Nutritional Anemias — MCQs

10 questions

A 29-year-old woman was found to have a hemoglobin level of 7.8 mg/dl, with a reticulocyte count of 0.8%. The peripheral blood smear showed microcytic hypochromic anemia. On high-performance liquid chromatography (HPLC), hemoglobin A2 and hemoglobin F were 2.4% and 1.3%, respectively. The serum iron and total iron-binding capacity (TIBC) were 15 mg/dl and 420 micrograms per deciliter, respectively. What is the most likely cause of anemia in this patient?

Acrodermatitis enteropathica is seen with deficiency of?

Which of the following is least likely to cause iron deficiency anemia?

A 65-year-old male presents with fatigue, pallor, and low hemoglobin. Which laboratory finding is most indicative of iron deficiency anemia?

All are increased in IDA except

What is/are the characterstics of Iron defficiency Anemaia(IDA)?

Megaloblastic anemia should be treated with both folic acid and vitamin B12 because -

Which of the following is not a characteristic of Fanconi's anemia?

What is the Chandler's Index for Hookworm that indicates a significant health problem?

Q10

A 5-year-old male child presents with episodic anaemia and jaundice since birth. He is least likely to have which of the following conditions?

Nutritional Anemias Indian Medical PG Practice Questions and MCQs

Question 1: A 29-year-old woman was found to have a hemoglobin level of 7.8 mg/dl, with a reticulocyte count of 0.8%. The peripheral blood smear showed microcytic hypochromic anemia. On high-performance liquid chromatography (HPLC), hemoglobin A2 and hemoglobin F were 2.4% and 1.3%, respectively. The serum iron and total iron-binding capacity (TIBC) were 15 mg/dl and 420 micrograms per deciliter, respectively. What is the most likely cause of anemia in this patient?

A. Iron deficiency anemia (Correct Answer)
B. Beta thalassemia minor
C. Sideroblastic anemia
D. Anemia due to chronic infection

Explanation: ### Iron deficiency anemia - The **low serum iron** level (15 mg/dl) and **high TIBC** (420 micrograms/dl) are classic indicators of iron deficiency. - Microcytic hypochromic anemia with a low reticulocyte count further supports this diagnosis, indicating insufficient **iron** for erythropoiesis [1]. [2] ### Beta thalassemia minor - Typically presents with **normal serum iron** levels, which is not consistent with the low iron levels seen here. - HPLC would show elevated hemoglobin A2, which is **not observed** in this patient's results. ### Sideroblastic anemia - Characterized by the presence of **ringed sideroblasts** in the bone marrow and often has normal or increased serum iron levels. - The iron levels reported here do not align with what is expected in sideroblastic anemia. ### Anemia due to chronic infection - Often associated with normocytic or mild microcytic anemia but does not typically lead to such **low serum iron** levels with high TIBC [1]. - This type typically presents with **inflammatory markers** and altered iron metabolism different from the findings in this case.

Question 2: Acrodermatitis enteropathica is seen with deficiency of?

A. Zinc (Correct Answer)
B. Copper
C. Vitamin A
D. Iron

Explanation: ***Zinc*** - **Acrodermatitis enteropathica** is a rare, inherited disorder characterized by a triad of **dermatitis**, **diarrhea**, and **alopecia**, primarily due to impaired zinc absorption. - **Zinc supplementation** is the cornerstone of treatment and typically leads to rapid resolution of symptoms. *Copper* - Copper deficiency can lead to **anemia**, **neutropenia**, and **neurological symptoms** like ataxia and peripheral neuropathy. - It does not cause the characteristic skin lesions of acrodermatitis enteropathica. *Vitamin A* - Vitamin A deficiency is associated with **xerophthalmia** (dry eyes), **night blindness**, and impaired immune function. - It does not present with acrodermatitis enteropathica. *Iron* - Iron deficiency causes **microcytic hypochromic anemia**, fatigue, and pica. - It does not manifest as the specific dermatological and gastrointestinal symptoms seen in acrodermatitis enteropathica.

