Snapshot A 56-year-old man presents to his annual physical exam with weight loss, fatigue, and weakness. He is a long-term smoker and also recently immigrated from Southeast Asia. He complains of a chronic cough for the past year with occasional bloody mucus. He agrees to undergo imaging for lung lesions and a blood test for tuberculosis. Iron studies reveal decreased serum iron, increased ferritin, and decreased TIBC. Peripheral blood smear shows basophilic stippling. Introduction Anemia of chronic disease resulting from decreased red blood cell production is a normochromic, normocytic anemia Pathogenesis iron is stored in macrophages or bound with ferritin hepcidin is an acute-phase reactant that is increased in states of inflammation inflammation causes release of hepcidin by the liver ↑ hepcidin inhibits iron absorption from diet and prevents release of iron bound by ferritin from macrophages Associated conditions chronic inflammatory condition chronic infection tuberculosis longstanding malignancy Prognosis varied based on underlying inflammatory condition Presentation Symptoms of anemia generalized weakness fatigue shortness of breath headache Physical exam pallor tachycardia Evaluation Labs ↑ ferritin ↓ serum iron ↓ TIBC, transferrin saturation, and MCV Peripheral blood smears normochromic RBCs may be normocytic or microcytic basophilic stippling can be seen in alcohol abuse, lead poisoning, thalassemias, and hereditary pyrimidine 5'-nucleotidase deficiency Differential Diagnosis Anemia of renal disease Iron deficiency anemia Aplastic anemia Treatment Treat underlying disease If underlying disease is unknown or treatment of underlying disease does not improve symptomatic anemia measure EPO if low, administer EPO or erythropoiesis-stimulating agents (ESAs) make sure iron stores are sufficient if insufficient, patients may be resistant to EPO if normal, give packed RBCs Complications Severe anemia