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Explain me
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Reading File
Case Analysis
Vignette: 35-year-old woman, rheumatoid arthritis (2 years, on treatment), 2 months of progressive breathlessness, mild pallor on exam, joints otherwise unremarkable.
Labs:
- Hb - 9 g/dl (anaemia)
- MCV - 55 fl (microcytic)
- WBC - 5000 (normal)
- Plt - 250 (normal)
- ESR - 25 mm/1st hr (mildly raised)
- Blood picture - hypochromic microcytic anaemia
Answer: (a) Anaemia of chronic disease (ACD)
Why ACD fits best here:
Rheumatoid arthritis is one of the classic causes of anaemia of chronic disease. Persistent inflammatory cytokines (IL-6 in particular) drive hepcidin production, which traps iron within macrophages and blocks its release to erythroid precursors - this is "functional iron deficiency" even though total body iron stores are normal or increased. The result is a hypochromic, microcytic-to-normocytic anaemia developing gradually over weeks to months, exactly as described (2 months of breathlessness).
- Normal WBC and platelet count argue against an acute inflammatory flare or a myeloproliferative/marrow infiltrative process.
- Mildly raised ESR (25) fits low-grade chronic inflammation from underlying RA rather than acute severe inflammation.
- Onset in adulthood with a clear chronic inflammatory trigger (RA) rather than a lifelong history fits ACD rather than an inherited haemoglobinopathy.
Why the other options are less likely:
- (b) Beta thalassaemia trait - this is inherited and present since birth; it wouldn't newly present with 2 months of symptoms in a 35-year-old, and there'd usually be a family history or long-standing mild anaemia rather than a new, more marked drop to Hb 9.
- (c) Iron deficiency anaemia - a real and important differential (RA patients often take NSAIDs, which can cause chronic GI blood loss). Distinguishing ACD from IDA requires iron studies: IDA shows low ferritin and high TIBC/transferrin, while ACD shows normal-to-high ferritin (an acute-phase reactant) with low TIBC. The vignette doesn't give iron studies, but the "most likely" diagnosis in an RA patient with chronic hypochromic microcytic anaemia and no bleeding history pointed to is ACD; IDA would need to be excluded with ferritin/serum iron/TIBC before finalizing.
- (d) Hereditary spherocytosis - a haemolytic anaemia, typically normocytic or even macrocytic (MCV often normal/raised) with reticulocytosis, jaundice, splenomegaly, and raised indirect bilirubin - none of which fit a hypochromic microcytic picture with normal WBC/platelets.
- (e) Autoimmune haemolytic anaemia - also haemolytic, so MCV is usually normal to raised (due to reticulocytosis), with evidence of haemolysis (raised LDH, indirect bilirubin, low haptoglobin, positive Coombs test) - inconsistent with a hypochromic microcytic picture.
Key teaching point: In any chronic inflammatory disease (RA, IBD, chronic infection, malignancy) presenting with anaemia, always send serum iron, ferritin, TIBC/transferrin saturation, and CRP to differentiate ACD from coexisting iron deficiency - this is a very common exam and clinical pitfall since RA patients are also prone to NSAID-induced GI bleeding.
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