Differential Diagnosis for Anemia in an 87-year-old

Given the laboratory results for an 87-year-old patient (RBC 2.14, Hg B7.1, HCT 23%, MCV 107.8, MCH 33.1, MCHC 30.7, RDW 35.4), we can categorize the differential diagnosis as follows:

• Single Most Likely Diagnosis

  • Vitamin B12 or Folate Deficiency Anemia: The patient's elevated MCV (107.8) indicates a macrocytic anemia. Given the age of the patient, a deficiency in vitamin B12 or folate is a common cause of macrocytic anemia due to decreased absorption, dietary deficiencies, or increased demand.

• Other Likely Diagnoses

  • Anemia of Chronic Disease: Although the MCV is elevated, suggesting a macrocytic anemia, anemia of chronic disease can sometimes present with a normocytic or slightly macrocytic picture, especially if there are underlying inflammatory conditions affecting the patient.
  • Myelodysplastic Syndrome (MDS): This condition can cause macrocytic anemia and is more common in the elderly. The elevated RDW (35.4) also supports this diagnosis, as MDS can lead to a significant variation in red blood cell size.
  • Chronic Liver Disease: Liver disease can lead to macrocytosis due to impaired liver function affecting lipid metabolism and leading to the production of abnormal lipoproteins that affect the red blood cell membrane.

• Do Not Miss Diagnoses

  • Hemolytic Anemia: Although less likely given the macrocytic picture, certain types of hemolytic anemia (e.g., autoimmune hemolytic anemia) can present with elevated MCV and must be considered due to their potential severity and need for specific treatment.
  • Bone Marrow Failure: Conditions like aplastic anemia or pure red cell aplasia can have a macrocytic component and are critical to diagnose due to their potential for severe anemia and the need for specific treatments, including possible bone marrow transplantation.

• Rare Diagnoses

  • Orotic Aciduria: A rare genetic disorder leading to megaloblastic anemia due to defects in pyrimidine synthesis. It's less likely but could be considered in the differential diagnosis of macrocytic anemia, especially if common causes are ruled out.
  • Congenital Dyserythropoietic Anemia: A group of rare genetic disorders affecting erythropoiesis, which could potentially present with macrocytosis, although they are typically diagnosed earlier in life.

Each of these diagnoses should be considered in the context of the patient's full clinical picture, including symptoms, other laboratory results, and imaging studies as appropriate.