC LEVEL, protein electrophoresis, immuno histo chemistry, and cytogenetic are not possible in our setup. Endoscopy was not done in subjects as it is not available in our institute. Patient with unidentified etiology could not be evaluated further.

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