1. Jean's blood picture: CBC results are relatively normal except , WBC's are elevated at 12.

1 (normal reference
5-10) meaning a possible stress on body or infectious process going on in the body. RBC's are at the lower end
of the normal range of 4.0-15.0
Her MCV is also normal per the chart normals, but on the low range, and her platelet level is 230, a normal
level.
1. a.In general, there are three major types of anemia, classified according to the size of the red blood cells:
Anemia is actually a sign of a disease process rather than a disease itself. It is usually classified as either chronic
or acute. Chronic anemia occurs over a long period of time. Acute anemia occurs quickly. Determining whether
anemia has been present for a long time or whether it is something new, assists doctors in finding the cause.
This also helps predict how severe the symptoms of anemia may be. In chronic anemia, symptoms typically
begin slowly and progress gradually; whereas in acute anemia symptoms can be abrupt and more distressing.
1. If the red blood cells are smaller than normal, this is called microcytic anemia. The major causes of
this type are iron deficiency (low level iron) anemia and thalassemia (inherited disorders of hemoglobin).
2. If the red blood cells size are normal in size (but low in number), this is called normocytic anemia,
such as anemia that accompanies chronic disease or anemia related to kidney disease.
3. If red blood cells are larger than normal, then it is called macrocytic anemia. Major causes of this type
are pernicious anemia and anemia related to alcoholism.
MCV: Abbreviation for mean cell volume, the average volume of a red blood cell. This is a calculated value
derived from the hematocrit and the red cell count (The hematocrit is the ratio of the volume of red cells to the
volume of whole blood while the red cell count is the number of red blood cells in a volume of blood). The
normal range for the MVC is 86 - 98 femtoliters. The MCV is a standard part of the complete blood count
(CBC). Each lab has different reference ranges for normal depending on the values
A rational approach to determining etiology is to begin by examining the peripheral smear and laboratory values
obtained on the blood count. If the anemia is either microcytic (mean corpuscular volume [MCV] 96) or if
certain abnormal RBCs or white blood cells (WBCs) are observed in the blood smear, the investigative
approach can be limited
b.Pathogenesis: The development of a disease and the chain of events leading to that disease.
Many medical conditions cause anemia. Common causes of anemia include the following:
* Anemia from active bleeding: Loss of blood through heavy menstrual bleeding or,wounds can cause
anemia.Gastrointestinal ulcers or cancers such as cancer of the colon may slowly ooze blood and can also cause
anemia.
* Iron deficiency anemia: The bone marrow needs iron to make red blood cells. Iron plays an important
role in the proper structure of the hemoglobin molecule. If iron intake is limited or inadequate due to poor
dietary intake, anemia may occur as a result. This is called iron deficiency anemia. Iron deficiency anemia can
also occur when there are stomach ulcers or other sources of slow, chronic bleeding (colon cancer, uterine
cancer, intestinal polyps, hemorrhoids, etc). In these kinds of scenarios, because of ongoing, chronic slow blood
loss, iron is also lost from the body (as a part of blood) at a higher rate than normal and can result in iron
deficiency anemia.
* Anemia of chronic disease: Any long-term medical condition can lead to anemia. The exact
mechanism of this process in unknown, but any long-standing and ongoing medical condition such as a chronic
infection or a cancer may cause this type of anemia.

* Anemia related to kidney disease: The kidneys release a hormone called the erythropoietin that helps
the bone marrow make red blood cells. In people with chronic (long-standing) kidney disease, the production of
this hormone is diminished, and this in turn diminishes the production of red blood cells, causing anemia. This
is called anemia related to chronic kidney disease.
* Anemia related to pregnancy: Water weight gain during pregnancy dilutes the blood, which may be
reflected as anemia.
* Anemia related to poor nutrition: Vitamins and minerals are required to make red blood cells. In
addition to iron, vitamin B12 and folate are required for the proper production of hemoglobin. Deficiency in any
of these may cause anemia because of inadequate production of red blood cells. Poor dietary intake is an
important cause of low folate and low vitamin B12 levels. Strict vegetarians who do not take sufficient vitamins
are at risk to develop vitamin B12 deficiency.
* Pernicious Anemia: There also may be a problem in the stomach or the intestines leading to poor
absorption of vitamin B12. This may lead to anemia because of vitamin B12 deficiency known as pernicious
anemia.
* Sickle cell anemia: In some individuals, the problem may be related to production of abnormal
hemoglobin molecules. In this condition the hemoglobin problem is qualitative, or functional. Abnormal
hemoglobin molecules may cause problems in the integrity of the red blood cell structure and they may become
crescent-shaped (sickle cells). There are different types of sickle call anemia with different severity levels. This
is typically hereditary and is more common in those of African, Middle Eastern, and Mediterranean ancestry.
* Thalassemia: This is another group of hemoglobin-related causes of anemia. There are many types of
thalassemia, which vary in severity from mild (thalassemia minor) to severe (thalassemia major). These are also
hereditary, but they cause quantitative hemoglobin abnormalities, meaning an insufficient amount of the correct
hemoglobin type molecules is made. Thalassemia is more common in people from African, Mediterranean, and
Southeast Asian ancestries.
* Alcoholism: Poor nutrition and deficiencies of vitamins and minerals are associated with alcoholism.
Alcohol itself may also be toxic to the bone marrow and may slow down the red blood cell production. The
combination of these factors may lead to anemia in alcoholics.
* Bone marrow-related anemia: Anemia may be related to diseases involving the bone marrow. Some
blood cancers such as leukemia or lymphomas can alter the production of red blood cells and result in anemia.
Other processes may be related to a cancer from another organ spreading to the bone marrow.
* Aplastic anemia: Occasionally some viral infections may severely affect the bone marrow and
significantly diminish production of all blood cells.Chemotherapy (cancer medications) and some other
medications may pose the same problems.

