definition, normal values,types

1. ANEMIA
BY SANJAY ARALIKATTI

2. DEFINITION
Anemia is defined as the
• Decrease in the total amount of red blood cells
• Or hemoglobin the blood
• Or lowered ability to carry oxygen
• Below the level that is expected for healthy person of same age
gender and in pregnency
SOURCE WIKIPEDIA

3. CLASSIFICATION
1.BLOOD LOSS ANEMIA
a. Acute blood loss . Ex trauma
b. Chronic blood loss. Ex gi tract lesions and menstrual disturbances
2. INCREASED RED CELL DESTRUCTION (HEMOLYSIS)
a. Inherited genetic defects
i) red cell membrane disorders. Ex hereditary spherocytosis or
elliptocytosis
ii) enzyme deficiencies. Ex G6PD deficiency, glutathione synthase
deficiency, pyruvate kinase deficiency, hexokinase deficiency
SOURCE ROBBINS

4. 2.INCREASED RED CELL DESTRUCTION
b. Hemoglobin abnormalities
i) Deficient globin synthesis. Ex thalassemia syndromes
ii) structurally abnormal hemoglobin. Ex sickle cell disease
c. Acquired genetic defects. Ex deficiency of phosphatidylinositol linked
glycoproteins leads to paroxysmal nocturnal hemoglobinuria
d. Antibody mediated destruction. Ex hemolytic disease of the newborn(rh
incompatibility), transfusion reactions, drug induced reactions and the
autoimmune disorders
e. Infections of the red cells. Ex malaria, babesiosis
f. Toxic or chemical injury. Ex clostridial sepsis, snake venom, lead poisoning.

5. 3. DECREASED RED CELL PRODUCTION
a. Inherited genetic defects. Ex Fanconi anemia, telomerase deficiency,
thalassemia syndromes
b. Nutritional deficiencies. Ex B12 ,folate, iron deficiencies
c. Erythropoietin deficiency. Ex renal failure, anemia pf chronic disease
d. Immune mediated injury of progenitors. Ex aplastic anemia, pure red cell
aplasia.
e. Inflammation mediated iron sequestration. EX anemia of chronic disease
f. Infection of red cell progenitors. Ex parvovirus b19 infection

7. Other clinical features
• Pallor is seen In skin lining mucosa, conjunctiva, nail beds and
toungue

8. • Koilonychia during iron deficiency

9. BASIC LABORATORY INVESTIGATIONS
HEMATOCRIT
• men-39-49%
• women-33-43%
• paediatric reference range
0-1 month
1-2 months
2-3 months
3-6 months
6 months-1 year
42-65%
33-55%
28-41%
29-41%
31-41%

10. BASIC LABORATORY INVESTIGATIONS
HEMOGLOBIN ESTIMATION
Men 13.6-17.2 g/dl
Women 12.0-15.0 g/dl
Children
0-30days- 13.4-19.9 g/dl
31-60 days- 10.7-17.1 g/dl
2-3 months- 9.0-14.1g/dl
3-6 months- 9.5-14.1g/dl
6-12 months- 11.3-14.1g/dl
1-5 years- 10.9-15.0g/dl
5-11 years- 11.9-15.0g/dl
11-18 years- male -12.7-17.7g/dl
female-11.9-15.0g/dl

11. BASIC LABORATORY INVESTIGATIONS
RED CELL COUNT (in x106 / µl)
Male- 4.3-5.9
Female- 3.5-5.0
Newborn- 6-8
2-4months -3-4
10years- approx. 5

12. BASIC LABORATORY INVESTIGATIONS
Reticulocyte count .5-1.5%
Mean cell volume- 82-96 fl
Mean cell haemoglobin- 27-33pg
Mean cell haemoglobin concentration- 33-37gm/dl
Red cell distribution width- 11.5-14.5
Stained peripheral blood smear
Marrow examination
Tests of iron- normal serum iron level bound to transferrin 50-150
mcg/dl

13. BASIC LABORATORY INVESTIGATIONS
LEUCOCYTE AND PLATELET COUNT- helps distinguish pure anemia
from pancytopenia in which the red cells, granulocytes and platelets
are reduced.
ERYTHROCYTE SEDIMENTATION RATE- The ESR usually gives the clue to
underlying organic disease but the rise in the ESR is also observed in
the anemia

