anaemia summary and cases

1. ANAEMIA

2. Anaemia - definition
 A state where the blood haemoglobin
concentration is below that expected
taking into account age and sex.
 Adult male: <13 g/dl
 Adult female: <12g/dl

3. Copyright ©2006 American Society of Hematology. Copyright restrictions may apply.
Beutler, E. et al. Blood 2006;107:1747-1750
Figure 1. A reproduction of the page of the WHO report that has been used as a standard for
anemia in epidemiologic studies

4. Proposed lower limits of normal for hemoglobin
concentration of the blood for white and black adults
Group Hemoglobin, g/dL
White men, y
20-59 13.7
60 + 13.2
White women, y
20-49 12.2
50 + 12.2
Black men, y
20-59 12.9
60 + 12.7
Black women, y
20-49 11.5
50 + 11.5
Based on Scripps-Kaiser data for the 5th percentiles given in Table 2. NHANES
data are considered to be confirmatory.
Blood 2006. 107; 1747-1750

5. Clinical features
– reduced oxygen delivery
 Symptoms
Tiredness, lethargy,
dyspnoea on
exertion,
dizziness,
palpitations,
audible pulse in ears,
angina.
 Signs
Pallor,
tachycardia,
Bounding pulse,
flow murmur,
signs of heart failure
(in severe cases)

6. Clinical features depend on:
 Level of haemoglobin
 The degree of change in the blood volume
 The rate of change of above
 The underlying pathology causing
anaemia
 Individuals capacity to compensate
(cardiorespiratory reserve)

7. Causes of anaemia
Reduced red cell
production
 Reduced essential
factor(s)
 Exogenous bone
marrow suppression
 Bone marrow
pathology
Increased red cell
destruction/loss
 Bleeding
 Acute
 Chronic
 Haemolysis
 Hypersplenism
Is there a test that will help you discern which of these is likely?

8. Causes of anaemia
Reduced essential factor
 Iron
 Folic acid
 Vitamin B12
 Protein
Small print – possible/experimental :
ascorbic acid, niacin, riboflavin, vitamin E, pyridoxime, thiamine,
cobalt, copper

9. Causes of Anaemia
Exogenous marrow suppression
 Anaemia of chronic disease
 Toxins e.g.Lead, chemicals, drugs
 Renal failure (erythropoietin deficiency)
 Endocrinopathies
 Hypothyroidism
 Addison’s disease
 Hypopituitarism

10. Causes of anaemia
Bone marrow pathology
 Aplastic anaemia/red cell aplasia
 Myelodysplasia
 Infiltration
 Leukaemias
 Lymphomas
 Myeloma
 Myelofibrosis
 Carcinoma

11. Causes of anaemia
Haemolysis
Membrane defects
HS, HE, PNH
Haemoglobin
Disorders
Enzyme defects
-Glycolysis
-Glutathione synthesis
-Nucleotide synthesis
Parasites
Antibodies
Microangiopathy

12. Causes of anaemia
Hypersplenism
 Primary
 Secondary
 Infection
 Haematological malignancy
 Storage disease
 Portal hypertension
 Felty’s syndrome

13. Red cell indices may help
 Microcytosis
 Macrocytosis
 N/N

14. Case 1
 A 70 year old woman presents with
a short history of dizziness and
lethargy.
Hb 8.1g/dl
WBC 9.5 x 109/l
Platelets 465 x 109/l
MCV 71 fl
 Highlight abnormal results

15. Abnormalities on blood film?

16.  What aspects of the history &
examination would you concentrate
on?
 What tests would you request at
this stage?

17. What abnormalities are shown?

18. Case 1
 Ferritin 5 (normal 14 - 186)
 She has PR bleeding
 What further history do you need?
 What investigations would you request now?
 What treatment would you advise now?
 Give a differential diagnosis

19. Case 2
 A 60 year old woman presents with a 3
month history of increasing lethargy. Apart
from pallor, physical examination is
unremarkable.
 Hb 5.2 g/dl
 WBC 3.1 x 109/l
 Platelets 95 x 109/l
 MCV 120 fl
 Highlight abnormal results

20. Abnormalities on blood film?
List the tests you would
request next

21. Case 2
 B12 95 (normal 215-400)
 Folate 2.1 (normal 2.0-5.0)
What tests would you request now?
What treatment would you order?
Name serious complications of this disorder.

22. Case 3
 A 25 year old male presents with lethargy
and spontaneous bruising
 Hb 7.5 g/dl
 WBC 1.3 x 109/l
 Platelets 17 x 109/l
 MCV 101 fl
 Ferritin/B12/folate all normal
 Highlight abnormal results
 Give a differential diagnosis

23. Abnormalities on blood film?
What test will
provide the diagnosis?

24. Case 4
 A 56 year old woman presents with a 3 day
history of lethargy. She is pale and jaundiced.
Her spleen is palpable 3cm below the left
costal margin.
 Hb 6.3 g/dl
 WBC 10.0 x 109/l
 Platelets 220 x 109/l
 MCV 108 fl
 Bili 76 Alk Phos 89 ALT 42
 Highlight abnormal results

25. Abnormalities on blood film?
What is the likely mechanism
For anaemia?
What further test would you
request with this in mind?
Give 2 possible diagnoses and
explain how you would
distinguish between them.

26. When would you request this
test?

27. Case 5
 A 79 year old man complains of tiredness
and palpitations.
 Hb 9.2 g/dl
 WBC 6.9 x 109/l
 Platelets 350 x 109/l
 MCV 98 fl
 What further history would you want?
 What tests would you request at this
point?

28. Case 5
 He has lost weight. No localising symptoms.
No past medical history of note
 ESR 89
 Ferritin 230 B12/folate normal
 U&E/LFT normal
 Microscopic haematuria
 ECG – atrial fibrillation
 What further tests would you request?
 Suggest possible diagnoses.