A 46-year-old woman is being evaluated for tiredness, low energy level, and poor exercise tolerance. She also complains of joint pains and takes non-steroidal anti-inflammatory agents. Her past medical history is significant for hypertension and type 2 diabetes mellitus.
Her blood pressure is 130/80 mm Hg, pulse is 96/min, and respirations are 12/min. Her BMI is 32 kg/m2. The cardiac, pulmonary, and abdominal examinations are within normal limits. Her skin shows areas of hypopigmentation consistent with vitiligo in the upper extremities bilaterally.
Her laboratory studies are shown below.

Bone marrow aspiration is performed, and the aspirate is stained with Prussian blue for iron. It shows dense iron staining in macrophages but no staining of erythrocyte precursors.
Which of the following is the most likely diagnosis?

Question

A 46-year-old woman is being evaluated for tiredness, low energy level, and poor exercise tolerance.  She also complains of joint pains and takes non-steroidal anti-inflammatory agents.  Her past medical history is significant for hypertension and type 2 diabetes mellitus.
Her blood pressure is 130/80 mm Hg, pulse is 96/min, and respirations are 12/min.  Her BMI is 32 kg/m2.  The cardiac, pulmonary, and abdominal examinations are within normal limits.  Her skin shows areas of hypopigmentation consistent with vitiligo in the upper extremities bilaterally.
Her laboratory studies are shown below.

Bone marrow aspiration is performed, and the aspirate is stained with Prussian blue for iron.  It shows dense iron staining in macrophages but no staining of erythrocyte precursors.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient likely has anemia of chronic disease (ACD), a normocytic normochromic anemia associated with a chronic systemic disease (e.g., infectious, autoimmune, inflammatory, or malignancy). ACD is likely due to decreased RBC production in the bone marrow from abnormal iron metabolism, decreased erythropoietin production, decreased response to normal erythropoietin, or decreased RBC survival. These effects are likely due to the underlying systemic disease causing increased cytokine release (IL-6, TNF, etc.) or increased levels of hepcidin, an acute phase reactant that inhibits iron transport in the intestine and iron release from the macrophages. 11ec193a_9820_1691_853d_dffd3875a4f9_MD0002_00 The table above summarizes the typical laboratory findings of ACD compared to iron deficiency anemia (IDA), which frequently co-exists with ACD. Ferritin is also an acute phase reactant and may be elevated in ACD. Bone marrow aspiration with Prussian blue can help differentiate between IDA and ACD in clinically difficult cases. ACD shows no iron staining in the red cell precursors but abundant staining in the macrophages (due to iron trapping), while IDA shows no iron staining in either macrophages or red cell precursors (Choice D). Treatment for ACD is directed at the underlying systemic illness, but symptomatic patients may benefit from erythropoietin and iron supplementation to increase the hemoglobin to 12 g/dL. (Choice B) Aplastic anemia causes pancytopenia and a hypocellular bone marrow with reduced, but morphologically normal, iron staining patterns. (Choice C) Essential thrombocytosis is defined as a platelet count >500,000 cells/µL, which is unlikely in this patient with only a slightly elevated platelet count. Mild thrombocytosis is probably reactive from the underlying systemic disease. (Choice E) Pernicious anemia presents as a macrocytic anemia with normal-low reticulocyte count, WBC, and platelet counts. Bone marrow aspiration shows a hypercellular marrow with megaloblastic RBC precursors and normal iron staining patterns. Educational objective: Anemia of chronic disease (ACD) is usually due to a systemic illness that alters iron metabolism or decreases erythropoiesis. Clinically difficult cases can be distinguished from IDA through bone marrow analysis which shows increased iron staining in the macrophages, but decreased staining in the erythrocyte precursors. __________ References: Advancements in anemias related to chronic conditions. (http://www.ncbi.nlm.nih.gov/pubmed/20618092)

A 46-Year-Old Woman Is Being Evaluated for Tiredness, Low Energy