Question 3: Which of the following is least likely to cause iron deficiency anemia?

A. Chronic blood loss
B. Achlorhydria
C. Extensive surgical removal of the proximal small bowel
D. Excess of meat in the diet (Correct Answer)

Explanation: ***Chronic blood loss*** - Chronic blood loss is a **significant cause** of iron deficiency anemia as it depletes iron stores over time [1]. - Conditions such as **peptic ulcers** or heavy menstrual bleeding can lead to significant blood loss, contributing to anemia [1], [2]. *Achlorhydria* - Achlorhydria refers to the **absence of stomach acid**, which can impair iron absorption, potentially leading to deficiency. - It is important but is **not a direct cause** of anemia, rather a contributing factor. *Excess of meat in the diet* - A diet high in meat actually provides **heme iron**, which is readily absorbed and can prevent deficiency rather than cause it [2]. - Iron deficiency is more likely in diets **low in meat** or in vegetarians unless iron supplements are included. *Extensive surgical removal of the proximal small bowel* - This can lead to **malabsorption** of nutrients, including iron, thus contributing to iron deficiency anemia indirectly [2]. - However, it can also cause deficiencies in other nutrients, not solely related to iron.

Question 4: A 65-year-old male presents with fatigue, pallor, and low hemoglobin. Which laboratory finding is most indicative of iron deficiency anemia?

A. Low ferritin level (Correct Answer)
B. High reticulocyte count
C. High TIBC
D. Normal MCV

Explanation: ***Low ferritin level*** - **Ferritin** is the primary storage protein for iron in the body, and its level is the most accurate indicator of the body's iron stores. - A **low ferritin level** directly reflects depleted iron stores, which is characteristic of iron deficiency anemia [2]. *High reticulocyte count* - A **high reticulocyte count** typically indicates that the bone marrow is actively producing red blood cells, which is usually a response to anemia, but not specifically diagnostic of iron deficiency. - In iron deficiency anemia, the bone marrow's ability to produce new red blood cells is impaired due to lack of iron, so the reticulocyte count might be normal or even low, not high. *High TIBC* - **Total iron-binding capacity (TIBC)** measures the blood's capacity to bind to iron and is usually high in iron deficiency anemia due to an increase in transferrin, which tries to capture any available iron [1]. - While a high TIBC is consistent with iron deficiency, a **low ferritin** is a more direct and reliable indicator of iron stores. *Normal MCV* - **Mean corpuscular volume (MCV)** measures the average size of red blood cells. In established iron deficiency anemia, MCV is typically low, indicating **microcytic anemia** [1]. - A normal MCV (normocytic anemia) can occur in the very early stages of iron deficiency or in other types of anemia, making it less specific for iron deficiency than ferritin levels.

Question 5: All are increased in IDA except

A. Transferrin saturation (Correct Answer)
B. TIBC
C. Soluble transferrin receptor
D. Erythropoietin

Explanation: ***Transferrin saturation*** - In **iron deficiency anemia (IDA)**, there is insufficient iron to saturate transferrin, leading to a **decreased** transferrin saturation. This is the exception among the given options. - Transferrin saturation is calculated as (serum iron / TIBC) x 100, and both **serum iron** and its percentage saturation are low in IDA. *TIBC* - **Total iron-binding capacity (TIBC)** is typically **increased** in IDA as the liver produces more transferrin in an attempt to capture more iron [1]. - This elevated TIBC reflects the body's compensatory mechanism to maximize available iron uptake. *Soluble transferrin receptor* - **Soluble transferrin receptor (sTfR)** levels are **elevated** in IDA because iron-deficient erythroblasts upregulate the production of transferrin receptors on their surface as they try to scavenge more iron. - The elevated sTfR is a sensitive and specific marker for **iron deficiency**, particularly useful in differentiating IDA from anemia of chronic disease [1]. *Erythropoietin* - **Erythropoietin (EPO)** levels are **increased** in IDA due to the kidney's response to the decreased oxygen-carrying capacity of the blood (anemia) [1]. - EPO stimulates the bone marrow to produce more red blood cells, which exacerbates the demand for iron, often leading to further iron depletion if iron stores are low.