14. DEGREE OF ANEMIA
• Mild anemia– 9-11g/dl
• Moderate anemia– 7-9g/dl
• Severe anemia– 4-7g/dl
• Very severe anemia— <4g/dl

15. HYPOCHROMIC ANEMIAS
• Hypochromic anemia due to iron deficiency
• hypochromic anemia other than iron deficiency. Ex sideroblastic anemia.
• SIDEROBLASTIC ANEMIA
the erythrocytes and the normoblasts show the characteristic cytoplasmic
granules of the iron. Caused due to defects in the heme sytnthesis by virtue
of defects in Aminolevulonic acid synthase enzyme defects or deficiencies.
SIDEROCYTES- these are the erythrocytes that contain the non-heme iron
granules these are seen as the pink granules in the cytoplasm of the
erythrocytes. These are referred as pappenheimer bodies.
These are normally not present in the human body and are only found after
splenectomy, because the reticulocytes after released from the bone marrow
are sequestered in the spleen for maturation into erythrocytes. Thus in
absence of the spleen the maturation takes place in the peripheral blood and
the siderocytes are seen in the blood

17. SIDEROBLASTIC ANEMIA
• SIDEROBLASTS-
• NORMAL SIDEROBLASTS- contain few scattered cytoplasmic granules,
normally 30-50% of normoblast population in bone marrow. Not seen
during iron deficiency.
• RING SIDEROBLASTS- these contain numerous large granules forming a
complete or partial ring around the nucleus. The ring like arrangement in
the ring form is due to the granule laden mitochondria that are arranged
around the nucleus
• LAB FINDINGS- 1. moderate to severe anemia
2.Microcytic and hypochromic anaemia
3.MCV,MCH,MCHC are reduced
4.Bone marrow examination- ringed sideroblasts are more in number
5. Serum ferritin levels are raised
TREATMENT- pyridoxine-200mg per day for 2-3 months.

18. IRON DEFICIENCY ANEMIA
• Caused by iron deficiency which leads to the inadequate haemoglobin
synthesis.
• Risk groups toddlers, adolescent girls, women of childbearing age.

19. IRON METABOLISM
• The amount of iron obtained from the diet should replace the
losses from the skin, bowel and genitourinary tract. These losses
together are about 1 mg daily in an adult male or in a non
menstruating female, while in a menstruating woman there
is an additional iron loss of 0.5-1 mg daily.
Sources of iron
ingestion of foods containing iron (e.g. leafy vegetables, beans,
meats, liver etc) and recycling of iron from senescent red cells.

20. AVERAGE DAILY IRON INTAKE
CHILDREN
2-11 YEARS - 13.7-15.1 mg/day
12-19 YEARS- 16.3mg/day
MEN- 19.3-20.5 mg/day
WOMEN(older than 19)- 17.0-18.9 mg/day
PREGNANT WOMEN(median iron intake)-14.5mg /day

21. IRON METABOLISM- ABSORPTION, TRANSPORT
AND STORAGE.
• Mainly in the duodenum and proximal jejunum

23. RISK GROUPS FOR IRON DEFICIENCY ANEMIA
WOMEN IN REPRODUCTIVE YEARS OF LIFE
During pregnancy and adolescence,the demand of body for iron is
increased.
During anormal pregnancy, about 750 mg of iron may be siphoned off
from the mother—about 400 mg to the fetus, 150 mg to the placenta,
and 200 mg is lost at parturition and lactation.
If several pregnancies occur at short intervals, iron deficiency anaemia
certainly follows.

24. RISK GROUPS FOR IRON DEFICIENCY ANEMIA
TODDLERS
The toddlers are at risk of development of iron deficiency anemia
because they restricted diet and gradual shift of the source of food
from mothers milk to solid and liquid foods which we consume.
PREMATURE INFANTS
Since premature infants lack the iron reserves in the body they are at
the risk of getting iron deficiency anemia

25. CLINICAL FEATURES
• ANEMIA- the people with iron deficiency anemia show weakness,
fatigue, palpitation, dyspnoea, pallor of the skin,mucus membrane
and sclerae. Older people may develop angina and cardiac failure.
• The distinguishing feature of iron deficiency anemia is the dietary
craving such as pica
• PICA- chewing of substances that have no nutritional value.
EPITHELIAL TISSUE CHANGES- koilonychia, atrophic glossitis, angular
stomatitis, esophageal web causing Plummer Vinson syndrome.

