Microcytosis in a 43-Year-Old Man

Clinical History Patient: A 43-year-old African-American male. Chief Complaint: The patient sustained left upper arm pain after falling on his left elbow while moving furniture. He self-medicated with Tylenol, but pain increased in severity and was exacerbated by movement. Medical History: Significant for diabetes mellitus for the past 10-15 years and has been on oral hypoglycemic agents up to the time of the injury. He also had a history of facial cellulitis in 2005, a snake bite in 2001, and occasional acid reflux. There was no history of jaundice, pain crisis, or blood transfusions. Social History: The patient did not smoke or drink alcoholic beverages. He is a mechanic. Family History: Not available. Physical Examination: Was significant for the following: obese, alert, oriented to time, place, and person; heart: tachycardia without murmurs, gallops or rubs; lung and abdomen: unremarkable; extremity: erythematous, indurated, painful left upper extremity. Vital Signs: blood pressure: 134/82; pulse: 112/minute; respiratory rate: 20/minute; temperature: 101.3 degrees F; pulse oximetry: 97%. Principal Laboratory Findings: Upon admission, laboratory tests were performed. Results are in Table 1. Additional Testing: The patient's peripheral blood smear showed hypochromia, microcytosis, and a few target cells. No sickle were identified. Because of the abnormal hemoglobin A1C result, high-performance liquid chromatography (HPLC) and hemoglobin electrophoresis were ordered (Figure 1 HPLC, Figure 2 alkaline electrophoresis, and Figure 3 acid electrophoresis). Serum iron performed after admission was 11(31-144 ug/dL), bilirubin was 0.6 (0.2-1.2 mg/dL), and glycohemoglobin was 19.8 (<9%). A CT scan of the left upper extremity showed extensive fluid collection. He underwent exploration and debridement of the left upper arm and received intravenous antibiotics and insulin. Swelling gradually subsided, and he was discharged after 2 weeks of hospitalization.