Heme synthesis disorders Quiz: Ace Your Exams
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A 40-year-old man comes to the office because of fever, cough, and night sweats. The patient has felt fatigued over the past six-months and has experienced a 15 lb (6.8 kg) weight loss. Past medical history is significant for hypertension and hyperlipidemia. Temperature is 37.7°C (99.9°F), pulse is 78/min, respirations are 17/min, and blood pressure is 142/88 mmHg. A chest radiograph shows a cavitary lesion in the left upper lobe and an interferon-gamma release assay is positive. The patient is started on appropriate antimicrobial therapy. Three months later, he is seen in the office for follow-up. Laboratory testing reveals the following results:
A peripheral blood smear shows Pappenheimer bodies. Bone marrow aspirate is subsequently obtained and demonstrates the following:

Image reproduced from Wikimedia Commons
Which of the following processes is most likely impaired in this patient?
| Laboratory Value | Result (U.S. Conventional Units) | Results (S.I. Units) |
| Hemoglobin | 9.2 g/dL | 5.71 mmol/L |
| Leukocyte count | 11,000/mm3 | 11.0*109/L |
| Platelet count | 230,000/mm3 | 230*109/L |
| Mean corpuscular volume | 75 μm3 | 75 fL |
A peripheral blood smear shows Pappenheimer bodies. Bone marrow aspirate is subsequently obtained and demonstrates the following:

Image reproduced from Wikimedia Commons
Which of the following processes is most likely impaired in this patient?
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