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A 61-year-old man is evaluated for fatigue and diminished exercise tolerance of 2 months' duration. His medical history includes hypercholesterolemia for which he takes pravastatin. He also smoked cigarettes for 30 years before quitting 5 years ago.

On physical examination, pulse rate is 90/min, and blood pressure is 140/80 mm Hg. There is no abdominal tenderness, splenomegaly, or lymphadenopathy. Laboratory studies indicate a hemoglobin of 8.6 g/dL (86 g/L), leukocyte count of 4200/μL (4.2 x 109/L), mean corpuscular volume of 96 fL, platelet count of 157,000/μL (157 × 109/L), and reticulocyte count of 0.5% of erythrocytes. The peripheral blood smear shows dysplastic neutrophils. On bone marrow aspirate smear, dysplastic changes in myeloid and erythroid precursors are noted, with no increase in myeloblasts and no karyotypic abnormalities.

He receives a transfusion consisting of two units of packed red blood cells with improvement in his symptoms; however, he returns 3 weeks later with the return of his symptoms and a hemoglobin of 8.2 g/dL (82 g/L).

Which of the following is the most appropriate treatment in addition to red blood cell transfusions in this patient?

A. Imatinib mesylate
B Testosterone patch
C Prednisone
D Erythropoietin
E Oral iron supplementation

D Erythropoietin

This is myelodysplasia

AAAA

Imatinab... this could be CML

Ans is D

This patient has transfusion-dependent myelodysplastic syndrome. He has a relatively well-preserved leukocyte and platelet count but a defect in erythrocyte synthesis. Subcutaneous erythropoietin therapy has been shown to improve anemia and reduce transfusion requirements in some patients with this condition.

Imatinib mesylate has been shown to be effective only in patients with a bcr-abl chromosomal translocation typically found in chronic myeloid leukemia and in some cases of acute lymphoblastic leukemia. In general, androgen replacement therapy has not been shown to be effective in treating this disease, with minor improvement in anemia occurring only rarely; therefore, a testosterone patch is not indicated in this patient. Prednisone therapy has occasionally resulted in improvement in anemia but with low response rates and an increased risk for infections. Most patients with myelodysplastic syndrome have adequate or high levels of iron stores. Furthermore, because transfusion support typically results in iron overload in patients with myelodysplasia, supplemental iron in these patients should be strictly avoided.