Differential Diagnosis for Low Hemoglobin, Low Iron, Normal B12, High Ferritin, High Folic Acid, and Normal MCV

• Single Most Likely Diagnosis
  • Anemia of Chronic Disease (ACD): This condition is characterized by low iron levels, elevated ferritin (indicating iron storage), and a normal or slightly elevated MCV. The high ferritin level, despite low iron, suggests an inflammatory process where iron is sequestered and not available for erythropoiesis. Normal B12 and folic acid levels help rule out megaloblastic anemias, making ACD a leading consideration.
• Other Likely Diagnoses
  • Chronic Kidney Disease (CKD) with associated anemia: CKD can lead to a complex anemia picture, including low hemoglobin, and while iron studies might be affected by the disease process, high ferritin could be seen due to inflammation or previous iron therapy. Normal MCV and the presence of other CKD-related findings would support this diagnosis.
  • Hemoglobinopathies or Thalassemia trait: Although these conditions often present with microcytosis (low MCV), some forms, especially when combined with iron deficiency, can have a normocytic anemia. The high ferritin might be seen in cases with co-existing inflammation or in response to previous transfusions.
• Do Not Miss Diagnoses
  • Hemophagocytic Lymphohistiocytosis (HLH): A rare but potentially fatal condition characterized by excessive immune activation, leading to phagocytosis of blood cells and their precursors. High ferritin levels are a hallmark, often >10,000 ng/mL, and can be associated with anemia, low iron, and normal or elevated MCV.
  • Malignancy-associated anemia: Certain cancers can cause anemia of chronic disease, characterized by low iron, high ferritin, and a normocytic anemia. It's crucial to consider and rule out underlying malignancies, especially in patients with unexplained weight loss, lymphadenopathy, or other systemic symptoms.
• Rare Diagnoses
  • Porphyria Cutanea Tarda: A disorder of porphyrin metabolism that can lead to increased iron absorption and storage, resulting in elevated ferritin levels. Although less common, it could present with anemia and should be considered in the appropriate clinical context.
  • Genetic Hemochromatosis: A condition leading to excessive iron absorption and storage. While it typically presents with elevated iron and ferritin, in early stages or with co-existing anemia of chronic disease, the iron level might be low, making it a rare but possible diagnosis in this scenario.