Anemia in the elderly: not always what it seems.
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Abstract
Anemia in the elderly is a common but challenging clinical scenario. Here we the described the case of an elderly women who presented with anemia and elevated inflammation markers. After a complete diagnostic workup a clear etiology of the anemia could not be found and eventually a bone marrow biopsy was performed: she was diagnosed with myelodysplastic syndrome. She responded well to erythropoietin treatment but her inflammation markers remained elevated and a positron emission tomography was eventually performed. It turned out that the patient suffered from giant cell artheritis, and after steroid treatment her anemia completely resolved. Our case outlines that it is necessary to pay particular attention to anemia of chronic inflammation, which could be due to several and often masked conditions. Myelodysplatic syndromes should be considered when other causes have been ruled out, but their diagnosis can be difficult and requires expertise in the field.
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References
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Invernizzi R, Quaglia F and Della Porta MG. Importance of classical morphology in the diagnosis of myelodysplastic syndrome. Mediterr J Hematol Infect Dis 2015; 7(1): e2015035. http://dx.doi.org/10.4084/mjhid.2015.035
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Steurer M, Fritsche G, Tzankov A, Gotwald T, Sturm W, Konwalinka G and Gruber J. Large-vessel arteritis and myelodysplastic syndrome: report of two cases. Eur J Haematol. 2004; 73: 128–133. http://dx.doi.org/10.1111/j.1600-0609.2004.00265.x
Oostvogels R, Petersen EJ, Chauffaille ML and Abrahams AC. Systemic vasculitis in myelodysplastic syndromes. Neth J Med. 2012; 70(2):63-8. http://www.njmonline.nl/getpdf.php?id=1148
Frietsch JJ, Dornaus S, Neumann T, Scholl S, Schmidt V and Kunert C. Paraneoplastic inflammation in myelodysplastic syndrome or bone marrow failure: case series with focus on 5-azacytidine and literature review. Eur J Haematol. 2014; 93(3):247-59. http://dx.doi.org/10.1111/ejh.12311
Bach V, Schruckmayer G, Sam I, Kemmler G and Stauder R. Prevalence and possible causes of anemia in the elderly: a cross-sectional analysis of a large European university hospital cohort. Clin Interv Aging. 2014; 9:1187-96. http://dx.doi.org/10.2147/CIA.S61125
Goodnough LT and Schrier SL. Evaluation and management of anemia in the elderly. Am J Hematol. 2014; 89:88–96 http://dx.doi.org/10.1002/ajh.23598
Weiss G and Goodnough LT. Anemia of chronic disease. N Engl J Med. 2005; 352:1011-23. http://dx.doi.org/10.1056/NEJMra041809
Cilloni D, Gottardi E and Saglio G. WT1 overexpression in acute myeloid leukemia and myelodysplastic syndromes. Methods Mol Med. 2006; 125:199-211. http://dx.doi.org/10.1385/1-59745-017-0%3A199
Cheson BD, Greenberg PL, Bennett JM, Lowenberg B, Wijermans PW, Nimer SD, et al. Clinical application and proposal for modification of the International Working Group (IWG) response criteria in myelodysplasia. Blood. 2006; 108:419-425. http://dx.doi.org/10.1182/blood-2005-10-4149
Tefferi A and Vardiman J. Myelodysplastic Syndromes. N Engl J Med. 2009; 361:1872-85. http://dx.doi.org/10.1056/nejmra0902908
Pellagatti A and Boultwood J. Recent Advances in the 5q- Syndrome. Mediterr J Hematol Infect Dis. 2015; 7(1): e2015037. http://dx.doi.org/10.4084/mjhid.2015.037
Patnaik MM and Tefferi A. Refractory anemia with ring sideroblasts and RARS with thrombocytosis. Am J Hematol. 2015; 90:550–559. http://dx.doi.org/10.1002/ajh.24038
Steensma DP, Gibbons RJ and Higgs DR. Acquired ?-thalassemia in association with myelodysplastic syndrome and other hematologic malignancies. Blood. 2005; 105(2):443–452. http://dx.doi.org/10.1182/blood-2004-07-2792
Garcia-Manero G. Myelodysplastic syndromes: 2014 update on diagnosis, risk-stratification, and management. Am J Hematol. 2014; 89:98–108. http://dx.doi.org/10.1002/ajh.23642
Invernizzi R, Quaglia F and Della Porta MG. Importance of classical morphology in the diagnosis of myelodysplastic syndrome. Mediterr J Hematol Infect Dis 2015; 7(1): e2015035. http://dx.doi.org/10.4084/mjhid.2015.035
Vardiman JW, Thiele J, Arber DA, Brunning RD, Borowitz MJ, Porwit A, et al. The 2008 revision of the World Health Organization (WHO) classi?cation of myeloid neoplasms and acute leukemia: rationale and important changes. Blood. 2009; 114:937-951. http://dx.doi.org/10.1182/blood-2009-03-209262
Della Porta MG, Picone C, Pascutto C, Malcovati L, Tamura H, Handa H, et al. Multicenter validation of a reproducible flow cytometric score for the diagnosis of low-grade myelodysplastic syndromes: results of a European LeukemiaNET study. Haematologica. . 2012; 97(8):1209-17. http://dx.doi.org/10.3324/haematol.2011.048421
Naqvi K, Jabbour E, Bueso-Ramos C, Pierce S, Borthakur G, Estrov Z, et al. 2011. Implications of discrepancy in morphologic diagnosis of myelodysplastic syndrome between referral and tertiary care centers. Blood 118(17):4690-4693. http://dx.doi.org/10.1182/blood-2011-03-342642.
DeLima M, Albitar M, O’B.rien S, Pierce S, Kantarjian H, Andreeff M, et al. Comparison of Referring and Tertiary Cancer Center Physicians’ Diagnoses in Patients with Leukemia. Am J Med. 1998.; 104: 246–251. http://dx.doi.org/10.1016/S0002-9343(98)00032-1
Cheung PP and Richards G. Masked giant cell arteritis. Aust Fam Physician. 2006; 35(11):893-5. http://www.racgp.org.au/afpbackissues/2006/200611/20061103cheung.pdf
Steurer M, Fritsche G, Tzankov A, Gotwald T, Sturm W, Konwalinka G and Gruber J. Large-vessel arteritis and myelodysplastic syndrome: report of two cases. Eur J Haematol. 2004; 73: 128–133. http://dx.doi.org/10.1111/j.1600-0609.2004.00265.x
Oostvogels R, Petersen EJ, Chauffaille ML and Abrahams AC. Systemic vasculitis in myelodysplastic syndromes. Neth J Med. 2012; 70(2):63-8. http://www.njmonline.nl/getpdf.php?id=1148
Frietsch JJ, Dornaus S, Neumann T, Scholl S, Schmidt V and Kunert C. Paraneoplastic inflammation in myelodysplastic syndrome or bone marrow failure: case series with focus on 5-azacytidine and literature review. Eur J Haematol. 2014; 93(3):247-59. http://dx.doi.org/10.1111/ejh.12311