Iron Deficiency Anemia. B12 & Folat Deficiency Anemia

1. Iron-Deficiency Anemia.
В12- and Folat- Deficiency
Anemia.

2. Sponsored
Medical Lecture Notes – All Subjects
USMLE Exam (America) – Practice

3. Definition
Аnemia is a condition where red blood cells
are not providing adequate oxygen to body
tissues.
Anemias are reveled by Decreases in
numbers of RBCs or Hb content.

5. Ethiology of anaemias
blood loss deficient
erythropoiesis
excessive
hemolysis
excessive
hemolysis
blood loss

6. General symptoms of anaemia:
complaints
• tiredness,
• breathlessness,
• palpitations (rapid or irregular heart beats),
• dizziness, and
• headache,
• spots before the eyes,
• irritability, and even bizarre behavior,
• amenorrhea, loss of libido,
• loss of appetite,
• constipation, varyating pain in abdomen,
• dyspnoe,
• edema in the legs.

7. General symptoms of anaemia:
physical examinations.
• weight loss,
• pailness of skin,
• increase of breathing rate,
• tachicardia,
• heart systolic murmure,
• weakness of 1-st heart sound
• edema in the legs,
• tenderness on colone palpation,
• sometimes liver and spleen enlargment.

8. Laboratory Tests
• RBC counts: normal range is 5.4 ± 0.8
million/µL for men and 4.8 ± 0.6 million/µL
for women.
• Hb: normal Hb is 160 ± 20 g/L for men and
140 ± 20 g/L for women.
• Hct (ratio of blood cell volume and
plasma volume): normal Hct is 47 ±
5% for men and 42 ± 5% for women.

9. Laboratory Tests
The diagnostic criterion for anemia
in men are:
RBC < 4.5 million/µL, Hb < 14 g/dL,
Hct < 42%;
for women are:
RBC < 4 million/µL, Hb < 12 g/dL,
Hct < 37%.

10. Reticulocyte count
• Norma - 0.5 to 1.5%
of the total RBC count
• Types of anaemia:
Hyperregenerative - > 1,5%,
Normoregenerative -
- 0,5 -1,5%
Hyporegenerative - < 0,5%

11. RBC indices
• mean corpuscular volume (MCV)
norma 80-95 fL
• mean corpuscular Hb (MCH)
norma 28-33 pg/cell
• mean corpuscular Hb concentration (MCHC)
norma 320-360 g/l
• calour index CI = Hb (g/l) / RBC count (first
three figures)
norma of CI – 0,85 – 1,05

12. microcytic anaemia
• MCV < 80 fL

13. macrocytic anaemia
• MCV > 95 fL

14. hypochromia
• MCH < 27 pg/RBC
or
• MCHC < 320 g/l
or
CI < 0,8

15. hyperchromia
• MCH > 33 pg/RBC
or
• MCHC > 360 g/l
or
• CI > 1,05

16. Bone marrow aspiration and
biopsy
• Normal
bone
marrow

17. Bone marrow aspiration and
biopsy
• Aplasia
of bone
marrow

18. Iron-Deficiency Anemia
• Iron deficiency anemia is the most common
form of anaemia. Approximately 20% of
women, 50% of pregnant women, and 3%
of men are iron deficient.

19. Ethiology of Iron-Deficiency Anemia
loss of blood
little iron in
the diet
poor
absorption of
iron

20. Factors contributing to Iron-Deficiency Anemia
• increased loss through menstruation in women
• Pregnancy and lactation
• Fibromioma of uterus
• Aspirine and NSAID usage
• Peptic ulcer disease
• Inflamatory bowel disease
• Colon cancer
• Intestinal removal

21. Pathophysiology of Iron-Deficiency Anemia
Stage 1: Fe loss exceeds intake, causing
progressive depletion of storage Fe).
Although Hb and serum Fe remain normal,
serum ferritin concentration falls (< 20
ng/mL). As storage Fe decreases, there is a
compensatory increase in absorption of
dietary Fe and in the concentration of
transferrin (represented by a rise in Fe-
binding capacity).

22. Pathophysiology of Iron-Deficiency Anemia
Stage 2: Exhausted Fe stores cannot meet the needs
of the erythroid marrow. While the plasma-
transferrin level increases, the serum Fe
concentration declines, leading to a progressive
decrease in Fe available for erythropoiesis. When
serum Fe falls to < 50 µg/dL (< 9 µmol/L) and
transferrin saturation to < 16%, erythropoiesis is
impaired. The serum ferritin receptor
concentration rises (> 8.5 mg/L).

23. Pathophysiology of Iron-Deficiency Anemia
Stage 3: Anemia with normal-appearing
RBCs and indices occurs.
Stage 4: Microcytosis and then hypochromia
are present.
Stage 5: Fe deficiency affects tissues,
resulting in symptoms and signs.

