What condition is characterized by hypoferritinemia, low Total Iron-Binding Capacity (TIBC), anemia, and a normal Mean Corpuscular Volume (MCV)?

Low Iron, Low TIBC, Low Hemoglobin with Normal MCV: Anemia of Chronic Disease

The combination of low iron, low TIBC, low hemoglobin, and normal MCV most strongly indicates anemia of chronic disease (ACD), which requires evaluation for underlying inflammatory, infectious, or neoplastic disorders. 1, 2

Laboratory Pattern Interpretation

This specific laboratory pattern shows:

• Low serum iron: Decreased circulating iron
• Low TIBC: Decreased transferrin (unlike iron deficiency where TIBC is elevated)
• Low hemoglobin: Anemia
• Normal MCV: Normocytic red blood cells

Differentiating from Iron Deficiency Anemia

This pattern distinctly differs from iron deficiency anemia, which typically shows:

• Low serum iron
• High TIBC (not low)
• Low hemoglobin
• Low MCV (microcytic)
• Low ferritin

The key distinguishing factor is the low TIBC, which points away from iron deficiency and toward ACD 1, 2.

Diagnostic Criteria for Anemia of Chronic Disease

According to the European Consensus guidelines, ACD is characterized by:

• Serum ferritin >100 μg/L
• Transferrin saturation <20%
• Evidence of inflammation (elevated CRP or clinical signs)
• Normal MCV (though it can sometimes be low) 1

The low TIBC is particularly important as it reflects decreased transferrin production, which occurs in inflammatory states 3.

Recommended Diagnostic Workup

1. Complete blood count with indices to confirm anemia and normocytic pattern

2. Iron studies:

   • Serum ferritin (likely elevated >100 μg/L)
   • Transferrin saturation (likely <20%)
   • Confirm low TIBC

3. Inflammatory markers:

   • C-reactive protein (CRP)
   • Erythrocyte sedimentation rate (ESR)

4. Evaluation for underlying causes:

   • Chronic infections
   • Inflammatory disorders (IBD, rheumatoid arthritis)
   • Malignancy
   • Chronic kidney disease 1

Mixed Picture Consideration

In some cases, a mixed picture of ACD and iron deficiency may exist:

• If serum ferritin is between 30-100 μg/L with low transferrin saturation
• This represents a combination of true iron deficiency and ACD 1

Management Approach

Treatment should target the underlying cause of inflammation rather than focusing solely on iron supplementation:

1. Identify and treat the underlying inflammatory condition
2. Consider erythropoiesis-stimulating agents if inadequate response to treatment of underlying condition
3. Iron supplementation only if concurrent iron deficiency is confirmed
4. Avoid unnecessary iron supplementation in pure ACD as it may not improve anemia and could potentially worsen inflammation 2

Common Pitfalls to Avoid

• Misdiagnosing as iron deficiency: The normal MCV and low TIBC are key indicators that this is not simple iron deficiency
• Inappropriate iron supplementation: In pure ACD, iron supplementation may be ineffective or potentially harmful
• Failure to investigate underlying cause: ACD is a symptom of an underlying disorder that requires diagnosis and treatment
• Overlooking mixed deficiency: Some patients may have both ACD and true iron deficiency 1, 2

Remember that while ACD is the most likely diagnosis with this pattern, definitive diagnosis requires evaluation of additional parameters including ferritin levels and inflammatory markers.