Question 6: What is/are the characterstics of Iron defficiency Anemaia(IDA)?

A. Increased TIBC
B. Low serum ferritin
C. All of the options (Correct Answer)
D. Low serum iron
E. Low transferrin saturation

Explanation: ***All of the options*** - **Iron deficiency anemia (IDA)** characteristically presents with a combination of these markers due to a true depletion of the body's iron stores [2]. - A comprehensive evaluation of iron studies, including **TIBC**, **ferritin**, **serum iron**, and **transferrin saturation**, is essential for an accurate diagnosis of IDA [3]. *Increased TIBC* - **Total iron-binding capacity (TIBC)** is typically **elevated in IDA** as the body attempts to maximize iron absorption and transport by increasing the production of transferrin [1]. - Transferrin, the primary iron-binding protein, is less saturated with iron, leading to an **increased capacity to bind more iron**. *Low serum ferritin* - **Serum ferritin** is a direct measure of **iron storage** in the body and is considered the most sensitive and specific marker for iron deficiency. - In IDA, **ferritin levels are markedly decreased**, indicating depleted iron reserves. *Low serum iron* - **Serum iron** measures the amount of iron circulating in the blood, primarily bound to transferrin [4]. - In IDA, the **absolute amount of circulating iron is reduced** due to insufficient iron supply [1]. *Low transferrin saturation* - **Transferrin saturation** represents the percentage of transferrin binding sites occupied by iron. - In IDA, due to **low serum iron** and **high transferrin (indicated by increased TIBC)**, the transferrin saturation is significantly reduced.

Question 7: Megaloblastic anemia should be treated with both folic acid and vitamin B12 because -

A. It is an enzyme
B. It is a cofactor
C. Folic acid alone causes improvement of hematologic symptoms but worsening of neurological symptoms (Correct Answer)
D. None of the above

Explanation: ***Folic acid alone causes improvement of hematologic symptoms but worsening of neurological symptoms*** - Treating **B12 deficiency** with **folic acid alone** can normalize hematologic parameters, which can mask the underlying B12 deficiency. - This can lead to the progression of **irreversible neurological damage** because folic acid does not address the metabolic pathways dependent on B12 for myelin maintenance. *It is an enzyme* - **Folic acid** and **vitamin B12** are not enzymes; they function as **coenzymes** or **cofactors** in metabolic reactions. - Enzymes are proteins that catalyze biochemical reactions, a role not played by these vitamins themselves. *It is a cofactor* - While both **folic acid** and **vitamin B12** are cofactors, this statement alone does not explain why both are needed to treat megaloblastic anemia. - The critical reason for co-administration lies in the potential for **neurological deterioration** if B12 deficiency is missed and only folate is given. *None of the above* - This option is incorrect because there is a valid and specific reason (the neurological consequences mentioned above) for treating megaloblastic anemia with both supplements. - The interaction between **folate** and **B12 metabolism** is crucial in understanding the treatment approach.

Question 8: Which of the following is not a characteristic of Fanconi's anemia?

