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1. A 60-year old male patient with history of rheumatoid arthritis presents with
the following: Hb:4.5g/dL. platelet count is 2 lakh/mm3 . TLC: 6000/mL, serum
ferritin is 200µg/dL, serum iron 30mg/dL and TIBC 280ng/L. Which of the
following is the most likely diagnosis?
(a) Anaemia of chronic disease
(b) Thalassemia minor
(c) Iron deficiency anemia
(d) Autoimmune haemolytic anemia
ANSWER a
| Parameter with value in question | Normal range | Inference in our patient |
| Hemoglobin 4.5gm/dl | 13-17g/dl | Decreased |
| Platelet count 2 lakh/ml | 1.5-4.5lakh/m | Normal |
| TLC 6000/mm3 | 4000-11000/mm3 | Normal |
| Serum ferritin 200 µg/L | 15-300 µg/L | Normal |
| Serum iron 30 mg/L | 50-150 µg/L | Reduced |
| TIBC 280 ng/L | 300-400 mg/L | Reduced |
2. A 20 year old female presents with the following laboratory values: hemoglobin 9gm%, MCV is 55%, RBC is 4.5 million/mm3 . There is no history of blood transfusion. What is the most likely diagnosis out of the following?
(a) Thalassemia major
(b) Thalassemia minor
(c) Iron deficiency anemia
(d) Anemia of chronic disease
ANSWER b
Thalassemia major patient presents with severe anemia and cannot survive without blood transfusion, so this option can be easily ruled out. For other options, Mentzer index is useful for differentiating between thalassemia minor and iron deficiency anemia.
| Mentzer index is calculated as MCV/RBC count. Its value is >13 in iron deficiency anemia and < 13, so it is a case of thalassemia minor. |
3. A 13 yr girl with fatigue and weakness was found to be having reduced hemoglobin. Her MCV 70fl, MCH 22pg and RDW was 28. What is her most likely diagnosis?
(a) Iron deficiency anemia
(b) Thalassemia minor
(c) Sideroblastic anemia
(d) Thalassemia major
ANSWER a
- Decreased hemoglobin with the clinical features of fatigue and weakness is diagnostic of anemia
- MCV is 70 fl, so, microcytosis is present (normal MCV is 82-96fl)
- MCH is 22pg, so, decreased MCH is suggestive of hypochromic anemia (normal MCH is 27-33pg)
- Red cell distribution width (RDW) is the coefficient of variation of size of RBCs. Normal value is 11.5-14.5. It is anindicator of anisocytosis which may present in IDA as well as hemolytic anemias.
- In early iron deficiency anemia, RDW increases along with low MCV while in beta thalassemia trait, RDW is normal with low MCV, thus distinguishing from each other.
- Increased reticulocytosis is a feature of iron deficiency anemia.
4. Ringed sideroblasts are seen in:
(a) Iron deficiency anemia
(b) Myelodysplastic syndrome
(c) Thalassemia
(d) Anemia of chronic disease
ANSWER b
Sideroblastic anemia can be hereditary (due to decreased ALA synthase activity) or acquired (secondary to leukemias, myelodysplastic syndrome, alcoholism, copper deficiency, pyridoxine deficiency or lead poisoning)
5. The pathogenesis of hypochromic anemia in lead poisoning is due to:
(a) Inhibition of enzymes involved in heme biosynthesis
(b) Binding of lead to transferrin, inhibiting the transport of iron
(c) Binding of lead to cell membrane of erythroid precursors.
(d) Binding of lead to ferritin inhibiting their breakdown into hemosiderin
ANSWER a
- Lead inhibits the enzymes δ aminolevulinic acid dehydrase, red cell pyrimidine 5’ nucleotidase and ferrochelatase which are involved in the synthesis of heme.
- Deficiency of heme causes microcytic hypochromic anemia because heme is an integral part of hemoglobin and hemoglobin deficiency causes microcytic hypochromic anemia.
