Paper I
Question
A 38-year-old pregnant woman with history of multiple, closely spaced pregnancies, develops fatigue, pallor, koilonychia, alopecia, and atrophic changes of the tongue of one-month duration (
- (a) What is your provisional diagnosis ( 1 mark(s)
- (b) Describe the peripheral smear and Bone marrow finding ( 6 mark(s)
- (c) What are the other laboratory investigations to be done for confirming the diagnosis in this patient ( 3 mark(s)
- (d) Describe the pathogenesis and complications of this condition 5 mark(s)
Answer
(a) Provisional diagnosis
- Iron deficiency anaemia — supported by multiparity (chronic iron loss/increased demand from repeated pregnancies), fatigue, pallor, koilonychia (spoon-shaped nails), alopecia, and atrophic glossitis, all classic features of chronic iron deficiency
(b) Peripheral smear and bone marrow findings
Peripheral smear
- Microcytic, hypochromic red cells (low MCV, MCH, MCHC)
- Increased central pallor of red cells (>1/3 of cell diameter)
- Anisocytosis and poikilocytosis, including pencil cells (elongated cells)
- Normal or slightly reduced platelet count (may be elevated with active bleeding)
Bone marrow findings
- Normoblastic erythroid hyperplasia (increased erythroid precursors, but small and poorly haemoglobinized — micronormoblastic)
- Absent or markedly reduced stainable iron on Perls’ Prussian blue stain (the key diagnostic marrow finding)
(c) Other laboratory investigations for confirmation
- Serum iron: Reduced
- Total iron-binding capacity (TIBC): Increased
- Transferrin saturation: Reduced (<15%)
- Serum ferritin: Reduced (most sensitive and specific test for iron stores, though it is an acute-phase reactant and can be falsely normal/elevated in concurrent inflammation)
- Red cell distribution width (RDW): Increased (reflects anisocytosis)
(d) Pathogenesis and complications
Pathogenesis
- Chronic negative iron balance (increased loss/demand exceeding intake/absorption) depletes body iron stores (first from the marrow/liver/spleen reserves, reflected by falling ferritin)
- As stores are exhausted, serum iron falls and transferrin (TIBC) rises compensatorily
- Insufficient iron delivery to erythroid precursors impairs haemoglobin synthesis, producing progressively smaller (microcytic) and less haemoglobinized (hypochromic) red cells
- In this patient, closely spaced multiple pregnancies represent chronic, repeated iron depletion (fetal/placental iron transfer, blood loss at delivery) without adequate replenishment between pregnancies
Complications
- Severe anaemia — cardiac strain, high-output cardiac failure in longstanding severe cases
- Plummer-Vinson syndrome (iron deficiency anaemia, atrophic glossitis, oesophageal web — increased risk of postcricoid oesophageal carcinoma)
- Impaired cognitive/developmental effects (if occurring during pregnancy, risk to fetal development)
- Reduced work capacity/quality of life
- Increased susceptibility to infections