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Anemia

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  • 1. AnemiaAnemia D/DD/D Ortho R2Ortho R2 侯君翰侯君翰 2002/12/232002/12/23
  • 2. CriteriaCriteria  Hb < 12 g/dL(Hct < 36%) in womenHb < 12 g/dL(Hct < 36%) in women  Hb < 14 g/dL (Hct < 41%) in menHb < 14 g/dL (Hct < 41%) in men
  • 3. Clinical ManifestationClinical Manifestation  Vary depending on the disorder’s etiology,Vary depending on the disorder’s etiology, degree, and rapidity of onset,degree, and rapidity of onset,  Other underlying disordersOther underlying disorders  Hb <7: symptom of tissue hypoxiaHb <7: symptom of tissue hypoxia  Fatigue, headache, dyspnea, light-headness, anginaFatigue, headache, dyspnea, light-headness, angina  Pallor, visual impairment, syncope, andPallor, visual impairment, syncope, and tachycardia => anemic hypovolemiatachycardia => anemic hypovolemia
  • 4. History & PEHistory & PE  Acute vs. ChronicAcute vs. Chronic  Family Hx , Drug exposure, Blood lossFamily Hx , Drug exposure, Blood loss
  • 5. LabLab  Hb, HctHb, Hct  % Reticulocyte count% Reticulocyte count  absolute reticulocyte countabsolute reticulocyte count  MCV –microcytic; normocytic; macrocyticMCV –microcytic; normocytic; macrocytic  Peripheral blood smearPeripheral blood smear  Anisocytosis, poikilocytosisAnisocytosis, poikilocytosis  Additional testing:Additional testing:  G6PD, Hb electropheresisG6PD, Hb electropheresis
  • 6. Decreased RBC productionDecreased RBC production  Iron Deficiency anemia (IDA)Iron Deficiency anemia (IDA)  ThalassemiaThalassemia  Myelodysplastic syndrome (MDS)Myelodysplastic syndrome (MDS)  Megaloblastic anemiaMegaloblastic anemia  Anemia from chronic renal insufficiencyAnemia from chronic renal insufficiency  Anemia from chronic diseaseAnemia from chronic disease  Anemia associated with HIV infectionAnemia associated with HIV infection  Aplastic anemiaAplastic anemia
  • 7. Increased RBC loss or destructionIncreased RBC loss or destruction  BleedingBleeding  Hemolytic anemiaHemolytic anemia  Intravascular hemolysisIntravascular hemolysis  Extravascular hemolysisExtravascular hemolysis  Sickle cell diseaseSickle cell disease  G6PD deficiencyG6PD deficiency  Autoimmune hemolytic anemia (AIHA)Autoimmune hemolytic anemia (AIHA)  Drug-induced hemolytic anemiaDrug-induced hemolytic anemia  Microangiopathic hemolytic anemiaMicroangiopathic hemolytic anemia
  • 8. Decreased RBC productionDecreased RBC production
  • 9. Iron-deficiency anemia (IDA)Iron-deficiency anemia (IDA)  History + PEHistory + PE  PB smear: hypochromic microcyticPB smear: hypochromic microcytic  Ferritin <10ng/ml in women or 20 ng/dl inFerritin <10ng/ml in women or 20 ng/dl in men => low iron storagemen => low iron storage  acute-phase reactantacute-phase reactant  Fe <50 ug/dlFe <50 ug/dl  TIBC >420 ug/dlTIBC >420 ug/dl  BM biopsy: absent iron stainingBM biopsy: absent iron staining
