A 28-year-old woman presents with fatigue and pagophagia. CBC shows hemoglobin 8.2 g/dL, MCV 68 fL, RDW increased. Ferritin is 4 ng/mL and total iron binding capacity is elevated. Peripheral smear shows microcytic hypochromic cells with pencil cells. Which additional finding would be most consistent with her underlying disorder?

• A Hypersegmented neutrophils
• B Koilonychia and angular cheilitis ✓
• C Basophilic stippling of erythrocytes
• D Venous thrombosis

Explanation

Severe iron deficiency produces epithelial changes including koilonychia (spoon nails) and angular cheilitis, along with glossitis and dysphagia from esophageal webs (Plummer Vinson syndrome). Hypersegmented neutrophils indicate megaloblastic anemia, basophilic stippling suggests lead poisoning or thalassemia, and venous thrombosis is linked to hemolysis in PNH, not to depleted iron stores. The low ferritin with raised TIBC already confirms the diagnosis.

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

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Written and medically reviewed by the StethoPrep medical team.