A 72-year-old man comes to the office due to severe fatigue. He says that 5 months ago he was able to climb 4 flights of stairs without shortness of breath, but now he has to rest after 2 flights. His appetite has decreased, but he has not had any abdominal discomfort or black stool. Physical examination reveals firm, enlarged cervical, inguinal and supraclavicular lymph nodes. A soft II/VI grade systolic murmur is heard along the left sternal border. Abdomen is soft and nontender. His liver span is 10 cm and the spleen is palpated 4 cm below the left costal margin. His blood hemoglobin level is 7.1 mg/dL. Which of the following is the most likely cause of this patient's anemia?

Question

A 72-year-old man comes to the office due to severe fatigue.  He says that 5 months ago he was able to climb 4 flights of stairs without shortness of breath, but now he has to rest after 2 flights.  His appetite has decreased, but he has not had any abdominal discomfort or black stool.  Physical examination reveals firm, enlarged cervical, inguinal and supraclavicular lymph nodes.  A soft II/VI grade systolic murmur is heard along the left sternal border.  Abdomen is soft and nontender.  His liver span is 10 cm and the spleen is palpated 4 cm below the left costal margin.  His blood hemoglobin level is 7.1 mg/dL.  Which of the following is the most likely cause of this patient's anemia?

Quizplus · Accepted Answer

Explanation: The numerous causes of anemia may be divided into 3 categories: Decreased red blood cell (RBC) production (eg, bone marrow infiltration) Increased RBC destruction (eg, hemolysis) Blood loss The patient in this vignette has several signs and symptoms suggestive of a lymphoproliferative disorder, most likely lymphoma, including generalized lymphadenopathy, splenomegaly, and constitutional symptoms (eg, fatigue). The anemia of lymphoproliferative disorders, such as leukemia and lymphoma, is due to the replacement of RBC progenitor cells with cancer cells in the bone marrow. Treatment of the malignancy may improve the patient's anemia, though many chemotherapeutic agents are myelosuppressive. (Choices A, B, and C) Iron deficiency, folate deficiency, and cobalamin deficiency are not associated with lymphadenopathy or splenomegaly. (Choices D, E, and F) Glucose-6-phosphate dehydrogenase (G6PD) deficiency, hereditary spherocytosis, and hemoglobinopathies (sickle cell disease and thalassemias) are not associated with lymphadenopathy. (Choice H) Intravascular hemolysis refers to the breaking down of RBCs in the blood vessels. Schistocytes are seen on the peripheral blood smear. Common causes include shearing secondary to prosthetic valves, disseminated intravascular coagulation (DIC), thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), and paroxysmal nocturnal hemoglobinuria (PNH). Of note, the spleen and reticuloendothelial system are considered extravascular. Therefore, autoimmune hemolytic anemia in patients with chronic lymphocytic leukemia (CLL) is extravascular! (Choice I) Erythropoietin deficiency is due to decreased erythropoietin production, most often in patients with renal failure. (Choice J) Bone marrow aplasia is seen in aplastic anemia. Splenomegaly is very unlikely to occur with aplastic anemia; its presence suggests an alternate diagnosis. Educational objective: Anemia can be due to decreased red blood cell (RBC) production, increased RBC destruction, and frank blood loss. The anemia of lymphoproliferative disorders is due to bone marrow infiltration with cancerous cells.

A 72-Year-Old Man Comes to the Office Due to Severe