* Hemolytic anemia: The normal red blood cell shape is important for its function. Hemolytic anemia is
a type of anemia in which the red blood cells rupture (known as hemolysis) and become dysfunctional. This
could happen due to a variety of reasons. Some forms of hemolytic anemia can be hereditary with constant
destruction and rapid reproduction of red blood cells (for example, as in hereditary spherocytosis, hereditary
elliptocytosis, and glucose-6-phosphate dehydrogenase or G6GD deficiency) . This type of destruction may also
happen to normal red blood cells in certain conditions, for example, with abnormal heart valves damaging the
blood cells or certain medications that disrupt the red blood cell structure.
* Anemia related to medications: Many common medications can occasionally cause anemia as a side
effect in some individuals. The mechanisms by which medications can cause anemia are numerous (hemolysis,
bone marrow toxicity) and are specific to the medication. Medications that most frequently cause anemia are
chemotherapy drugs used to treat cancers. Other common medications that can cause anemia include some
seizure medications, transplant medications, HIV medications, some malaria medications, some antibiotics
(penicillin, chloramphenicol), antifungal medications, and antihistamines.

1. Jean being a female can be one cause, Young women are twice as likely to have anemia than young men
because of regular menstrual bleeding. Anemia occurs in both young people and in old people, but anemia in
older people is more likely to cause symptoms because they typically have additional medical problems.
Red cell distribution width: A measurement of the variability of red blood cell size. Higher numbers indicate
greater variation in size. The normal range for the red cell distribution width (RDW) is 11 - 15. The RDW is a
standard part of the complete blood count.
The CBC documents the severity of the anemia. In chronic iron deficiency anemia, the cellular indices show a
microcytic and hypochromic erythropoiesisthat is, both the mean corpuscular volume (MCV) and the mean
corpuscular hemoglobin concentration (MCHC) have values below the normal range for the laboratory
performing the test. Reference range values for MCV and MCHC are 83-97 fL and 32-36 g/dL, respectively.
Often, the platelet count is elevated (>450,000/L); this elevation normalizes after iron therapy. The white
blood cell (WBC) count is usually within reference ranges (4500-11,000/L), but it may be elevated.
If the CBC is obtained after blood loss, the cellular indices do not enter the abnormal range until most of the
erythrocytes produced before the bleed are destroyed at the end of their normal lifespan (120 d).
Tests to distinguish :
In modern counters, four parameters (RBC count, hemoglobin concentration, MCV and RDW) are measured,
allowing others (hematocrit, MCH and MCHC) to be calculated, and compared to values adjusted for age and
sex
Complete blood count (CBC): Determines the severity and type of anemia (microcytic anemia or small sized
red blood cells, normocytic anemia or normal sized red blood cells, or macrocytic anemia or large sized red
blood cells) and is typically the first test ordered. Information about other blood cells (white cells and platelets)
are also included in the CBC report.
Peripheral Smear
Examination of the peripheral smear is an important part of the workup of patients with anemia. Examination of
the erythrocytes shows microcytic and hypochromic red blood cells in chronic iron deficiency anemia. The
microcytosis is apparent in the smear long before the MCV is decreased after an event producing iron
deficiency. Platelets usually are increased in this disorder.
Low serum iron and ferritin levels with an elevated TIBC are diagnostic of iron deficiency. While a low serum
ferritin is virtually diagnostic of iron deficiency, a normal serum ferritin can be seen in patients who are

