Anemia of Unknown Origin in an 80-Year-Old Woman

Kathy D. Miller, MD; Jill Kremer, MD


July 30, 2015


The differential diagnosis is broad in an older patient with anemia. Important considerations can be grouped into several broad categories, including the following:

  • Blood loss (acute or chronic)

  • Increased red cell destruction (hemolysis)

  • Decreased or defective red cell production (chronic disease, renal dysfunction, myelodysplastic syndrome, malignancy)

Figure 1.

Figure 2.

Figure 3.

In this patient with a prior malignancy and chemotherapy exposure, disease recurrence or treatment-related myelodysplastic syndrome or frank leukemia is a concern. The diagnosis of myelophthisic anemia was initially suspected on the basis of the peripheral smear (Figures 1-3) with tear-drop cells, nucleated red blood cells, and occasional immature myeloid cells. A bone marrow examination was performed which uncovered the underlying etiology of the myelophthisic anemia: a hypocellular specimen with marked decrease in trilineage hematopoiesis and fibrosis, as well as areas of metastatic cancer. Additional testing confirmed that the cancer cells were strongly estrogen– and progesterone receptor–positive, similar to her initial breast cancer. A bone scan found asymmetric distribution of bony lesions, further supporting metastatic disease.

Myelophthisic anemia is a common manifestation of the myeloproliferative disorders, especially myelofibrosis.[1] Although myelophthisic anemia can be a feature of hematologic malignancies, it is more common in patients with metastatic involvement from a solid tumor, particularly gastric and prostate cancer.[2] Further evaluation and treatment are based on the underlying disease rather than the myelophthisic process itself.

In this case, further evaluation was aimed at determining the extent of her metastatic disease, with CT scans of the chest and abdomen. Significant findings included verification of the bone lesions, thyroid heterogeneity, and multiple indeterminate liver lesions (all less than 2 cm). Her total bilirubin, aspartate, and alanine transaminases levels were normal as was the alkaline phosphatase. Her serum albumin was 4.1 g/dL.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.