This is about high ferritin and low hemoglobin and/or hematocrit. This patient had a history of severe Crohn’s, which is now in remission. Had been on sublingual methylcobalamin awhile. His ferritin is 149, but then all the iron markers were low, MCV is a bit high, and then MCH, MCHC, and RDW were all normal.

This is a pattern that is referred to as anemia of chronic illness or anemia of chronic disease. What’s happening is that the patient has high ferritin because ferritin is an acute-phase reactant. There are two things that can raise ferritin. I mean, there’s more than two, but one is excess iron storage, and two is that it’s an acute-phase reactant. Just like C-reactive protein, they can be elevated in inflammatory response. When you see high ferritin, you have to look at other iron markers to see what’s going on. That’s why I always do a full iron panel with all the patients and look at the red blood cell indices. What can happen is that in a situation where the patient has some kind of inflammatory process, you’ll see high ferritin, and in that case, it’s not really a sign of excess iron, iron overload, iron supplementation, or something like that. It’s actually a sign of the inflammatory process. In that case, it’s a different situation if all iron markers are high or all the iron markers are low.

Now, originally it was thought to be associated primarily with infectious inflammatory or neoplastic diseases, but now research has shown that it can be found in a whole bunch of different conditions, like kidney disease, diabetes, any condition with chronic immunoactivation, autoimmunity like Crohn’s, inflammatory bowel disease, and it’s typically, not always, normochromic, normocytic, and mild in degree. But in this case, you see the levels of hemoglobin and RBC are actually a little bit low. The first thing I would do here would be to retest. In many cases, actually, you’ll see it normalize. If it doesn’t normalize, then the main thing would be often to actually treat the inflammatory conditions, and maybe that even though this patient’s Crohn’s was seemingly in remission, there’s still some significant inflammation going on there that needs to be addressed.

I don’t think that giving iron in this situation is necessarily the best thing to do. One of the markers that you can order to clarify, though, which I talked about in the content, is the soluble transferrin receptor. This is a marker that is not affected by inflammation as ferritin is, and it’s an inverse marker, so if it’s high, it means iron stores are low, and if it’s low, it means iron stores are high. I would run insoluble transferrin receptor to see what’s actually happening here, and if the anemia that you’re seeing here is a sign of iron deficiency truly or if it’s more of this anemia chronic disease and inflammation. I’m pretty sure we talk about anemia of chronic disease and inflammation in the course itself.