A 67-year-old male presents with increasing fatigue and is found to be anemic. Physical examination reveals a hard 1-cm nodule in the left lobe of the prostate. The prostatic-specific antigen (PSA) level is found to be elevated. Examination of the peripheral blood reveals an occasional myelocyte. The erythrocytes are mainly normochromic and normocytic, and teardrop RBCs are not found. There are however, about two nucleated red blood cells per 100 white cells. What is the best diagnosis for this patient’s anemia?

**Core Concept**
The patient's presentation suggests anemia of chronic disease, characterized by normochromic and normocytic anemia, elevated nucleated red blood cells, and the presence of myelocytes in the peripheral blood. This type of anemia is often seen in patients with chronic infections, malignancies, or inflammatory conditions.

**Why the Correct Answer is Right**
The presence of elevated nucleated red blood cells (NRBCs) in the peripheral blood is a hallmark of anemia of chronic disease. This occurs due to the release of immature red blood cells into the circulation as a result of bone marrow stimulation. The patient's elevated PSA level and the physical examination finding of a hard nodule in the prostate suggest a possible diagnosis of prostate cancer, which can be a chronic disease leading to anemia of chronic disease. The occasional presence of myelocytes, which are immature granulocytes, also supports this diagnosis.

**Why Each Wrong Option is Incorrect**
**Option A:** This option is incorrect because anemia of chronic disease is not typically associated with teardrop-shaped red blood cells (dacryocytes), which are more characteristic of myelofibrosis or other bone marrow disorders.

**Option B:** This option is incorrect because anemia of chronic disease is not typically associated with a significant increase in reticulocytes, which are immature red blood cells. A reticulocytosis would be more characteristic of a regenerative anemia, such as seen in iron deficiency anemia.

**Option C:** This option is incorrect because anemia of chronic disease is not typically associated with a normocytic anemia with a significant decrease in hemoglobin. A normocytic anemia with a significant decrease in hemoglobin would be more characteristic of a dilutional anemia, such as seen in severe burns or multiple transfusions.

**Clinical Pearl / High-Yield Fact**
In patients with chronic diseases, such as cancer, the anemia is often normochromic and normocytic, and is characterized by the presence of elevated nucleated red blood cells in the peripheral blood. This type of anemia is often referred to as anemia of chronic disease.

**Correct Answer: D. Anemia of chronic disease.**

✓ Correct Answer: C. Myelophthisic anemia