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NBME 21 Answers

nbme21/Block 2/Question#7 (reveal difficulty score)
A 50-year-old man with rheumatoid arthritis ...
Anemia of chronic disease ๐Ÿ” / ๐Ÿ“บ / ๐ŸŒณ / ๐Ÿ“–
tags: hemeonc repeat

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 +4  upvote downvote
submitted by โˆ—dr.xx(176)
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Among the most prevalent hematologic abnormalities in patients with rheumatologic disorders are the anemia of chronic disease (ACD), a mild anemia that is generally asymptomatic, and iron deficiency anemia.

In iron-deficiency anemia, the TIBC would higher than 400โ€“450 mcg/dL because stores would be low.

Patients with RA occasionally have concurrent iron deficiency anemia and ACD. When this occurs, the hemoglobin level usually drops to below 9.5 g/dL, and the MCV is less than 80.

https://www.uptodate.com/contents/hematologic-manifestations-of-rheumatoid-arthritis

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sympathetikey  Got the right answer too, but man, that whole "1 month after starting therapy" almost threw me off. +1
fkstpashls  all I do is put the wrong answer when I'm between two. Fuck +1



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submitted by โˆ—ragacha(17)
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FA 2018 page 409. Associated with inflammation (RA, SLE, CKD).

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 +0  upvote downvote
submitted by bartolomoose(3)
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This one is fairly logical if you remember that bacteria LOVE our iron. So much so, that our body came up with a way around it. When an infection is detected by the body, it makes like a doomsday prepper and batons down the hatches.

"All the iron into the bones, quick (^ferritin)! Hide it from the intruders! Get those iron delivery trucks (ferritin) off the road (blood)!

with decreased ferritin comes a decrease capacity for binding iron in the blood

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cooldudeboy1  i like the way to remember acd but there is no bacterial etiology in Rheumatoid arthritis is there? +
the_enigma28  The body recognises chronic inflammatory states as infections +
fatboyslim  Ferritin is not the "iron delivery trucks", that's actually TRANSFERRIN (transfers iron to liver and bone marrow). Ferritin is the STORAGE form of iron in the liver and bone marrow. In anemia of chronic disease, there usually is an inflammatory process going (whether infectious, auto-immune [as in this case of Rheumatoid Arthritis], or cancer). During inflammation, the body releases IL-6, which releases hepcidin. Hepcidin downregulates ferroportin channels in the gut and on macrophages; therefore you absorb less iron from the GI and iron is trapped in macrophages (ferritin) and cannot be used for RBC production. All this causes INCREASED FERRITIN, decreased TIBC (if ferritin goes up, TIBC goes down and vice versa), and decreased serum iron levels and TIBC saturation (the bone marrow will suck up all the serum iron to make RBCs because it cannot make use of the iron stored as ferritin). +13



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submitted by โˆ—namesthegame22(13)
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ACD is common in patients with rheumatologic diseases such as SLE; it is the result of increased hepcidin secretion mediated by increased concentrations of inflammatory cytokines.

This results in the increased retention of iron within the RES and impaired iron exportation for use in erythropoiesis with consequent anemia.

  • Ferritin concentrations: normal to increased.
  • Serum iron concentrations: low.
  • TIBC: low.
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namesthegame22  "If doubt exists in distinguishing between ACD and iron deficiency anemia, measurement of the soluble transferrin receptor can be useful." - NBME +



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