Question

A 35-year-old woman with type I diabetes was admitted to the hospital with severe anemia, vomiting, and fever. She had not felt well for the past several months. She had lost more than 25 lb without dieting.Physical examination revealed a pale and slightly obese female with a distended abdomen. She was the mother of two young children, ages 3 and 5. Her menstrual periods were regular. A CBC, blood glucose, urinalysis, and pregnancy test were ordered.

■ Laboratory Data Hemoglobin 11.40 g/dL RBC 4.06 ́ 1012/L Hematocrit 35.5% MCV 87 fL MCH 28.1 MCHC 32 g/dL RDW 16% WBC 22.1 ́ 109/L Her peripheral blood smear showed abnormal erythro-cyte morphology, anisocytosis, poikilocytosis, and some teardrop (dacryocytes) cells. Her serum blood glucose was elevated. Her urinalysis was normal, except for an elevated blood glucose. The result of her pregnancy test was negative. A follow-up ultrasound of the abdomen revealed a 20-cm extrauterine mass. Subsequent surgical excision of the mass revealed a malignant epithelial tumor of the left ovary with metastases to the pelvic lymph nodes, opposite ovary, and right lung. ■ Questions 1. Does this patient have AOI? 2. Which hematopoietic cells are involved in an inflammatory response? 3. What are the characteristic iron and iron storage results in anemia of chronic inflammation?

Answer 1

1. Approved Outcome indicator (AOI) of cancer includes the oncological outcomes (over all survival or disease free survival), toxicity or complications following treatment (surgery, radiation therapy or systemic therapy), functional outcomes following therapy, quality of life (pain, fatigue or psychosocial issues) and patient satisfaction.

Here in oncological outcome the patient still needs further management to treat metastasis and cannot be counted as disease free survival. There are no complications mentioned following the treatment. Quality of life following treatment is not mentioned yet it can be assumed as compromised because the cancer treatment may cause pain, fatigue and psychological issues as this patient may need long term management.

2. Hematopoeitic cells are immature forms that later develops into different types of blood cells (RBC, WBC and platelets). Immunity providing cells forms and develops inside the bone marrow. WBCs predominantly forms the cells involved in inflammatory response. They develops from the the hematopoietic stem cells in the bone marrow.

3. Anemia due to chronic inflammation is diagnosed when the serum iron levels are markedly low despite of adequate iron stores. Inflammation raises the level of proinflammatory cytokine, interleukin 6 which in turn stimulates the hepcidin production and release of stored iron from the liver. This will block the function of ferroportin which facilitates the transport of iron from the intestine and from the cells that stores iron (macrophages). Due to all these mechanisms the level of iron in the blood is decreased . Inflammatory process also prevents the utilization of stored iron for erythropoiesis worsening the signs and symptoms of anemia.