24. Symptoms and Signs of Ferrum deficiency
• sore tongue (glossitis),
• pinful cracks at the corners of the mouth
(cheilosis),
• brittle, flaking nails,
• spoon-shaped nails,
• unusual dietary cravings (pica),
• difficulty in swallowing (dysphagia),
• pallor (pale skin), and
• loss of weight.
• Muscular weakness
• Disuria coused by detrusor insifficiency

25. Laboratory findings
• Iron deficiency
anaemia is microcytic
(decrease of MCV),
hypochromic
(decrease of MCH and
MCHC) and in
prominent stages
hyporegenerative
(decrease of
reticulocytes count)

26. Laboratory findings
• Absent marrow stores of Fe
• Low serum ferritin concentration (< 12
ng/mL)
• Decrease of transferrine saturation
(< 20% )
• Low serum iron level (< 9 mmol/l)

27. Additional examination needed
for evaluation of primary reason
of Iron Deficiency Anaemia
• gynecologists examination,
• upper endoscopy,
• rectoscopy and colonoscopy,
• chest X-ray,
• abdominal and kidney ultrasound

28. TREATMENT
of Iron Deficiency Anaemia
• Red Cell Transfusion
• Oral Iron Therapy
• Parenteral Iron Therapy

29. Red Cell Transfusion
Indications:
• Hb level < 50 g/l
• cardiovascular instability
• continued and excessive blood loss from
whatever source

30. Oral Iron Therapy
• Iron sulfate (fumarat, lactat) + citric acid,
mucoproteases, ascorbinic acid
Actiferrine Feroplex Tardiferron
Ferronat Globiron Fenotec

31. Parenteral Iron Therapy
Ganzoni formula:
• Iron requirment = body weight (kg) × 2.3
×(150 − patient's hemoglobin, g/L) + 500 or
1000 mg (for stores).
• Venofer
• Ferrlecit

32. Anemia Caused by Vitamin B12
Deficiency

33. Specific symptoms of Vitamin B12
-
Deficiency Anaemia
• Splenomegaly and hepatomegaly
• Various GI manifestations including anorexia, intermittent
constipation and diarrhea, and poorly localized abdominal
pain.
• Glossitis
• Considerable weight loss
• Neurologic symptomps: peripheral loss of position and
vibratory sensation in the extremities, weakness and reflex
loss, spasticity, Babinski's responses, more severe loss of
proprioceptive and vibratory sensation in the lower
extremities, and ataxia. Paranoia (megaloblastic madness),
delirium, confusion, spastic ataxia, and at times postural
hypotension

34. Diagnosis and Laboratory Findings
• Macrocytosis (MCV > 100
fL).
• Macro-ovalocytosis,
anisocytosis, and
poikilocytosis.
• Howell-Jolly bodies
(residual fragments of the
nucleus).
• Reticulocytopenia is present
• Hypersegmentation of the
granulocytes
• Bone marrow -erythroid
hyperplasia and
megaloblastic changes

35. Diagnosis and Laboratory Findings
• Decrease of serum vitamin B12
(<150 pg/mL)
• Elevation of serum indirect bilirubin
• Elevation of LDH
• Serum ferritin is usually increased (> 300 ng/mL),
• Autoantibodies to gastric parietal cells can be
identified in 80 to 90% of patients with pernicious
anemia
• Presence of antibodies to intrinsic factor,
• Achlorhydria (pH > 6.5 )
• Absent secretion of intrinsic factor

36. Treatment
• Vitamin B12
(Cyanocobalamin) 1000 mg IM
2 to 4 times/wk is given until hematologic
abnormalities are corrected, and then it is
given once monthly.
• Giving folic acid (instead of B12) to any
patient who is B12-deprived is
contraindicated because it may result in
fulminant neurologic deficit.

37. Folat deficiency anaemia.
Risk factors.
• Prolonged cooking
• Alcohol intake
• Marginal diet (eg, "tea-and-toasters," chronic
alcoholics)
• Pregnancy and lactation
• Intestinal malabsorption
• Long-term treatment of some medications
(anticonvulsants, oral contraceptives,
methotrexate, trimethoprim-sulfamethoxazole)
• Chronic (especially congenital) hemolytic anemias
• Psoriasis
• Long-term dialysis.

38. Diagnosis and Laboratory Findings
• The anaemia caused by Folate deficiency is
similar to B12 –deficiency anaemia on
hematologic and clinical features but
nuerologic changes do not occur.
• Folate deficiency anaemia is also
megaloblastic
• Serum folic acid levels < 4 ng/mL (< 9
nmol/L) suggest a deficiency

39. Treatment
• Folic acid 1 mg/day is necessary for treatment
Folate deficiency anaemia. The normal
requirement is about 50 µg/day of folate, with 2 to
3 times more in pregnancy and childhood.
• Caution: In megaloblastic anemia, it is important
to rule out vitamin B12 deficiency before treating
with folic acid, which would alleviate the anemia
but permit neurologic damage to progress. )