Review Question - QID 106247

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Anemia of Chronic Disease Introduction Associated conditions QID: 106247 (M1.HE.14.201)

QID 106247 (Type "106247" in App Search)

A 37-year-old woman presents to her primary care physician with a 6-month history of fatigue. She denies any recent history of fevers, chills or headaches. She does not smoke or drink alcohol. A CBC demonstrates a microcytic anemia. Iron studies are ordered and demonstrate the following:
Serum iron: 40 µg/dL (normal 50–170 µg/dL);
TIBC: 230 µg/dL (normal 250–370 µg/dL);
Transferrin saturation: 10% (normal 15–50%);
Serum ferritin: 180 µg/L (normal 15-150 µg/L);
Which of the following is a likely cause of this patient's iron studies findings?

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Lead poisoning

12%

18/149

Dysfunctional uterine bleeding

11%

16/149

Splenic sequestration of RBCs

11/149

Rheumatoid arthritis

62%

92/149

RBC enzyme deficiency

10/149

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The patient presents with fatigue and iron studies findings consistent with anemia of chronic disease. Rheumatoid arthritis creates a state of chronic inflammation and can cause anemia of chronic disease.

Anemia of chronic disease most frequently presents as a normocytic anemia but can present as a microcytic anemia in severe cases. In response to inflammatory cytokines, the liver produces hepcidin, which prevents cells from releasing iron stores. Iron is thus sequestered and RBC production suffers accordingly. Iron studies reveal high ferritin and low serum iron, TIBC, and transferrin saturation.

Brill et al. review normocytic anemias. Anemia of chronic disease is the most common normocytic anemia. Worldwide, it is second to iron deficiency anemia as the most common form of anemia. The pathogenesis of anemia of chronic disease is multifactorial. In addition to iron-restricted erythropoiesis, there is hypo-activity of the bone marrow, with relatively inadequate production of erythropoietin or a poor response to erythropoietin, and slightly shortened red blood cell survival.

Weiss et al. review the pathophysiology of anemia of chronic disease. Iron homeostasis is profoundly altered. Increased uptake of iron and its retention within cells of the reticuloendothelial system leads to a diversion of iron from the circulation into storage sites of the reticuloendothelial system. This limits the availability iron for erythroid progenitor cells, diminishing erythropoiesis.

Illustration A is a flow diagram demonstrating the evaluation of anemias. Evaluating the MCV is a critical first step.

Incorrect Answers:
Answer 1: Lead poisoning also presents as a microcytic anemia, but serum iron is elevated in this condition.
Answer 2: Dysfunctional uterine bleeding may lead to iron-deficiency anemia in pre-menopausal women. Serum ferritin is decreased.
Answers 3 and 5: Splenic sequestration of RBCs and RBC enzyme deficiency (most commonly G6PD) are both causes of hemolytic anemia. Hemolytic anemias are normocytic.

ILLUSTRATIONS: