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Ferrochelatase inhibition
7%
10/143
Folate deficiency
12%
17/143
Increased hepcidin expression
48%
69/143
Inherited hemoglobinopathy
4%
6/143
Iron deficiency
24%
34/143
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This patient with rheumatoid arthritis who presents with a microcytic anemia and has increased ferritin levels most likely has anemia of chronic disease. This disease is caused by increased hepcidin expression. Anemia of chronic disease is caused by increased expression of the acute phase reactant hepcidin in response to chronic inflammation. Hepcidin normally functions to suppress iron release from macrophages by binding to the iron transporter ferroportin. When active for short durations, this function allows the body to deny iron to infectious organisms; however, when active for long durations, hepcidin will cause anemia due to iron deficiency despite increased total body iron stores. Common underlying causes of this disease include autoimmune diseases, chronic infections, and malignancy. Treatment of the underlying condition is the most important factor for resolving anemia of chronic disease. Incorrect Answers: Answer 1: Ferrochelatase inhibition is seen in lead poisoning anemia, which can also present with a microcytic anemia; however, this disease will characteristically present with neurological deficits such as wrist drop in addition to anemia. Answer 2: Folate deficiency can be associated with methotrexate treatment; however, anemia due to folate deficiency would be megaloblastic and macrocytic rather than microcytic as seen in this case. Notably, no neurological deficits are seen in folate deficiency as compared with cobalamin deficiency. Answer 4: Inherited hemoglobinopathies such as alpha-thalassemia and beta-thalassemia will present with a normocytic anemia rather than a macrocytic anemia. Furthermore, they usually present in childhood rather than adulthood. Answer 5: Iron deficiency anemia will present as a microcytic anemia; however, this disease would present with decreased total body iron stores and therefore have decreased serum ferritin levels. Bullet Summary: Anemia of chronic disease is caused by increased expression of the acute phase reactant hepcidin.
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