Paper I
Question
A 45-year-old lady with menorrhagia for 5-6 months presented with fatigue and loss of appetite. Lab investigations showed Hb - 9gm% and peripheral smear showed small RBCs with enhanced central pallor
- (a) What is the likely diagnosis 2 mark(s)
- (b) What lab investigations would confirm your diagnosis 5 mark(s)
- (c) Describe the peripheral smear findings with a labelled diagram 5 mark(s)
- (d) List other causes that can lead to this condition 3 mark(s)
Answer
(a) Likely diagnosis
- Iron deficiency anaemia, secondary to chronic blood loss from menorrhagia — supported by the history of prolonged heavy menstrual bleeding, fatigue, reduced Hb (9 g%), and microcytic hypochromic red cells with increased central pallor on peripheral smear
(b) Laboratory investigations to confirm diagnosis
- Serum iron: Reduced
- Total iron-binding capacity (TIBC): Increased
- Transferrin saturation: Reduced (<15%)
- Serum ferritin: Reduced (most sensitive/specific marker of depleted iron stores)
- Red cell indices: Low MCV, MCH, MCHC; increased RDW (anisocytosis)
- Bone marrow examination (if needed in atypical cases): Absent/reduced stainable iron on Perls’ Prussian blue stain
(c) Peripheral smear findings
- Microcytic red cells (reduced MCV) with markedly increased central pallor, occupying more than one-third of the cell diameter (normal is about one-third)
- Hypochromia — pale-staining cells due to reduced haemoglobin content
- Anisocytosis (variation in cell size) and poikilocytosis (variation in cell shape), including elongated “pencil cells”
- Occasional target cells may be seen
- White cell and platelet morphology typically normal (platelet count may be mildly elevated with active bleeding)
(A labelled diagram cannot be rendered in this text-based answer; the description above covers the key labelled features — microcytosis, increased central pallor, anisopoikilocytosis, and pencil cells — that would be annotated on a peripheral smear diagram.)
(d) Other causes of iron deficiency anaemia
- Chronic gastrointestinal blood loss — peptic ulcer disease, colorectal carcinoma, haemorrhoids, hookworm infestation
- Inadequate dietary iron intake — malnutrition, strict vegetarian diet
- Increased iron demand — pregnancy, lactation, growth spurts in children/adolescents
- Malabsorption — coeliac disease, post-gastrectomy states
- Chronic haemoglobinuria (rare) — intravascular haemolysis with urinary iron loss