From the Guidelines
The patient's blood smear indicates a mild normocytic, hypochromic anemia with anisopoikilocytosis, suggesting a possible early iron deficiency anemia or mild chronic disease anemia, and thus, further investigation with iron studies is warranted. The presence of ovalocytes, elliptical, and burr cells, although not specific, can be seen in various anemias, including iron deficiency anemia 1. The normal reticulocyte count, albeit on the lower end of normal, and normal erythropoietin levels, suggest that the bone marrow is not significantly compensating for the anemia, which could indicate a production problem rather than a loss or destruction issue 1.
Given the morphologic approach to evaluating anemia, as outlined in the study by 1, the patient's normocytic anemia could be due to several causes, including hemorrhage, hemolysis, bone marrow failure, anemia of chronic inflammation, or renal insufficiency. However, the absence of significant reticulocytosis and the normal erythropoietin level make some of these causes less likely.
Key points to consider in the management of this patient include:
- Investigating the cause of the anemia, with a focus on iron deficiency given the hypochromic nature of the anemia
- Ordering iron studies (serum iron, ferritin, total iron binding capacity) to confirm or rule out iron deficiency 1
- Considering the possibility of chronic disease anemia if iron studies are normal
- Assessing for occult blood loss, malabsorption, or poor dietary intake if iron deficiency is confirmed
- Monitoring response to treatment with follow-up complete blood counts after 4-6 weeks of oral iron supplementation, if initiated.
The study by 1 emphasizes the importance of a comprehensive approach to anemia, including both morphologic and kinetic evaluations, to guide appropriate management and treatment. In this case, further investigation and potential treatment with oral iron supplementation are recommended to address the possible iron deficiency anemia, with careful monitoring of the patient's response to therapy.
From the Research
Blood Smear Results
The blood smear results indicate a mild normocytic anemia, characterized by:
- Normocytic red blood cells
- Hypochromia (reduced hemoglobin content)
- Increased anisopoikilocytosis (variation in red blood cell size and shape)
- Presence of ovalocytes, elliptical, and burr cells
- Normal reticulocyte count, although on the lower end of normal
- Normal erythropoietin levels
- Normal leukocyte count and morphology
- Normal platelet count and morphology
Possible Causes of Normocytic Anemia
According to 2, normocytic anemia without reticulocytosis can be caused by various factors, including:
- Normocytic megaloblastic anemia
- Acquired immunodeficiency syndrome
- Other conditions that affect iron availability and erythropoiesis
Role of Reticulocyte Hemoglobin Content (CHr)
3 suggests that CHr is a useful indicator of iron availability and an early marker of iron-deficient erythropoiesis. CHr has moderate sensitivity and specificity for diagnosing iron deficiency and is less affected by inflammation than other biomarkers. However, there is no standardized cutoff point for CHr, which can affect its accuracy.
Importance of Blood Smear Examination
4 emphasizes the importance of blood smear examination in verifying automated hematology results, determining the need for manual differential leukocyte count, and providing a complete hematologic picture. Blood smear review can also help ensure that no clinically significant findings are missed.
Relevance of Other Studies
5 is not relevant to the interpretation of blood smear results or the diagnosis of anemia.