  • 10. ThalassemiaThalassemia  Alpha-thalassemiaAlpha-thalassemia  HbH, Hydops fetalisHbH, Hydops fetalis  Beta-thalassemiaBeta-thalassemia  Insoluble tetramer, more severeInsoluble tetramer, more severe  Thalassemia minor (trait)Thalassemia minor (trait)  Thalassemia intermediaThalassemia intermedia  Thalassemia major (Cooley’s anemia)Thalassemia major (Cooley’s anemia)
  • 11. Thalassemia 2Thalassemia 2  FHFH  SplenomegalySplenomegaly  Microcytic, hypo-chromic, poikilocytosisMicrocytic, hypo-chromic, poikilocytosis  Hb electrophoresisHb electrophoresis
  • 12. Myelodysplastic syndromeMyelodysplastic syndrome (MDS)(MDS)  Acquired clonal disorder of hematopoieticAcquired clonal disorder of hematopoietic stem cellstem cell  Idiopathic or secondary to C/T, R/T, toxinIdiopathic or secondary to C/T, R/T, toxin  MCV +/-MCV +/-  PB smear: marked anisocytosis andPB smear: marked anisocytosis and poikilocytosispoikilocytosis  Diagnosis ! =Diagnosis ! = Abnormal hematopoietic cell inAbnormal hematopoietic cell in BMBM
  • 13. Megaloblastic anemiaMegaloblastic anemia  A group of disorders associated with alteredA group of disorders associated with altered morphology of hematopoietic cells and other rapidlymorphology of hematopoietic cells and other rapidly dividing cells because ofdividing cells because of abnormalities in DNAabnormalities in DNA synthesis.synthesis.  Folic acid deficiency (months)Folic acid deficiency (months)  Alcoholism, malabsorption, increased useAlcoholism, malabsorption, increased use  Vit B12 deficiency (years)Vit B12 deficiency (years)  Pernicious anemia, gastrectomy, pancreatic insufficiency,Pernicious anemia, gastrectomy, pancreatic insufficiency, intestinal bacterial overgrowth, ileitis or ileal resection ,intestinal bacterial overgrowth, ileitis or ileal resection , intestine parasiteintestine parasite
  • 14. Megaloblastic anemia 2Megaloblastic anemia 2  S/S: anemiaS/S: anemia  Neurologic (VitB12)Neurologic (VitB12)  Macrocytic anemia (leukopenia+ thrombocytopenia)Macrocytic anemia (leukopenia+ thrombocytopenia)  PB smear: hypersegmented neutrophilPB smear: hypersegmented neutrophil  LDH, indirect BilLDH, indirect Bil ↑↑  Serum VitB12, RBC folateSerum VitB12, RBC folate  Serum methylmalonic acid and homocysteine (HC)Serum methylmalonic acid and homocysteine (HC)  Schilling test (pernicious anemia)Schilling test (pernicious anemia)  BM biopsyBM biopsy
  • 15. Anemia from CRIAnemia from CRI  Decreased EPO productionDecreased EPO production  Normocytic, Hct 20%-30%, normochromicNormocytic, Hct 20%-30%, normochromic  Echinocytes (burr cell); Acanthocyte (spur cell)Echinocytes (burr cell); Acanthocyte (spur cell)
  • 16. Anemia from chronic dzAnemia from chronic dz  Long-standing inflammatory dz, malignancy,Long-standing inflammatory dz, malignancy, autoimmune disorders, and chronic infection.autoimmune disorders, and chronic infection.  Usually normocytic, normochromicUsually normocytic, normochromic  PB smear: normalPB smear: normal  Ferritin: normal usually, but may elevatedFerritin: normal usually, but may elevated  No lab test.No lab test.
