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Endgames Picture quiz

Anaemia in a 17 year old student

BMJ 2008; 337 doi: (Published 08 October 2008) Cite this as: BMJ 2008;337:a1845
  1. A-R Abu-Sitta, specialist registrar in haematology1,
  2. Harry R Dalton, consultant gastroenterologist and honorary senior lecturer23
  1. 1Department of Haematology, Royal Cornwall Hospital, Truro TR1 3LJ
  2. 2Cornwall Gastrointestinal Unit, Royal Cornwall Hospital
  3. 3Peninsula College of Medicine and Dentistry, Royal Cornwall Hospital
  1. Correspondence to: H R Dalton harry.dalton{at}

    A 17 year old non-vegetarian Asian female student presented with a three year history of increasing lethargy and shortness of breath during exercise. On examination she was clinically anaemic but had no other physical signs.

    Haematological investigations, including a blood film (fig 1), were performed. Her haemoglobin was 85 g/l (normal range 120-160 g/l), mean cell volume was 79 fl (80-96 fl), mean cell haemoglobin was 25 pg (27.3-32.6 pg), haematocrit was 29% (0.36%-0.44%), white blood cell count was 5.0×109/l (4-11×109/l), differential cell count was normal, and platelets were 550×109/l (150-400×109/l).

    Fig 1 The patient’s blood film


    • 1. What abnormalities can be seen in the blood film?

    • 2. What type of anaemia is it?

    • 3. What is the likeliest cause?


    Short answers

    • 1. The blood film showed microcytosis, hypochromia, and pencil cells (fig 2[f2]).

    Fig 2 The patient’s blood film showing microcytosis (red arrow), hypochromia (green arrow), and pencil cells (black arrow)

    • 2. Iron deficiency anaemia.

    • 3. Menstrual blood loss.

    Long answers

    1. Abnormalities

    The blood film (fig 2) showed microcytosis, hypochromia, and pencil cells. Microcytes (red arrow) have normal morphology but are smaller than normal red blood cells. By definition the volume of a microcyte does not exceed 80 fl (the lower limit of normal mean cell volume). When looking at a blood film, a normal sized red cell should be about the same …

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