26. LABORATORY FINDINGS
Firstly, storage iron depletion occurs during which iron
reserves are lost without compromise of the iron supply for
erythropoiesis.
The next stage is iron deficient erythropoiesis during
which the erythroid iron supply is reduced without the
development of anaemia.
The final stage is the development of frank iron
deficiency anemia when the red cells become microcytic
and hypochromic

27. LABORATORY FINDINGS
BLOOD SMEAR EXAMINATION
Microcytic hypochromic anemia

28. LABORATORY FINDINGS
RED CELL INDICES
Hemoglobin concentration- reduced
Reticulocyte count raised
MCV, MCHC,MCH are reduced
Leucocytes are nomal
Platelet count normal

29. LABORATORY FINDINGS
BONE MARROW FINDINGS
Erythroid hyperplasia
Absence of siderotic iron granules in the normoblasts
BIOCHEMICAL FINDINGS
The serum iron level is low (normal 40-140 μg/dl); it is
often under 50 μg/dl. When serum iron falls below 15 μg/dl,
marrow iron stores are absent.
Total iron binding capacity (TIBC) is high (normal 250-
450 μg/dl) and rises to give less than 10% saturation (normal
33%). In anaemia of chronic disorders, however, serum iron
as well as TIBC are reduced.
Serum ferritin is very low (normal 30-250 ng/ml)
indicating poor tissue iron stores.

30. PRINCIPLES OF TREATMENT
ORAL IRON THERAPHY-These preparations have varying amount of
elemental iron in each tablet ranging from 39 mg to 105 mg
PARENTERAL IRON THERAPHY-
indications– a) Intolerance to oral iron therapy
b) In GIT disorders such as malabsorption
c) Post-operative cases
d) Cases requiring a rapid replenishment of iron stores e.g. in
women with severe anaemia a few weeks before expected date
of delivery.

31. MEGALOBLASTIC ANEMIA
Definition
Megaloblastic anaemia is a red blood cell disorder due to the inhibition
of DNA synthesis during erythropioesis.
Mitotically, the inhibition of the DNA synthesis impaires the
progression of the cell cycle development from G2 to (M)
stage.

32. MEGALOBLASTIC ANEMIA
Macrocytic blood picture caused by
1. Nutritional deficiency of the vitamin B12 or folate or both
2. Deficiency of intrinsic factor of castle causing a condition called
pernicious anemia.

34. Vitamin b12 is available from foods of animal
origin

42. • VITAMIN B12 DEFICIENCY
• Inadequate intake: This is common among pure vegetarians,
old and bed ridden patients
• Inability to absorb vitamin B12: after gastric surgery, lack of
hydrochloric acid in gastric juice, lack of intrinsic factor due to
auto antibodies to parietal cells.
• Competition for intestinal vit.B12 : Competitive absorption
of the vitamin by fish tape worm (Diphyllobothrium latum)
and bacteria overgrowth in blind-loop syndrome, intestinal
stasis.
• Drugs Inhibition: Metformin, Proton pump inhibitors

43. FOLATE METABOLISM
Vitamin b9 water soluble. Daily requirement 100-200 mcg
Sources
Folate exists in different plants, bacteria and
animal tissues. Its main dietary sources are fresh green leafy
vegetables, fruits, liver, kidney, and to a lesser extent, muscle
meats, cereals and milk. Folate is labile and is largely destroyed
by cooking and canning. Some amount of folate synthesised by
bacteria in the human large bowel is not available to the body
because its absorption takes place in the small intestine. Thus,
humans are mainly dependent upon diet for its supply.

