Iron deficiency anaemia

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Ans.D

Protoporphyrin is an intermediate in the pathway to heme synthesis. Under conditions in which heme synthesis is impaired, protoporphyrin accumulates within the red cell. Normal values are

Iron deficiency anemia is associated with increased Total iron binding capacity (TIBC) and decreased serum ferritin ( storage form of iron)

Ref: Harrison’s Principles of Internal Medicine, 17th Edition, Page 631, 663; Davidson’s principles and practice of Medicine, 20th Edition, Chapter 24, Page 1025-1027 &1030

Ans. is `b’ i.e., Anisocytosis

Anisocytosis, hypochromia and poikilocytosis are seen in iron deficiency anemia.

o MCV (normal — 82 to 96 IL) is decreased in iron deficiency anemia (60-90 fL)

o Howell-Jolly bodies are seen in megaloblastic anema, after splenectomy and in hemolytic anemia (not in iron deficiency anemia)

I think option ‘c’ requires specific mention here:

Polychromasia

o Polychromasia refers to variation in erythrocyte coloration.

o Normally younger (immature) erythrocytes stain blue with Romanowsky stain, whereas mature erythrocytes stain uniformly orange-pink.

o A slight degree of polychromasia is normal i.e. some degree of variation in colour may occur normally.

o When immature erythrocytes are released into circulation (from bone marrow) there is significant variation in color of erythrocytes —> Polychromasia.

• So, variation in color (polychromasia) largely relates to the maturation of cells.

o Polychromasia is seen when erythrocytes are released prematurely e.g. in response to erothropoietin or architectural damage to bone marrow (fibrosis, infiltration of bone marrow by malignant cells etc.)

Ans. is ‘a’ i.e., Decreases

Ans. is ‘c’ i.e., Serum Ferritin

• During an Iron deficient state, the body will mobilize its Iron Stores & so try to maintain a near normal supply of Iron to tissues e.g. Bone Marrow.
• So the first organ to be depleted of Iron wilt be the Iron stores.

o And we know Serum Ferritin reflects the body stores of Iron.

o Therefore serum ferritin is the first to be changed (i.e. depleted).

Ans. is ‘c’ i.e., 100 – 150 mg 

Ans. is ‘a’ i.e., 0-3 months 

Answer is B &  C  (↓TIBC;↑Ferritin)

Anemia of chronic disease is associated with decreased TIBC and increased serum Ferritin while Iron deficiency anemia is associated with Increased TIBC and reduced serum Ferritin

Differential diagnosis of Microcytic Hypochromic Anemia

Ans. D: Reduced ferritin

Ans. D i.e. Serum ferritin

In the appropriate clinical setting, a smear showing hypochromic and microcytosis are adequate for the diagnosis.

When more specific tests are needed, a positive diagnosis can be made from low levels of ferritin, and a low serum iron level in association with an elevated total iron-binding capacity.

Iron deficiency anaemia (IDA):

• The commonest cause of anaemia in India
• Increased iron absorption is seen in Iron deficiency anaemia, pregnancy, hypoxia, acidic pH of the stomach, ferrous iron salts
• Causes of IDA: Hookworms, celiac sprue, carcinoma colon
• Features diagnostic of IDA: Decreased serum ferritin, increased TIBC
• The earliest sign of IDA: Decrease in serum ferritin
• The most sensitive and specific test for diagnosing IDA: Serum ferritin levels
• Hypochromia may be preceded by microcytosis

Ans. is ‘c’ i.e., Hypochromic microcytic

Ans. is ‘D’ i.e., Bone marrow iron is decreased earlier than serum iron

“In iron deficiency anemia the first change is decrease in iron stores ”

The decrease in iron stores is demonstrated by decreased serum ferritin level.

Remember,

Serum ferritin reflects the amount of storage iron in the body.

As the total body iron level begins to fall a characteristic, sequence of events ensue :

• First Stage or Prelatent Stage of Iron Depletion
• When iron loss exceeds absorption, a negative iron balance exists.
• Stored iron begins to be, mobilized from stores. The iron present in the macrophages of liver, spleen and bone marrow are depleted
• Decrease in stored iron is reflected by decrease in serum ferritin.
• At this stage all other parameters of iron status are normal.

Second Stage or Stage of Latent Iron Deficiency :

• Iron stores are exhausted but the blood hemoglobin level remains higher than the lower limit of normal. o After the exhaustion of iron stores :
• The plasma iron concentration fallsQ.
• Plasma iron binding capacity increases2.
• Percentage saturation falls below 15%Q.
• The percentage of sideroblast decreases in the bone marrowQ.

Third Stage or Stage of Apparent Iron Deficiency Anemia

• Supply of iron to marrow becomes inadequate for normal hemoglobin production,
• So the blood hemoglobin concentration falls^Q below the lower limit of normal and iron deficiency anemia is apparent.

Ans. is ‘b’ i.e., Reticulocytosis 

Response to iron therapy

• When specific iron therapy is given, patients often show rapid subjective improvement, with disappearance or marked diminution of fatigue, lassitude, and other non-specific symptoms. This response may occur before any improvment in anemia is observed.
• The earliest hematological evidence of recovery is increase reticulocytes and their hemoglobin content. The reticulocytes attain a maximal value on the 5th to 10th day after institution of therapy and thereafter gradually return to nonnal. The reticulocyte response may not be detectable in mild iron deficiency anemia.
• The blood hemoglobin level is the most accurate measure of the degree of anemia in iron deficiency anemia. During the response to therapy, the red cell count may increase temporarily to values above normal, but the hemoglobin value lags behind.
• The red cell indices may remain abnormal for some time after the normal hemoglobin level is restored. As recovery occurs, a normocytic cell population gradually replaces the microcytic population; and one of the early signs of response to therapy is an increase in RBW from pretreatment level.
• When treatment is fully effective, hemoglobin reaches normal levels by 2 months after therapy is initiated, regard­less of starting values.
• Of the epithelial lesions in iron deficiency, those affecting the tongue and nails are the most responsive to treatment.