humpf!!
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A 32-year-old man has had malaise, a low-grade fever, and a 45-kg (10-lb) weight loss over the past 3 months. He has unilateral cervical lymphadenopathy Laboratory studies show:
Hemoglobin 11 g/dL
Hematocrit 33%
Mean corpuscular volume 80 !-1m3
Reticulocyte count 05%
Serum iron 25!-1g/dL
Total iron-binding capacity 150 !-Ig/dL (N=250-460)
Examination of tissue obtained on biopsy of a lymph node shows Hodgkin's disease, nodular sclerosing type. The most likely cause of the anemia is:
A) abnormal utilization of iron
B) extravascular hemolysis
C) folate deficiency
D) iron deficiency
E) marrow aplasia
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| robin082006
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E
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| Moslem Doctor
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cant really understand how he is low iron and he is normocytic!!!!
can any explain?!
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| aisha2
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E
i think the anemia is rleated to the anemia of chornic disease which presents as normocytic anemia , seen inc hronic inflammation (eg RA , TB ) ,alcoholism , cancer .
its due to the iron being trapped in the bone marrow macrophages and is unable to synthesize Hb.
plz correct me if im worng
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| Moslem Doctor
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no sister aisha , anemia of chronic disease classified under microcytic anemia type ,even it is logic ,macrophage eat and trape iron and deprive red blood cells from it ,so hemoglobin will decrease and red blood cell become smaller
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| shilahk
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muslem doctor ...anemia of chronic disease can be both nicrocytic and normocytic, but it's more with micro cytic
aisha2..........your explanation is good but you went to the wrong choice i think:marrow hypoplasia...i think A is most suitable for ur explanation and it's the right answer
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| jeyasudhahar
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It is anemia of chronic disease:
but here the reticulocyte count should be less than 2.Kindlty verify
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| robin082006
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this is myelophthisic anemia, there is leukoerythroblastic smear as immature cells are forced into pperipheral blood (Goljan 2004 pg88)
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| guest007
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the answer is A....abnormal utilization of iron....and not E.
this guy is having low TIBC.....catchy....then low serum iron.....catch the point the serum ferritin is not given which would be normal in this patient....
for the ones who are new to pathology....guys serum iron and serum ferritin are not the same....it's different....let me explain....serum ferritin is the stored form of iron in marrow....and serum iron is iron in serum .....to be more clear....in anaemia of chronic disease even though we have enough of serum ferritin but the serum iron is low because it is trapped in the marrow.....so serum ferritin is high.....serum iron is low...
now if what is iron-protein binding form...ferritin....so if ferritin in this patient is high what will be TIBC(total iron binding capacity).....low...right?
so in anaemia of chronic disease....serum ferritin is high....serum iron is low(marrow trapped iron so nothing in serum)TIBC is low........so anwser is A....abnormal utilization of iron...
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| robin082006
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Reticulocyte count 05%
I'm sure that answer is E, I did at least 3 questions like this one, this is myelophthisis anemia, due to avasion of maglinant disease.
in Anemia of chronic disease, reticulocyte is low.
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| robin082006
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Reticulocyte count 05%
I'm sure that answer is E, I did at least 3 questions like this one, this is myelophthisic anemia, due to invasion of maglinant disease.
in Anemia of chronic disease, reticulocyte is low.
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| truedeam59
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I agree iwth marrow aplasia but it is probably due to chemotherapy.
I just wonder why they give us Hodgkin in the question. It should be chemotherapy responsible of Bone marrow aplasia.
Hodgkin disease treatment is MOPP. Methotrexate is I think the culpride of this anemia
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| robin082006
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In chemotherapy reticulocytes decrease
They give Hodgkin as a key for diagnosing myelophthisic anemia (avasion of Hodgkin to marrow)
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| truedeam59
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Thanx Robin
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| mitty
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E is wrong b/c the reti count is 05% i.e the bone marrow is responding well.so I will go for A
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| tolito
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at this moment, my level of understanding is low. since the pt has anemia then we have to calculate the corrected reticulocyte.
ie 11/45 x 5 = 1.2
this value is less than 2 so the Bone Marrow is not responding to the anemia. so E is logical to me now.
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| netlover
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It is E
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| robin082006
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Tolito,
See Goljan rapid review, he mentions about myelothisic anemia and has 1 question in his CDs
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| tolito
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Thanks robin
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| mitty
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the corrected reti count is 3.67 i.e 33/45x 5=3.67 that means the marrow is responding well.
E could be the answer if the given reti count is 0.5 Humf might made mistake during typing.
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| tolito
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mitty, the formula for corrected retic count is
pt HB/ 45 multiplied by 5. you have used the packed cell volume that is why you have 3.67 which is wrong.
i have read more into this topic so i am now clear about it.
this is a clear cut case of anemia of chronic disease.
the TIBC is low
ser Fe is low
the cells are normocytic, which is why we need to do the corrected retic count.
with a corrected retic count of less than 2, we can confidently say that the bone marrow is not responding appropriately. given the history of hodgkins, the answer is marrow aplasia.
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| tolito
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aisha is right about the reason for the anemia. the fe is trapped in the macrophages and is not useful for production of heme even though the ser ferritin level will be high compared to pure Fe deff where the ser ferritin level is low. (useful fe is in transferrin formed in the liver. we know that transferrin level will also be low in chronic diseases)
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| Slacker
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Tolito. Check ur equation. The corrected reticulocyte count is (Hct/45) x reticulocyte count.
45 represents the normal Hct. Thats why u divide the abnormal Hct by this normal Hct.
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| vallia
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I would say it's anemia from chronic disease , the reticulocytes is not that low to think of marrow aplasia. I have seen blood smear with absolutely no reticulocyte in case of bone marrow aplasia. The anemia also is moderate. i think they want to show that is mainly a chronic disease (lost weight, malaise, etc) and not a myelodisplasia.
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| tolito
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hang on guys.
first, we agree there is anemia
second, we agree it is normocytic (just on the borderline)
third, we agree that ser FE is low
fourth, we agree tha TIBC is low
now retic count . my mistake. have checked formula, corrected retic count is 3.67. this means the marrow is responding appropriately.
let us assume there is no typo (wrt retic count by hunmpf)
the following (according to goljan) are the causes of normocytic anemia with corrected retic more than 3%. basically, they are all hemolytic anemias
1. intrinsic RBC abnormality
Membrane
Abnormal hemoglobin
Deficient enzymes
2. extrinsic RBC abnormality
autoimmune
microhemangiopathic
blood loss.
we know that the hemolysis can be intra or extra vascular. if we had haptoglob levels we can decide.
so, the answer will be B. i have not read hodgkins yet so i dont understand mech of that.
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