A 4-year-old child living near a battery recycling unit has Hb 8 g/dL, MCV 70 fL, abdominal colic, and coarse blue-staining granules in red cells on Leishman stain. Which finding on iron studies would be expected?

• A High free erythrocyte protoporphyrin with normal serum iron ✓
• B Low serum iron and low ferritin
• C Normal serum iron with high TIBC
• D High serum iron and high ferritin with ring sideroblasts

Explanation

Lead inhibits ferrochelatase, so iron cannot be inserted into protoporphyrin IX. Free erythrocyte protoporphyrin rises while serum iron remains available, giving a sideroblastic picture with basophilic stippling (ribosomal RNA aggregation). Option D describes hereditary or acquired sideroblastic anemia with iron overload, option B is iron deficiency, and option C fits anemia of chronic disease. The stippled cells plus elevated FEP point specifically to impaired heme insertion of iron.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

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