A 45 year-old female patient, who works as clerk in a school, goes to your office complaining of great fatigue, weakness, lassitude and palpitations. It is accompanied with a desire to eat “strange stuff, like chalk, paper, hair…and a lot of ice” . She is afraid she is “becoming crazy”
During the interview the patient shows a normal behavior but with some anxiety. When questioned she informs about abundant menstruation since some months ago. At the physical sign you find intense pallor and a moderate tachycardia.
Significative laboratory results are the following:
– Hemoglobin: 8.4
– Peripheral smear: mycrocitic hypochromic red blood cells, no target cells detected.
– Mean Corpuscular Volume (MCV) =65 fl (Reference range: 80-100 fl);
– Ferritin, serum: 7 ng/mL (Reference range:15-200 ng/mL).
– Total iron binding capacity (TIBC): Higher than normal
– Transferrine saturation: Decreased
– Free Erythrocyte protoporphyrin (FEP): Very increased
– Indirect bilirrubin: Normal
– Hemoglobin electrophoresis: Normal pattern
– Bone marrow aspirate stained for Iron: No sideroblasts, no stainable iron
Based in the characteristics of the patient and the lab results, you can assume that the signs in this patient can be explained by an anemia resulting from:
a) Anorexia nervosa
b) deficit of Cobalamine
c) deficit of Folic acid
d) deficit of Iron
e) deficit of Vitamin B6
f) deficit of Folate and cyanocobalamine
g) increased Hemolysis
j) Lead poisoning
k) Thalassemia Major
l) Thalassemia minor