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  • 1. Anemia D/D Ortho R2 侯君翰 2002/12/23
  • 2. Criteria
    • Hb < 12 g/dL(Hct < 36%) in women
    • Hb < 14 g/dL (Hct < 41%) in men
  • 3. Clinical Manifestation
    • Vary depending on the disorder’s etiology, degree, and rapidity of onset,
    • Other underlying disorders
    • Hb <7: symptom of tissue hypoxia
      • Fatigue, headache, dyspnea, light-headness, angina
      • Pallor, visual impairment, syncope, and tachycardia => anemic hypovolemia
  • 4. History & PE
    • Acute vs. Chronic
    • Family Hx , Drug exposure, Blood loss
  • 5. Lab
    • Hb, Hct
    • % Reticulocyte count
      • absolute reticulocyte count
    • MCV –microcytic; normocytic; macrocytic
    • Peripheral blood smear
      • Anisocytosis, poikilocytosis
    • Additional testing:
      • G6PD, Hb electropheresis
  • 6. Decreased RBC production
    • Iron Deficiency anemia (IDA)
    • Thalassemia
    • Myelodysplastic syndrome (MDS)
    • Megaloblastic anemia
    • Anemia from chronic renal insufficiency
    • Anemia from chronic disease
    • Anemia associated with HIV infection
    • Aplastic anemia
  • 7. Increased RBC loss or destruction
    • Bleeding
    • Hemolytic anemia
      • Intravascular hemolysis
      • Extravascular hemolysis
    • Sickle cell disease
    • G6PD deficiency
    • Autoimmune hemolytic anemia (AIHA)
    • Drug-induced hemolytic anemia
    • Microangiopathic hemolytic anemia
  • 8. Decreased RBC production
  • 9. Iron-deficiency anemia (IDA)
    • History + PE
    • PB smear: hypochromic microcytic
    • Ferritin <10ng/ml in women or 20 ng/dl in men => low iron storage
      • acute-phase reactant
    • Fe <50 ug/dl
    • TIBC >420 ug/dl
    • BM biopsy: absent iron staining
  • 10. Thalassemia
    • Alpha-thalassemia
      • HbH, Hydops fetalis
    • Beta-thalassemia
      • Insoluble tetramer, more severe
      • Thalassemia minor (trait)
      • Thalassemia intermedia
      • Thalassemia major (Cooley’s anemia)
  • 11. Thalassemia 2
    • FH
    • Splenomegaly
    • Microcytic, hypo-chromic, poikilocytosis
    • Hb electrophoresis
  • 12. Myelodysplastic syndrome (MDS)
    • Acquired clonal disorder of hematopoietic stem cell
    • Idiopathic or secondary to C/T, R/T, toxin
    • MCV +/-
    • PB smear: marked anisocytosis and poikilocytosis
    • Diagnosis ! = Abnormal hematopoietic cell in BM
  • 13. Megaloblastic anemia
    • A group of disorders associated with altered morphology of hematopoietic cells and other rapidly dividing cells because of abnormalities in DNA synthesis.
    • Folic acid deficiency (months)
      • Alcoholism, malabsorption, increased use
    • Vit B12 deficiency (years)
      • Pernicious anemia, gastrectomy, pancreatic insufficiency, intestinal bacterial overgrowth, ileitis or ileal resection , intestine parasite
  • 14. Megaloblastic anemia 2
    • S/S: anemia
    • Neurologic (VitB12)
    • Macrocytic anemia (leukopenia+ thrombocytopenia)
    • PB smear: hypersegmented neutrophil
    • LDH, indirect Bil 
    • Serum VitB12, RBC folate
    • Serum methylmalonic acid and homocysteine (HC)
    • Schilling test (pernicious anemia)
    • BM biopsy
  • 15. Anemia from CRI
    • Decreased EPO production
    • Normocytic, Hct 20%-30%, normochromic
      • Echinocytes (burr cell); Acanthocyte (spur cell)
  • 16. Anemia from chronic dz
    • Long-standing inflammatory dz, malignancy, autoimmune disorders, and chronic infection.
    • Usually normocytic, normochromic
    • PB smear: normal
    • Ferritin: normal usually, but may elevated
    • No lab test.
  • 17. Anemia -HIV
    • BM: similar to MDS
    • Mycobacterium avium complex
    • Parvovirus B19
      • Transfusion-dependent anemia with low reticulocyte count
      • Ab. Not elevated
      • PCR
    • Zivovudine
  • 18. Aplastic anemia
    • Acuired abdnormality of BM stem cell.
    • Idiopathic (most cases)
    • 20% related to drug or chemical
    • 10% viral (EBV, hepatitis, CMV)
    • pancytopenia
  • 19. Increased RBC loss or destruction Increased erythropoiesis (elevated reticulocyte count)
  • 20. Bleeding elevated normal LDH elevated normal Bil Less common More common hemolysis bleeding
  • 21. Hemolytic anemia
    • Intravascular hemolysis
      • F/C, T/C, bachache
      • Serum haptoglobin  , urine hemosiderin (chronic),
    • Extravascular hemolysis
      • RBC destruction in RE system (spleen)
      • Splenomegaly, Jaundice
      • Direct Coomb’s test
  • 22. Sickle cell anemia
    • Structurally abnormal Hb molecule that polymerize under reduced oxygen conditions.
    • S/S: vary widely (Infant & child)
    • Hb 5-10 g/dl
    • Chronic neutrophilia 10K-20K
    • PB smear
  • 23. G6PD deficiency
    • Sex-linked
    • RBC susceptible to oxidant
    • Mild / severe / most severe
    • PB smear: bite cell / RBC inclusion (Heinz bodies)
    • Lab : G6PD level
  • 24. Autoimmune hemolytic anemia (AIHA)
    • Warm AIHA
      • IgG
      • Idiopathic; underlying malignancy, autoimmune dz or drugs
      • Haptoglobin  , LDH  , DAT for IgG(+)
    • Cold AIHA
      • Cold agglutinin dz
      • Paroxysmal cold hemoglobulinuria
  • 25. Drug-induced hemolytic anemia
    • Drug-induced autoantibodies
    • Haptens
    • Immune complex
  • 26. Microangiopathic hemolytic anemia
    • Traumatic intravascular hemolysis caused by deposition of fibrin strands in the lumen of small BV
    • DIC
    • TCP
    • HUS
    • PB smear: fragmented RBC, thrombocytopenia
  • 27. Thank you 感謝 4C1 同仁一個月來對我的幫忙、指導、教育與鞭策
  • 28. 柯公文哲的 「結論」
    • 治療為什麼沒效?因為診斷不對!
    • 開哪裡想哪裡
    • 養成習慣,看不懂就回去唸書,再不然叫 intern 回去唸書…
    • 增加知識沒有壞處
    • 我什麼苦日子沒待過…
    • 我是國考第一名 !!!