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Q. We are not sure about my friend's diagnosis. Kindly help.

Answered by
Dr. Sadaf Mustafa
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Sep 20, 2016 and last reviewed on: Aug 24, 2020

Hi doctor,

I am a general practitioner. I would like to consult with you regarding my friend, who has a normochromic normocytic anemia. His hemoglobin is currently 7.5. His diagnosis is not clear. I have all his laboratory data and bone marrow biopsy as well as aspiration if you want. He used to take corticosteroid with moderate response, but he developed diabetes and that required Insulin to be controlled. I have attached his current medication list for your reference. I would be grateful if you could help me. Thank you for your attention in advance.

Dr. Sadaf Mustafa

General Medicine Internal Medicine


Welcome to

  • One thing for sure is that he is having periodic hemolysis with adequate bone marrow response and he has a severe vitamin B12 deficiency.
  • His corrected RPI (reticulocyte production index) is 2.7%, which means that his bone marrow is responding to the anemia appropriately. 
  • The broad differential here would be medication induced, hypothyroidism, vitamin B12, folate deficiency, lead poisoning, alcoholism and hemolysis due to SSD (sickle cell disease) or liver disease since he has transaminitis and elevated bilirubin.
  • Elevated LDH (lactate dehydrogenase), elevated reticulocyte count and low haptoglobin are indicators of hemolysis.
  • He has splenomegaly as well, which again favors either a chronic liver disease or most likely hemolysis. However, the only tricky portion is his low WBC (white blood count).
  • I do not think that it is a bone marrow process. It is more like peripheral destruction or nutritional deficiency.
  • I do see that the vitamin B12 is very low at 209 and he has a normal G6PD level (glucose-6-phosphate dehydrogenase). I also reviewed that his BM was normal and his electrophoresis does not comment upon the sickle cell S or C disease.
  • Please mention whether he had any additional testing or work up for hemolytic anemia. I would like to know if he had a TSH done.
  • Why is he taking medications (all of them) including Prednisolone, Azathioprine, Rituximab and Mycophenolate? Why is he not taking the Vitamin B12 and Vitamin D? These medications are toxic to BM and should not be used without a concrete diagnosis.

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