44. FOLATE METABOLISM
• Folate is normally absorbed
• from the duodenum and upper jejunum and to a lesser
• extent, from the lower jejunum and ileum

45. FOLATE STORAGE
The liver and red cells are the main storage sites of folate, largely as
methyl THF polyglutamate form. The total body stores of folate are about
10-12 mg enough for about 4 months. Normally, folate is lost from the
sweat, saliva, urine and faeces.

46. Pathophysiology
When vitamin B12 or folate is deficient, thymidine synthase function is
impaired and DNA synthesis is interrupted but RNA synthesis remains
unimpaired. The inability to synthesize DNA leads to ineffectual
erythropoiesis resulting in excess hemoglobin and enlarged erythroid
precursors being produced. The developing red cell has difficulty in
undergoing cell division but RNA continues to be translated and
transcribed into protein leading to growth of the cytoplasm while the
nucleus lags behind. Often one or more cell division are skipped
leading to a larger than normal cell.
There is often erythroid hyperplasia in the marrow but most of these
immature cells die before reaching maturity leading to - elevated
Lactate Dehydrogenase (LDH) and hyperbilirunemia.

47. CLINICAL PRESENTATION
Anaemia symptoms
Neurological symptoms
Gastro- intestinal complain
Symptoms of Anemia
weakness, palpitation, fatigue, lightheadedness,,
shortness of breath, premature graying
of hair, jaundice and pallor.
Severe pallor and slight jaundice combine to produce
a telltale lemon-yellow skin in patient with
megaloblastic anemia.

48. Neurological symptoms
The syndrome usually begins with paraesthesia
(numbness and tingling) in the feet and fingers,
difficulties in balance and walking.
Vitamin B12 deficiency causes a demyelinization
of the peripheral nerves, the spinal cord, and the
brain, resulting in more severe neurological
symptoms.
When it affects the spinal cord it causes spastic
ataxia( stiffness of the muscles with uncoordinated
movement). At the brain it results in dementia,
psychotic depression and paranoid schizophrenia.
This has been termed “megaloblastic madness.”

49. • Gastro- intestinal complains : symptom include loss of
ppetite, glossitis (red, sore, smooth tongue) and diarrhoea

50. General Laboratory Findings
• Haemoglobin- decreased
• RBC MORPHOLOGY- megaloblasts and marked anisocytosis,
poikilocytosis and presence of macroovalocytes. Basophilic stippling
and occasional normoblast may also be seen.

51. Bone marrow smear: Bone marrow examination
reveals myeloid cell changes (giant bands,
metamyelocytes and hypertsegmentation) and
megakariocytes are decreased and show abnormal
morphology.

53. TESTS FOR VIT B12 DEFICIENCY-
SERUM VITAMIN B12 ASSAY Assay of vitamin B12 in blood can be done by 2
methods—microbiological assay and radioassay.
Microbiological assay In this test, the serum sample to be assayed is added
to a medium containing all other essential growth factors required for a
vitamin B12-dependent microorganism. The medium along with
microorganism is incubated and the amount of vitamin B12 is determined
turbimetrically which is then compared with the growth produced by a
known amount of vitamin B12. Several organisms have been used for this
test such as Euglena gracilis, Lactobacillus leichmannii, Escherichia coli and
Ochromonas malhamensis. E. gracilis is, however, considered more sensitive
and accurate. The addition of antibiotics to the test interferes with the
growth and yields false low result.

54. Radioassay Assays of serum B12 by radioisotope
dilution (RID) and radioimmunoassay (RIA) have been
developed.
These tests are more sensitive and have the
advantage over microbiologic assays in that they are simpler
and more rapid, and the results are unaffected by antibiotics
and other drugs which may affect the living organisms

