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:

 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:

A microscopic view of numerous cells, some round and pale, others larger with blue-stained cytoplasm and internal structures, on a light background.
Image reproduced from Wikimedia Commons

Which of the following processes is most likely impaired in this patient?

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