Chronic Abdominal Pain and Anemia in a 59-Year-Old Man

A 59-year-old elementary school principal with a history of cholecystectomy and appendectomy and no use of alcohol, illicit drugs, or cigarettes presented to the emergency department for the fourth time in 3 months with diffuse abdominal pain not associated with nausea, vomiting, diarrhea, constipation, hematochezia, weight loss, fever, or anorexia. On physical examination, the patient had normal vital signs, mild diffuse abdominal tenderness without rebound or guarding, and bluish pigmentation along his gingival margin (Figure, panel A). Blood testing showed alanine aminotransferase level 51 U/L (0.85 μkat/L; reference range, 7-23 U/L [0.12-0.38 μkat/L]), aspartate aminotransaminase 68 U/L (1.14 μkat/L; reference range, 13-30 U/L [0.22-0.50 μkat/L]), total bilirubin 3.2 mg/dL (54.73 μmol/L; reference range, 0.4-1.5 mg/dL [6.84-25.66 μmol/L]) and direct bilirubin 0.9 mg/dL (15.39 μmol/L; reference range, 0.0-0.4 mg/dL [0.0-6.84 μmol/L]). Hemoglobin level was 8.7 g/dL with a normal mean corpuscular volume, and ferritin level was 637.9 ng/mL (reference range, 39.9-465 ng/mL). Blood testing revealed normal lactate dehydrogenase, haptoglobin, iron, vitamin B₁₂, folate, zinc, and copper levels, and results of urinalysis were normal. A peripheral blood smear demonstrated small, bluish-purple punctate inclusions in erythrocytes (Figure, panel B). Results of upper and lower endoscopy and abdominal-pelvic computed tomography performed within the past 3 months were unremarkable.