  • 17. Anemia -HIVAnemia -HIV  BM: similar to MDSBM: similar to MDS  Mycobacterium avium complexMycobacterium avium complex  Parvovirus B19Parvovirus B19  Transfusion-dependent anemia with lowTransfusion-dependent anemia with low reticulocyte countreticulocyte count  Ab. Not elevatedAb. Not elevated  PCRPCR  ZivovudineZivovudine
  • 18. Aplastic anemiaAplastic anemia  Acuired abdnormality of BM stem cell.Acuired abdnormality of BM stem cell.  Idiopathic (most cases)Idiopathic (most cases)  20% related to drug or chemical20% related to drug or chemical  10% viral (EBV, hepatitis, CMV)10% viral (EBV, hepatitis, CMV)  pancytopeniapancytopenia
  • 19. Increased RBC loss orIncreased RBC loss or destructiondestruction Increased erythropoiesis (elevatedIncreased erythropoiesis (elevated reticulocyte count)reticulocyte count)
  • 20. BleedingBleeding bleedingbleeding hemolysishemolysis MoreMore commoncommon LessLess commoncommon BilBil normalnormal elevatedelevated LDHLDH normalnormal elevatedelevated
  • 21. Hemolytic anemiaHemolytic anemia  Intravascular hemolysisIntravascular hemolysis  F/C, T/C, bachacheF/C, T/C, bachache  Serum haptoglobinSerum haptoglobin↓↓, urine hemosiderin (chronic),, urine hemosiderin (chronic),  Extravascular hemolysisExtravascular hemolysis  RBC destruction in RE system (spleen)RBC destruction in RE system (spleen)  Splenomegaly, JaundiceSplenomegaly, Jaundice  Direct Coomb’s testDirect Coomb’s test
  • 22. Sickle cell anemiaSickle cell anemia  Structurally abnormal Hb molecule thatStructurally abnormal Hb molecule that polymerize under reduced oxygen conditions.polymerize under reduced oxygen conditions.  S/S: vary widely (Infant & child)S/S: vary widely (Infant & child)  Hb 5-10 g/dlHb 5-10 g/dl  Chronic neutrophilia 10K-20KChronic neutrophilia 10K-20K  PB smearPB smear
  • 23. G6PD deficiencyG6PD deficiency  Sex-linkedSex-linked  RBC susceptible to oxidantRBC susceptible to oxidant  Mild / severe / most severeMild / severe / most severe  PB smear:PB smear: bite cell / RBC inclusion (Heinz bodies)bite cell / RBC inclusion (Heinz bodies)  Lab : G6PD levelLab : G6PD level
  • 24. Autoimmune hemolytic anemiaAutoimmune hemolytic anemia (AIHA)(AIHA)  Warm AIHAWarm AIHA  IgGIgG  Idiopathic;Idiopathic; underlying malignancy, autoimmune dz or drugsunderlying malignancy, autoimmune dz or drugs  HaptoglobinHaptoglobin↓↓ , LDH, LDH↑↑, DAT for IgG(+), DAT for IgG(+)  Cold AIHACold AIHA  Cold agglutinin dzCold agglutinin dz  Paroxysmal cold hemoglobulinuriaParoxysmal cold hemoglobulinuria
  • 25. Drug-induced hemolytic anemiaDrug-induced hemolytic anemia  Drug-induced autoantibodiesDrug-induced autoantibodies  HaptensHaptens  Immune complexImmune complex
  • 26. Microangiopathic hemolytic anemiaMicroangiopathic hemolytic anemia  Traumatic intravascular hemolysis caused byTraumatic intravascular hemolysis caused by deposition of fibrin strands in the lumen ofdeposition of fibrin strands in the lumen of small BVsmall BV  DICDIC  TCPTCP  HUSHUS  PB smear: fragmented RBC,PB smear: fragmented RBC, thrombocytopeniathrombocytopenia
  • 27. Thank youThank you 感謝感謝 4C14C1 同仁一個月來對我的幫同仁一個月來對我的幫 忙、指導、教育與鞭策忙、指導、教育與鞭策
  • 28. 柯公文哲的柯公文哲的「結論」「結論」  治療為什麼沒效?因為診斷不治療為什麼沒效?因為診斷不 對!對!  開哪裡想哪裡開哪裡想哪裡  養成習慣,看不懂就回去唸書養成習慣,看不懂就回去唸書 ,再不然叫,再不然叫 internintern 回去唸書…回去唸書…  增加知識沒有壞處增加知識沒有壞處  我什麼苦日子沒待過…我什麼苦日子沒待過…  我是國考第一名我是國考第一名 !!!!!!

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