A 45-year-old woman recently diagnosed with rheumatoid arthritis visits the GP with recent weakness, lethargy, and shortness of breath. On examination, she is noted to have developed angular stomatitis.


A full blood count (FBC) and blood film is requested.


||||
|--------------|:-------:|---------------|
|Haemoglobin|89 g/L|(M) 130 - 170, (F) 115 - 155|

|Mean Cell Haemoglobin (MCH)|19 pg|27 - 33|
|Mean Cell Volume (MCV)|68 fL|80 - 96|
|Reticulocytes|130x10<sup>9</sup>/L|25 - 100|


Which of the following mechanisms best accounts for the patient's anaemia?

Options:
explanation: No, this is not the correct answer: the patient has symptoms of iron deficiency, rather than overload.

The patient has developed anaemia of chronic disease. Having a chronic inflammatory condition such as rheumatoid arthritis leads to an increased production of inflammatory cytokines such as IL-6. IL-6. This in turn can directly increase the production of hepcidin from the liver, which inhibits ferroportin (a channel responsible for the transport of iron (II)), leading to reduced release of iron from the reticuloendothelial system and reduced absorption of iron from the GI tract. This overall leads to a functional iron deficiency, which leads to microcytic anaemia (MCV < 80 fL) and an increased reticulocyte count.
name: Increased production of hepcidin from the liver leading to iron overload
label: b
answer: no
explanation: No, this is not the correct answer. This patient has developed anaemia of chronic disease. Having a chronic inflammatory condition such as rheumatoid arthritis leads to increased production of inflammatory cytokines such as IL-6. IL-6. This in turn can directly increase the production of hepcidin from the liver, which inhibits ferroportin (a channel responsible for the transport of iron (II)), leading to reduced release of iron from the reticuloendothelial system and reduced absorption of iron from the GI tract. This overall leads to a functional iron deficiency, which leads to microcytic anaemia (MCV < 80 fL) and an increased reticulocyte count.
name: Decreased production of hepcidin from the kidney leading to the activation of ferroportin
label: e
answer: no
explanation: No, this is not the correct answer. Although the patient does have chronic inflammation, their haemoglobin level is reduced, rather than raised.
name: Chronic inflammation causing an increase in haemoglobin
label: d
answer: no
explanation: No, this is not the correct answer. The patient has developed anaemia of chronic disease, and a resulting functional iron deficiency, which is associated with microcytic rather than macrocytic anaemia. This can also be seen in the patient's reduced MCV.
name: Increased production of hepcidin from the kidney leading to a macrocytic anaemia
label: c
answer: no
explanation: Yes, this is the correct answer. This patient has developed anaemia of chronic disease. Having a chronic inflammatory condition such as rheumatoid arthritis leads to increased production of inflammatory cytokines such as IL-6. IL-6. This in turn can directly increase the production of hepcidin from the liver, which inhibits ferroportin (a channel responsible for the transport of iron (II)), leading to reduced release of iron from the reticuloendothelial system and reduced absorption of iron from the GI tract. This overall leads to a functional iron deficiency, which leads to microcytic anaemia (MCV < 80 fL) and an increased reticulocyte count.
name: Increased production of hepcidin from the liver leading to a functional iron deficiency
label: a
answer: yes

Correct answer: a