Question

A 35 year old woman with type 1 diabetes was admitted to the hospital with severe anemia, vomiting and fever. She had not been feeling well for the past several months. She lost more than 25 pounds without dieting. Physical examination revealed a pale female with a distended abdomen. A CBC, glucose, pregnancy test and urinalysis were ordered.

Patient result Reference range WBC 22.1 x10^9/L RBC 4.06 x 10 ^12/L Hemoglobin 11.4 g/dl HCT 35.5 % MCV 87 fl MCH 28.1 pg MCHC 32 g/dl RDW 16% 16% 12.5 – 14.5 IRON STUDY Serum iron 40 ug/dL 50 - 160 TIBC 200 ug/dL 250 - 400 Percent saturation of transferrin 20.0 20 - 55 Ferritin 99 ng/ml 10 - 106

The pregnancy test was negative, the urinalysis had elevated glucose, and the blood glucose was also elevated. Blood smear showed anisocytosis, poikilocytosis and some tear drop cells. A diagnostic ultrasound found a 20-cm extrauterine mass. Subsequent surgical excision of the mass revealed a malignant epithelial tumor of the left ovary with metastases to the lymph nodes and lung.

3. What type of anemia do you suspect based on the CBC and morphology? 4. How is hepcidin involved in this anemia? 5. What key indicators are found in the CBC? 6. How does the iron study fit with this picture? 7. Will the soluble Transferrin receptors be increased or normal?

Answer 1

1. Based on the CBC and morphology the possible diagnosis is,

Secondary Myelophthisic anemia

It is a severe kind of anemia (anisocytosis-vary in size of RBC and poikilocytosis-abnormal shape of cells: tear drop cells) found in some people with diseases that affect the bone marrow. It occurs due to implantation or invasion by malignant cancer cells that have metastasized because of implantation of blood-borne tumor cells from a distant cancer.

2. Involvement of hepcidine in this anemia:

It is a protein which is the key regulator of the entry of iron into the circulation. Its level increased in blood due to inflammation (caused by metastatic cancer cells) leads to iron falls due to iron trapping within macrophages and liver cells and decreased iron gut absorption.

3. Key indicators are found in the CBC

• Elevate WBC count indicate inflammatory reaction
• Decreased RBC, HB, HCT, MCV, MCHC indicate patient develops anemia
• Serum iron study-decreased serum iron, TIBC and percentage saturation of transferring indicate low supply of iron for RBC production
• High RDW (red blood cells are vary in size) and low MCV (red blood cells occupies less space in total blood volume)-Indicate iron deficiency anemia which is caused by inadequate supply of iron

Overall impression Iron deficiency anemia (common in cancer patients)

4. How the Iron study will fit in this picture

In this Secondary Myelophthisic anemia the metastatic cancer cells cause inflammation and increased hepcidine which will cause iron deficiency. It is identified through Serum iron study-decreased serum iron, TIBC and percentage saturation of transferrin indicate low supply of iron for RBC production

5. What about the soluble transferrin receptors

Soluble transferrin receptor elevates in case of iron deficiency.