deficient in iron and have coexistent diseases (eg, hepatitis or anemia of chronic disorders). These test findings
are useful in distinguishing iron deficiency anemia from other microcytic anemias
b.The serum iron level represents the amount of circulating iron bound to transferrin.
In men, the reference range of serum iron is 55160 g/dL. In women, it is 40155 g/dL
The serum iron level represents the amount of circulating iron bound to transferrin. The total iron-binding
capacity (TIBC) is an indirect measure of the circulating transferrin.
1.
serum iron: Serum iron is a medical laboratory test that measures the amount of circulating iron that is bound to
transferrin. Clinicians order this laboratory test when they are concerned about iron deficiency, which can cause
anemia and other problems.
65% of the iron in the body is bound up in hemoglobin molecules in red blood cells. About 4% is bound up in
myoglobin molecules. Around 30% of the iron in the body is stored as ferritin or hemosiderin in the spleen, the
bone marrowand the liver. Small amounts of iron can be found in other molecules in cells throughout the body.
None of this iron is directly accessible by testing the serum.
However, some iron is circulating in the serum. Transferrin is a molecule produced by the liver that binds one or
two iron(III) ions, i.e. ferric iron, Fe3+; transferrin is essential if stored iron is to be moved and used.
Iron-binding capacity:Total iron-binding capacity (TIBC) is a medical laboratory test that measures the blood's
capacity to bind iron with transferrin. It is performed by drawing blood and measuring the maximum amount of
iron that it can carry, which indirectly measures transferrin since transferrin is the most dynamic carrier. TIBC is
less expensive than a direct measurement of transferrin.
The TIBC should not be confused with the UIBC, or "unsaturated iron binding capacity" The UIBC is
calculated by subtracting the serum iron from the TIBC
percent saturation:Transferrin saturation, abbreviated as TSAT and measured as a percentage, is a medical
laboratory value. It is the ratio of serum iron and total iron-binding capacity, multiplied by 100. Of the
transferrin that is available to bind iron, this value tells a clinician how much serum iron is actually bound. For
instance, a value of 15 % means that 15 % of iron-binding sites of transferrin is being occupied by iron. For an
explanation of some clinical situations in which this ratio is important, see Total iron-binding capacity. The
three results are usually reported together.
Ferritin is a ubiquitous intracellular protein that stores iron and releases it in a controlled fashion. The amount
of ferritin stored reflects the amount of iron stored. The protein is produced by almost all living organisms,
including algae, bacteria, higher plants, and animals. In humans, it acts as a buffer against iron deficiency and
iron overload.
Ferritin is a globular protein complex consisting of 24 protein subunits and is the primary intracellular ironstorage protein in both prokaryotes and eukaryotes, keeping iron in a soluble and non-toxic form. Ferritin that is
not combined with iron is called apoferritin.
Zinc protoporphyrin (ZPP) is a compound found in red blood cells when heme production is inhibited by lead
and/or by lack of iron. Instead of incorporating a ferrous ion, to form heme,protoporphyrin IX, the immediate
precursor of heme, incorporates a zinc ion, forming ZPP. The reaction to insert a ferrous ion into protoporphyrin
IX is catalyzed by the enzyme ferrochelatase.
serum transferring receptors: Serum Transferrin receptor (TfR) is a carrier protein for transferrin. It is needed
for the import of iron into the cell and is regulated in response to intracellular iron concentration. It imports iron
by internalizing the transferrin-iron complex through receptor-mediated endocytosis. TS = (Serum Iron / Total
Iron Binding Capacity) x 100%
~~~~~~~~~~~~~~~~.

1. ferritin Jean's results of 80 (10-300mg/L) normal : Ferritin concentrations increase drastically in the presence
of an infection or cancer; this is necessary to counter the infective agent's attempt to bind iron from the host's
tissue. The inflammatory response (such as Jean has with arthritis) may cause ferritin to migrate from the
plasma to within cells, in order to deny iron to the infective agent or inflamatory processes.
1. instead of a bone marrow sample~~ There are numerous tests performed on peripheral blood that have
traditionally been used to diagnose iron deficiency. Of these tests, the serum ferritin is by far the most powerful.
A serum ferritin value less than 12g/L is a highly specific indicator of iron deficiency. However, because it is
an acute phase reactant, the ferritin may be normal or increased in iron deficient patients with other medical
problems. Thus, some patients may require a bone marrow biopsy or a trial of iron therapy to differentiate iron
deficiency from other causes of anemia. Two peripheral blood tests for iron deficiency, the soluble transferrin
receptor and the reticulocyte hemoglobin content, have recently become available. These tests are sensitive for
iron deficiency and, when used in conjunction with ferritin, provide a significant advance in the ability to
accurately diagnose iron deficiency using non-invasive testing

jean l a 30 year old white woman was seen in the office of a rheumatologist. She was diagnosed in childhood
with rheumatoid arthritis. Even at the relatively young age of 30 years, the joint of her hands were noticeably
enlarged and deformed, and her gait was affected by knee and hip pain.