A. Skeletal anomalies
B. Pancytopenia
C. Chromosome fragility
D. Bone marrow failure in infancy (Correct Answer)

Explanation: ***Bone marrow failure in infancy*** - Fanconi anemia patients are typically **asymptomatic at birth** with normal blood counts. - **Progressive bone marrow failure** develops gradually, with median age of onset around **7 years** (range 5-10 years). - While subtle hematologic changes (macrocytosis, elevated HbF) may appear earlier, clinically significant **pancytopenia does not occur in infancy**. - This delayed hematologic presentation distinguishes Fanconi anemia from other congenital bone marrow failure syndromes. *Pancytopenia* - **Pancytopenia** is the hallmark hematologic feature of Fanconi anemia, but develops in **mid-childhood**, not infancy. - Results from progressive bone marrow failure affecting all three cell lines: **red blood cells, white blood cells, and platelets**. - Thrombocytopenia is often the first manifestation, followed by anemia and neutropenia. *Skeletal anomalies* - **Skeletal anomalies** are common congenital malformations present in approximately **60-75%** of patients. - Include **radial ray defects** (absent or hypoplastic thumbs, absent radius), **short stature**, and other limb abnormalities. - These are present from birth and often lead to early clinical suspicion. *Chromosome fragility* - **Chromosome fragility** is the **diagnostic hallmark** of Fanconi anemia due to defective DNA repair mechanisms. - Diagnostic test uses **diepoxybutane (DEB)** or **mitomycin C (MMC)** to induce DNA crosslinks, revealing increased chromosomal breaks and rearrangements. - This test is positive regardless of age or hematologic status.

Question 9: What is the Chandler's Index for Hookworm that indicates a significant health problem?

A. > 200
B. > 100
C. > 300
D. > 50 (Correct Answer)

Explanation: ***> 50*** - A Chandler's Index of **> 50** indicates a significant public health problem due to **hookworm infection**. - **Chandler's Index** is calculated as the **average egg count per person in a community** (total hookworm eggs counted ÷ number of persons examined), used to assess the population-level burden of hookworm infection. - A value **> 50** suggests that the community has a significant hookworm problem requiring public health intervention. *> 300* - This value is significantly higher than the threshold for a significant public health problem and would indicate an **extremely severe burden of infection**. - While this represents a very high Chandler's Index, it's not the standard cut-off for defining a "significant" health problem (which is the lower threshold of >50). *> 200* - A Chandler's Index of **> 200** would denote a very high intensity of hookworm infection in the community. - However, this is not the standard threshold used to define when hookworm becomes a "significant" public health issue - the threshold is lower at >50. *> 100* - A Chandler's Index of **> 100** represents a substantial level of hookworm infection within a population. - However, the widely recognized cutoff for a "significant health problem" is **> 50**, indicating public health concern even at this moderate level of community infection burden.

Question 10: A 5-year-old male child presents with episodic anaemia and jaundice since birth. He is least likely to have which of the following conditions?

A. Hereditary spherocytosis
B. PNH (Correct Answer)
C. G–6–PD deficiency
D. Sickle cell anemia

Explanation: ***PNH*** - **Paroxysmal nocturnal hemoglobinuria (PNH)** is a rare, acquired clonal disorder that can present with anemia and jaundice; however, it is most commonly diagnosed in **adulthood** (median age 30-40 years). - While it can occur in children, presentation **since birth** is highly atypical for this acquired condition. *Hereditary spherocytosis* - This is an **inherited hemolytic anemia** characterized by defective red blood cell membrane proteins, leading to spherocytes that are prematurely destroyed. - It commonly presents with **episodic anemia and jaundice beginning in childhood**, often detected at birth or in early infancy. *Sickle cell anemia* - A **hereditary hemoglobinopathy** where red blood cells become sickle-shaped under low oxygen conditions, leading to chronic hemolysis, anemia, and vaso-occlusive crises. - Symptoms including **anemia and jaundice typically manifest in infancy** after the decline of fetal hemoglobin. *G–6–PD deficiency* - This is an **inherited enzyme deficiency** that makes red blood cells susceptible to oxidative damage, causing hemolytic anemia upon exposure to certain triggers (e.g., fava beans, certain drugs, infections). - Presentation with **episodic anemia and jaundice is common in childhood**, occurring when the child encounters oxidative stressors.

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