A 44-year-old female is referred for anemia. Medical history includes systemic lupus erythematosus (SLE). Her medications include hydroxychloroquine and mycophenolate mofetil (MMF).
- What are potential CBC changes seen in SLE?
- What are two potential causes of this patient’s anemia?
Click for answer:
Diagnosis: anemia of chronic inflammation (AOCI) +/- MMF myelosuppression
CBC findings suggestive of diagnosis:
(1) Normocytic anemia with elevated RDW
(2) Neutropenia, potentially autoimmune
(3) Other cell lines preserved
Q1: What are potential CBC changes seen in SLE?
Normocytic or microcytic anemia, and neutropenia.
Q2: What are two potential causes of this patient’s anemia?
Anemia of chronic inflammation, MMF myelosuppression
Iron Indices in ACD
| ID | ACD | |
| Ferritin | ↓ | -/↑ |
| T. sat. | ↓ | -/↓ |
| TIBC | ↑ | ↓ |
TIBC = transferrin iron binding capacity
AOCI is a challenging diagnosis as there is no single test that can confirm the diagnosis. It requires a thorough history and physical, particularly looking for signs of inflammatory/infectious disease, and biochemical studies. It can be even more challenging to distinguish AOCI from iron deficiency. Whereas iron deficiency is an absolute lack of iron, AOCI involves inappropriate iron utilization in the setting of normal or increased iron storage. The Box shows useful differences in iron parameters that can help you distinguish between iron deficiency and AOCI.
You may recall that AOCI was part of our differential for microcytic anemia (TAILS). However, AOCI can be both normocytic and microcytic, making it an important consideration in this case.
CBC Pearls
• AOCI can be microcytic or normocytic
• AOCI has normal or low reticulocyte count
This patient’s ferritin is 251 in the context of a mildly elevated CRP. Although we would need the other iron parameters to confirm, it is unlikely that she has iron deficiency. We also cannot exclude that her medication (MMF) is contributing some degree of myelosuppression. Given that her anemia is mild with no significant symptoms, there is no need to make any changes at this time.