Evaluation of Shazia Jan, 25 F: MRI LS spine with pelvis screening, KFT/RBS/CRP/ESR and CBC (reports dated 01-11-2026)

1. MRI lumbosacral spine with pelvis screening

• There is no structural cause for radiculopathy. The back pain is therefore mechanical or non-specific.
• A single small STIR focus does not make sacroiliitis. Active sacroiliitis on MRI needs subchondral bone marrow edema that is clearly present and typical for spondyloarthritis. A single lesion needs to be seen on at least two slices, or two lesions on one slice. Harrison's, 22E notes that STIR bone marrow edema suggests active inflammation, and the Rheumatology 2-volume set lists the MRI lesions of axial spondyloarthritis.
• Mechanical stress is a plausible explanation. An L5 transitional vertebra can load the SI joint unevenly on one side, which is a Bertolotti-type mechanism. Pregnancy, the postpartum period and running are other common causes of this finding in young women.
• Follow-up depends on symptoms. If she has inflammatory-type back pain, I would check HLA-B27 and get a rheumatology opinion. Features of inflammatory pain are onset before age 40, night or early-morning pain, morning stiffness over 30 minutes, and improvement with exercise but not rest. If not, treat conservatively and repeat imaging only if symptoms persist.

2. Biochemistry (Baba Diagnostic)

3. CBC (Sysmex XQ-320 3-part)

• Why iron deficiency fits: the RDW is high, platelets are normal, and the RBC count is only low-normal.
• Mentzer index: MCV/RBC = 68.6/4.20 ≈ 16.3. A value above 13 favors iron deficiency over thalassemia trait. The Tietz Textbook of Laboratory Medicine describes beta-thalassemia trait as microcytosis with a normal to slightly raised RDW, and it gives MCV/(RBC × RDW) as another discrimination index.
• Likely causes in a 25-year-old woman: menstrual loss, poor dietary intake or malabsorption (celiac disease, H. pylori). Ask about heavy periods, diet, pregnancy and lactation, and GI blood loss.
• Differentials: thalassemia trait, and anemia of chronic inflammation. The latter is unlikely with a negative CRP.
• Mild neutrophilia: this is non-specific. Possible causes are a minor infection, stress or pain, smoking, or steroids and NSAIDs (ask about analgesic use). It is not alarming with a negative CRP and no spinal infection on MRI. Repeat the CBC after treatment.

4. Suggested next steps

1. Confirm the diagnosis of iron deficiency with ferritin, serum iron, TIBC and transferrin saturation. Add a reticulocyte count, a peripheral smear, and B12/folate if the picture is mixed. Ferritin can read falsely normal if there is inflammation.
2. If the iron studies are equivocal, or the picture suggests thalassemia trait, do Hb electrophoresis or HPLC. Do this before any transfusion and only after iron repletion.
3. Start oral iron, for example elemental iron 60-120 mg once daily or on alternate days. Add vitamin C or a dietary correction. Recheck Hb in 2-4 weeks. A rise of about 1 g/dl or more supports iron deficiency. Continue for 3 months after Hb normalizes to replenish stores.
4. Identify and treat the cause: a gynecologic history, plus stool occult blood or celiac serology if indicated.
5. Manage the back pain conservatively with physiotherapy, core and SI-stabilizing exercises, posture correction and short-course analgesia. Avoid NSAIDs if she has GI blood loss or anemia from an unknown source.
6. Refer to rheumatology, with HLA-B27 and repeat MRI, only if inflammatory back pain features are present.
7. Red flags needing urgent review: fever, night sweats, weight loss, neurological deficit, bladder or bowel symptoms, or Hb falling below 7 g/dl or symptomatic anemia.

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