Page 207 - Haematologica Atlas of Hematologic Cytology

CHAPTER 24 - Anemia of chronic in ammation
Chapter 24. ANEMIA OF CHRONIC INFLAMMATION
Anemia of chronic inflammation is commonly associated with systemic diseases (infection, inflammation, ma- lignancy) and represents the most common anemia among hospitalized patients. The conditions associated with this type of anemia are reported in Table 1.
Table 1. ondi ons associated with anemia of chronic in amma on.
hronic infec ons
Especially osteomyeli s, bacterial endocardi s, tuberculosis, abscesses, bronchiectasis, chronic urinary tract infec ons
ther chronic in ammatory disorders
Rheumatoid arthri s, uvenile rheumatoid arthri s, polymyalgia rheuma ca, systemic lupus erythematosus, scleroderma, in ammatory bowel diseases, thrombophlebi s
Malignant diseases
Carcinoma (especially metasta c or associated with infec on), lymphoma, myeloma
thers
Conges ve heart failure, ischemic heart disease, AIDS
Acute phase reactants, especially hepcidin, have an important pathogenetic role. Hepcidin levels increase during inflammation, regardless of iron levels in the body. As a result, there is a decrease in iron absorption from the intestine and iron release from macrophages and hepatocytes. Therefore, iron is unavailable to red cell pre- cursors because it is sequestered in the macrophages and hepatocytes; chronically high levels of hepcidin lead to diminished production of erythrocytes. Moreover, during infection and inflammation, neutrophil lactoferrin is released into the plasma where it binds available iron, at the expense of transferrin. Also increased levels of ferritin in the plasma bind some iron. Because red cell precursors do not have a lactoferrin or ferritin receptor, this iron is unavailable for incorporation into hemoglobin. The effect on the erythroid cells is essentially no dif- ferent from that in mild iron deficiency. Also a reduced response to erythropoietin may contribute to the anemia of chronic inflammation (Doig, 2012).
Diagnosis is based on hematologic and biochemical findings (Table 2).
Table 2. nemia of chronic in amma on hematologic and biochemical features.
Hemoglobin
9-11 g/dL
MCV
Normal or mildly reduced
MCH
sually normal; occasionally reduced
Serum iron
Reduced
TIBC
Reduced
Transferrin satura on
Mildly reduced
Serum ferri n
Normal or increased
Serum and urine hepcidin
Raised
reac ve protein
sually raised
rythrocyte sedimenta on rate
sually raised
MC : mean cell volume; MCH: mean cell hemoglobin; TIBC: total iron binding capacity.
Anemia of chronic in amma on is normochromic normocy c or hypochromic microcy c and is typically not severe. White blood cells show normal morphology. Bone marrow cellularity is normal with possible abnormali es of erythropoiesis similar to those observed in iron de ciency anemia (See Chapter “Iron de ciency anemia”) and a possible increase in in ammatory cells. The Perls stain shows abundant stainable iron in macrophages. Bone marrow examina on, however, is usually not necessary for diagnosis, but should be performed in cases of doubt.
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