Hookworm - Associated Iron Deficiency Anemia at Age Extremes: Two Case Reports from North Sulawesi, Indonesia

Iron deficiency anemia (IDA) is the most common form of anemia worldwide and remains a significant health concern in tropical countries where parasitic infections are endemic. Hookworm infestation is a leading but frequently overlooked etiology due to its subtle clinical manifestations and limited routine parasitological testing. We describe two contrasting cases of severe hookworm-related IDA from North Sulawesi, Indonesia: a 72-year-old woman and a 1-year-old infant. Both patients presented with profound microcytic hypochromic anemia but without overt gastrointestinal bleeding. Laboratory evaluation confirmed severe iron deficiency, while stool microscopy revealed hookworm eggs at early cleavage stages, establishing the diagnosis. Despite similar causes, their clinical courses diverged. The infant, whose anemia was compounded by inadequate weaning nutrition, responded rapidly to transfusion, iron supplementation, and single-dose albendazole. The elderly patient, with chronic cumulative exposure from barefoot walking in rural areas, improved more slowly following transfusion, prolonged iron therapy, and a short course of albendazole. These cases highlight the need for routine stool examination in all patients with unexplained IDA in endemic areas, regardless of age. They further emphasize gaps in deworming programs, which often exclude high-risk groups such as infants and older adults. Expanding preventive measures is essential to reduce morbidity and long-term complications.