A 32-year-old Italian-American man comes to the office for a routine checkup. The patient is a business executive and has been under significant stress recently. He drinks alcohol occasionally and has a 10-pack-year smoking history. Laboratory results are as follows: Serial fecal occult blood tests are negative. Peripheral blood smear is shown in the image below.
Which of the following is the best treatment for this patient?

Question

A 32-year-old Italian-American man comes to the office for a routine checkup.  The patient is a business executive and has been under significant stress recently.  He drinks alcohol occasionally and has a 10-pack-year smoking history.  Laboratory results are as follows:  Serial fecal occult blood tests are negative.  Peripheral blood smear is shown in the image below.
 Which of the following is the best treatment for this patient?

Quizplus · Accepted Answer

11ec25c8_d0e1_abe2_bc81_05afdd1a4df3_MD0003_00 Microcytic anemia (eg, mean corpuscular volume [MCV] <80 µm³) is most often due to iron deficiency or thalassemia minor. Although both can cause hypochromia and target cells, significant microcytosis in the setting of mild anemia and a normal (rather than low) erythrocyte count suggests thalassemia (abnormal alpha- or beta-globin synthesis). target cells Thalassemia is classified based on the number and type of globin chains affected. Mutations to 3 or 4 globin genes are usually incompatible with life or require lifelong blood transfusions. In contrast, patients with defects in 1 or 2 of the alpha-globin chains (alpha-thalassemia minima or minor) or 1 beta-globin chain (beta-thalassemia minor) are usually asymptomatic. Patients of Mediterranean descent (as in this case) are most likely to have beta-thalassemia, whereas patients from Southeast Asia are more likely to have alpha-thalassemia; electrophoresis can confirm the diagnosis. Laboratory findings in thalassemia minor typically demonstrate mild hematocrit reduction (>28%), significantly low MCV (55-75 µm³), and disproportionally elevated red blood cell (RBC) counts. The disproportionately elevated RBC count (eg, normal or high rather than low) and decreased MCV help distinguish thalassemia minor from iron deficiency anemia, which does not typically cause microcytosis until hemoglobin is <10 g/dL (Choice F). Patients with thalassemia minor show no improvement in hemoglobin with iron supplementation and do not require specific treatment. (Choices A and D) Cobalamin (vitamin B₁₂) and folic acid deficiency cause macrocytosis rather than microcytosis. (Choices B and E) Deferoxamine is used to treat iron overload in those with transfusion-dependent thalassemia major or sickle cell disease (eg, sickle cells on smear). Hydroxyurea decreases the frequency and severity of pain crises in patients with sickle cell anemia by increasing hemoglobin F levels. sickle cells (Choice C) Erythropoietin (EPO) can be used to treat anemia associated with chronic kidney disease or transient bone marrow failure after chemotherapy. EPO level elevations may occur in thalassemia (in response to anemia) but cannot compensate for the hemoglobin defect. (Choices G and I) Prednisone is the treatment of choice for autoimmune hemolytic anemia (eg, spherocytes on smear). Splenectomy can reduce erythrocyte or platelet sequestration in certain hematologic conditions (eg, hereditary spherocytosis, immune thrombocytopenia). Educational objective: Thalassemia minor is usually asymptomatic and no treatment is required. Patients typically have mild anemia, low mean corpuscular volume (55-75 µm³), target cells on peripheral smear, and disproportionately high red blood cell (RBC) count. Iron deficiency anemia is associated with low RBC count and no microcytosis until hemoglobin is <10 g/dL. References: Beta-thalassemia. (http://www.ncbi.nlm.nih.gov/pubmed/20492708)

A 32-Year-Old Italian-American Man Comes to the Office for a Routine