Refractory anemia with ring sideroblasts masked by iron deficiency anemia.

A 84-year-old woman with a long-standing history of progressive exertional dyspnea and fatigue was assessed for concomitant anemia. She also had coronary artery disease, chronic obstructive pulmonary disease, hypertension, and gout. Her hemoglobin was 109 g/L with a mean corpuscular volume of 76.1 fL and red blood cell distribution width (RDW) at 19.4%. White cell count including differential and platelets were within normal limits. Hypochromia and microcytosis were noted on the peripheral smear as well as an occasional hypogranular granulocyte. The serum ferritin was 18 ng/L. A bone marrow examination showed no iron and mild erythroid dysplasia (left). An extensive work-up for blood loss was negative.