Hematology Oncology · Year 2 · from Hematology Oncology

Case 2: Anemia of Chronic Disease

Patient Presentation

Demographics: 58-year-old male

Chief Complaint: Fatigue and mild dyspnea on exertion for 2 months

History of Present Illness: The patient has a 10-year history of rheumatoid arthritis requiring methotrexate and adalimumab. He reports progressive fatigue that has worsened despite good control of his joint symptoms. He denies any bleeding symptoms, melena, or hematochezia. His diet is well-balanced, and he takes folic acid supplementation as prescribed.

Physical Examination:

  • Vital signs: BP 128/78, HR 82, RR 16, Temp 37.0C
  • General: Mildly pale, no acute distress
  • HEENT: Mild conjunctival pallor, no glossitis
  • Cardiac: Regular rhythm, no murmurs
  • Extremities: Mild synovial thickening at MCPs bilaterally, no active synovitis
  • Abdomen: No hepatosplenomegaly

Workup and Results

Complete Blood Count:

  • WBC: 7,200/uL (normal)
  • Hemoglobin: 10.8 g/dL (low)
  • MCV: 88 fL (normal)
  • RDW: 14% (normal)
  • Platelets: 380,000/uL
  • Reticulocyte count: 1.0%

Iron Studies:

  • Serum iron: 40 mcg/dL (low)
  • TIBC: 220 mcg/dL (low to normal)
  • Transferrin saturation: 18% (low-normal)
  • Ferritin: 280 ng/mL (elevated)

Additional Labs:

  • ESR: 45 mm/hr (elevated)
  • CRP: 2.8 mg/dL (elevated)
  • B12: 450 pg/mL (normal)
  • Folate: 12 ng/mL (normal)

Diagnosis

Anemia of Chronic Disease (Anemia of Inflammation)

Key distinguishing features from iron deficiency:

  • Normal or elevated ferritin (vs. low in iron deficiency)
  • Low or normal TIBC (vs. elevated in iron deficiency)
  • Underlying inflammatory condition present
  • Normocytic anemia (can be mildly microcytic)

Treatment Plan

  1. Primary treatment:
  • Optimize treatment of underlying rheumatoid arthritis
  • Iron supplementation is NOT indicated (stores are adequate)
  1. If symptomatic anemia despite disease control:
  • Consider erythropoiesis-stimulating agents (ESAs)
  • Target hemoglobin of 10-11 g/dL to minimize symptoms
  1. Monitoring:
  • Follow hemoglobin with disease activity
  • Reassess if anemia worsens or becomes more severe

Teaching Points

  1. Anemia of chronic disease is the second most common cause of anemia worldwide
  2. The pathophysiology involves hepcidin-mediated iron sequestration in macrophages
  3. Key laboratory distinction: ferritin is normal/elevated (vs. low in iron deficiency)
  4. TIBC is low/normal (vs. elevated in iron deficiency)
  5. Treatment focuses on the underlying inflammatory condition, not iron replacement
  6. Iron therapy is ineffective and potentially harmful due to hepcidin-mediated absorption block

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