55. SCHILLING TEST (24-HOUR URINARY EXCRETION TEST) Schilling test is done to detect
vitamin B12 deficiency as well as to distinguish and detect lack of IF and malabsorption
syndrome. The results of test also depend upon good renal function and proper
urinary collection. Radioisotope used for labeling B12 is either 58Co or 57Co. The test
is performed in 3 stages as under:
Stage I: Without IF The patient after an overnight fasting is administered oral dose of 1
mg of radioactively labelled vitamin B12 (‘hot’ B12) in 200 μl of water. At the same
time, 1 mg of unlabelled vitamin B12 (‘cold’ B12) is given by intramuscular route; this
‘cold’ B12 will saturate the serum as well as the tissue binding sites. The patient is kept
fasting for a further period of 2 hours, following which urinary excretion of B12 is
estimated: ”
. In normal individuals, 24-hour urinary excretion is >10% of the oral dose
of ‘hot’ B12. ”
. Patients with IF deficiency excrete lower quantity of ‘hot’ B12 which is
further confirmed by repeating the test as in stage II
Stage II: With IF If the 24-hour urinary excretion of ‘hot’
B12 is low, the test is repeated using the same procedure as
in stage I but in addition high oral dose of IF is administered
along with ‘hot’ B12.

56. If the 24-hour urinary excretion of ‘hot’ B12 is now normal, the low value
in first stage of the test was due to IF deficiency (i.e. pernicious
anaemia). Patients with pernicious anaemia have abnormal test even
after treatment with vitamin B12 due to IF deficiency. However,
abnormal 24-hour urinary excretion of ‘hot’ B12 is further investigated in
stage III for a cause in intestinal malabsorption of ‘hot’ B’12.
Stage III: Test for malabsorption of vitamin B12 Some
patients absorb vitamin B12 in water as was stipulated in
the original Schilling test. Modified Schilling test employs
the use of protein-bound vitamin B12. In conditions
causing malabsorption,
the test is repeated after a course of
treatment with antibiotics or anti-inflammatory drugs.

57. TESTS FOR FOLATE DEFICIENCY
The normal range of serum folate is 6-18 ng/ml. Values of 4 ng/ml or
less are generally considered to be diagnostic of folate deficiency
URINARY EXCRETION OF FIGLU Folic acid is
required for conversion of formiminoglutamic acid (FIGLU)
to glutamic acid in the catabolism of histidine. Thus, on oral
administration of histidine, urinary excretion of FIGLU is
increased if folate deficiency is present.

58. SERUM FOLATE ASSAY
Microbiological assay This test is based on the principle
that the serum folate acid activity is mainly due to the
presence of a folic acid co-enzyme, 5-methyl THF, and that
this compound is required for growth of the microorganism,
Lactobacillus casei. The growth of L. casei is inhibited by
addition of antibiotics.

59. Radioassay The principle and method of radioassay
byradioisotope dilution (RID) test are similar to that for serum
B12 assay. The test employs labelled pteroylglutamic
acid or methyl-THF. Commercial kits are available which permit
simultaneous assay of both vitamin B12 and folate.

60. PRINCIPLES OF TREATMENT
This includes: hydroxycobalamin as
intramuscular injection 1000 μg for 3 weeks and oral folic acid
5 mg tablets daily for 4 months

63. 1.The most characteristic
pathologic finding in PA is gastric atrophy affecting the acid and
pepsin-secreting portion of the stomach and sparing
the antrum.
CLINICAL MANIFESTATIONS ARE MAINLY DUE VITAMIN B12
DEFICIENCY

64. PRINCIPLES OF TREATMENT FOR PERNICIOUS
ANEMIA
1. Parenteral vitamin B12 replacement therapy.
2. Symptomatic and supportive therapy such as physiotherapy
for neurologic deficits and occasionally blood transfusion.
3. Follow-up for early detection of cancer of the stomach.

65. CLASSIFICATION OF HEMOLYTIC ANEMIA
a. Inherited genetic defects
i) red cell membrane disorders. Ex hereditary spherocytosis or
elliptocytosis
ii) enzyme deficiencies. Ex G6PD deficiency, glutathione synthase
deficiency, pyruvate kinase deficiency, hexokinase deficiency
b. Hemoglobin abnormalities
i) Deficient globin synthesis. Ex thalassemia syndromes
ii) structurally abnormal hemoglobin. Ex sickle cell disease and unstable
hemoglobin
SOURCE ROBBINS

66. c. Acquired genetic defects. Ex deficiency of phosphatidylinositol linked
glycoproteins leads to paroxysmal nocturnal hemoglobinuria
d. Antibody mediated destruction. Ex hemolytic disease of the
newborn(rh incompatibility), transfusion reactions, drug induced
reactions and the autoimmune disorders
e. Infections of the red cells. Ex malaria, babesiosis
f. Toxic or chemical injury. Ex clostridial sepsis, snake venom, lead
poisoning.

