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Difficulty: MediumHematology and Oncology

A 5454-year-old female patient presents to the outpatient clinic reporting a 33-month history of decreased energy and generalized weakness. She states that she struggles to complete her usual daily tasks. The patient has a 55-year history of rheumatoid arthritis but stopped taking her prescribed medications 66 months ago due to a lapse in health insurance. She currently takes only ibuprofen occasionally for joint pain.

Vital signs are within normal limits. Physical examination reveals pale conjunctivae. Her bilateral metacarpophalangeal and proximal interphalangeal joints are swollen, warm, and tender to palpation.

Laboratory evaluation reveals the following:

ParameterResultReference Range
Hemoglobin9.89.8 g/dL12.0−16.012.0 - 16.0 g/dL
Mean corpuscular volume8181 fL80−10080 - 100 fL
Leukocyte count9,2009,200/mm3^34,500−11,0004,500 - 11,000/mm3^3
Platelet count450,000450,000/mm3^3150,000−400,000150,000 - 400,000/mm3^3
Reticulocyte count0.90.9%0.50.5% - 1.51.5%
Serum iron4040 µg/dL50−17050 - 170 µg/dL
Total iron-binding capacity (TIBC)220220 µg/dL250−450250 - 450 µg/dL
Serum ferritin410410 ng/mL15−20015 - 200 ng/mL

Which of the following is the most appropriate management for this patient's anemia?

  1. A
    Initiation of daily oral ferrous sulfate
  2. B
    Infusion of intravenous iron dextran
  3. C
    Administration of recombinant human erythropoietin
  4. D
    Transfusion of one unit of packed red blood cells
  5. Optimization of disease-modifying antirheumatic therapyAnswer

Answer

The correct answer is optimization of disease-modifying antirheumatic therapy.
The most appropriate management for this patient's anemia is optimization of disease-modifying antirheumatic therapy. This patient's laboratory findings (low serum iron, low TIBC, and elevated ferritin) in the setting of poorly controlled rheumatoid arthritis are pathognomonic for anemia of chronic disease (ACD). Chronic inflammatory states trigger the hepatic production of hepcidin. Hepcidin binds and degrades ferroportin on enterocytes and macrophages, preventing both intestinal iron absorption and the release of iron from storage sites. This creates a state of functional iron deficiency despite adequate total body iron stores (indicated by the elevated ferritin). The most effective initial treatment for ACD is resolving the underlying inflammatory condition, which in this case involves restarting appropriate disease-modifying antirheumatic drugs (DMARDs).

Step-by-Step Solution

1
Analyze the patient's laboratory findings in the context of her clinical presentation.
The laboratory profile shows a normocytic anemia with low serum iron, low total iron-binding capacity (TIBC), and elevated serum ferritin.
Identifying the exact pattern of iron studies is essential to distinguish between iron deficiency anemia and anemia of chronic disease.
2
Synthesize the laboratory data with the patient's medical history.
The patient has poorly controlled rheumatoid arthritis, an inflammatory condition that causes hepcidin release, which perfectly matches the laboratory pattern of anemia of chronic disease (ACD).
Establishing the precise etiology of the anemia dictates the appropriate therapeutic intervention.
3
Determine the most appropriate management for anemia of chronic disease.
The primary and most effective treatment for ACD is optimizing the management of the underlying inflammatory disorder.
Reducing inflammation decreases hepcidin levels, which subsequently restores normal iron mobilization and improves erythropoiesis.

Key Concept

Anemia of chronic disease is characterized by low serum iron, low TIBC, and elevated ferritin due to hepcidin-mediated iron sequestration. The primary treatment is addressing the underlying inflammatory condition.
Estimated Time:1m 30s
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Topics

Hematology and Oncology

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