67. HEREDITARY SPHEROCYTOSIS

70. THALASSEMIA
• Thalassemia are the group of hereditary hemolytic disorders
characterized by impairment of imbalance in the synthesis of globin
chain of hb
• Molecular basis of thalassemia

71. MOLECULAR BASIS
The basic concepts in the synthesis of globin chains have been described
Haemoglobin contains 2ALPHA and 2BETA globin chains.
The synthesis of individual chains is so
coordinated that each ALPHA-chain has a
BETA-chain partner and they combine to finally
give hemoglobin (α2β2). Thalassemias are
characterized by a defect in the production of
α-or β-globin chain. There is however, no
abnormality in the amino acids of the individual
chains.

72. Thalassemias occur due to a variety of
molecular defects
1. Gene deletion or substitution,
2. Underproduction or instability of mRNA,
3. Defect in the initiation of chain synthesis,
4. Premature chain termination.

73. ALPHA THALASSEMIA

74. LABORATORY FINDINGS
The patients of a-thalassaemia
trait may have the following haematological
findings:
1. Haemoglobin level normal or mildly reduced.
2. Blood film shows microcytic and hypochromic red cell
morphology but no evidence of haemolysis or anaemia.
3. MCV, MCH and MCHC may be slightly reduced.

75. BETA THALASSEMIA

78. LABORATORY FINDINGS
1. Anaemia, usually severe.
2. Blood film shows severe microcytic hypochromic red cell morphology, marked
anisopoikilocytosis, basophilic stippling, presence of many target cells, tear drop
cells and normoblasts
3. Serum bilirubin (unconjugated) is generally raised.
4. Reticulocytosis is generally present.
5. MCV, MCH and MCHC are significantly reduced.
6. WBC count is often raised with some shift to left of the neutrophil series, with
presence of some myelocytes and metamyelocytes.
7. Platelet count is usually normal but may be reduced in patients with massive
splenomegaly.
8. Osmotic fragility characteristically reveals increased resistance to saline
hemolysis i.e. decreased osmotic fragility

79. SICKLE-CELL ANEMIA
Sickle-cell anemia (HbS) is the most common
form of abnormal hemoglobins. It is so named
because the erythrocytes of these patients adopt
a sickle shape (crescent like) at low oxygen
concentration

80. Molecular basis of HbS

81. Homozygous and heterozygous HbS and
double heterozygous states
The erythrocytes of heterozygotes contain both HbS
and HbA and the disease is referred to as sicklecell
trait which is more common in blacks
(almost 1 in 10 are affected).These lead normal life
It provides resistance to malaria. Evolutionary advantage
• sickle b-thalassaemia,
• sickle-C disease (SC), sickle-D disease (SD).

82. Abnormalities associated with HbS
Life-long hemolytic anemia- The sickled
erythrocytes are fragile and their continuous
breakdown leads to life-long anemia.
Tissue damage and pain- The sickled cells
block the capillaries resulting in poor blood
supply to tissues. This leads to extensive damage
and inflammation of certain tissues causing pain.
Premature death- Homozygous individuals
of sickle-cell anemia die before they reach
adulthood (< 20 years).

83. Mechanism of sickling
in sickle-cell anemia
Glutamate is a polar amino acid and it is
replaced by a non-polar valine in sickle-cell
hemoglobin. This causes a marked decrease in
the solubility of HbS in deoxygenated form
(T-form). However, solubility of oxygenated HbS
is unaffected.

87. Diagnosis of sickle-cell anemia
1. Sickling test : This is a simple microscopic
examination of blood smear prepared by adding
reducing agents such as sodium dithionite.
Sickled erythrocytes can be detected under the
Microscope.
2. Electrophoresis-

88. Management of sickle-cell disease
Administration of sodium cyanate inhibits
sickling of erythrocytes, Cyanate increases the
affinity of O2 to HbS and lowers the formation of
deoxyHbS.

89. THANK YOU