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Microcytic anemia


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Microcytic hypochromic anemia- iron deficiency, anemia of chronic disease, thalassemia minor, sideroblastic anemia

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Microcytic anemia

  1. 1. MICROCYTIC ANEMIA Presented by- Dr. Monika Nema Dr. Monika Nema
  2. 2.  Anemia is the collection of signs and symptoms of reduced oxygen delivery to tissues as a result of a reduction in the number of red cells and/or reduction in blood concentration of hemoglobin below the level that is expected for healthy person of same age and sex. Dr. Monika Nema
  3. 3.  The world health organization (WHO) has defined anemia as Hb<13.0 g/dl for men and <12g/dl for women. Dr. Monika Nema
  4. 4. Hb ( g/dl ) Ht(%) MCV (fl) Adult men 13-17 39-49 80-100 Adult women 12-15 33-43 80-100 Children 6-12 yr 11.5-12.5 37-46 77-95 6m-6yr 11-14 36-42 74-87 2m-6m 9.5-14 32-42 76-84 Dr. Monika Nema
  5. 5.  Most common hematologic disorder by far  It is a clinical sign of disease  It is not a single disease by itself. Dr. Monika Nema
  6. 6. Dr. Monika Nema
  7. 7.  Average volume of a single red cell.  Normal : 83-101 femtolitre  Calculated as  MCV= Packed cell volume x 10 Red cell count Dr. Monika Nema
  8. 8.  Average amount of haemoglobin in each red cells.  Normal: 27-32 picogram.  MCH= Hemoglobin concentration x 10 Red cell count Dr. Monika Nema
  9. 9.  Represents the average concentration of haemoglobin in a given volume of packed cells.  Normal : 31.5-34.5 g/dl.  MCHC= Hemoglobin concentration x 100 Packed cell volume Dr. Monika Nema
  10. 10.  It is a measure of degree of variation in red cell size(anisocytosis) in a blood sample.  Normal :  As coefficient of variation(CV)- 11.6-14 %  As Standard deviation(SD) – 39-46% Dr. Monika Nema
  11. 11. Dr. Monika Nema
  12. 12.  Normocytic Normochromic  Microcytic Hypochromic  Macrocytic Dr. Monika Nema
  13. 13. Dr. Monika Nema
  14. 14.  A patient presented with fatigue, shortness of breath, weakness, irritability, reduced work concentration to the physician.  Doctor examined and found pallor.  He simply ordered a complete blood count. Dr. Monika Nema
  15. 15. Dr. Monika Nema
  16. 16.  When the average cell size (MCV) is reduced, the anemia is classified as MICROCYTIC ANEMIA. Usually associated with hypochromia It is very common in all age groups. Dr. Monika Nema
  17. 17. Dr. Monika Nema
  18. 18. Dr. Monika Nema
  19. 19.  Disorders of iron metabolism - Iron deficiency anemia. - Anemia of chronic disorder.  Disorder of globin synthesis - Alpha and Beta Thalassemia. Dr. Monika Nema
  20. 20.  Sideroblastic anemia - Hereditary. - Acquired. - Reversible Acquired.  Lead Intoxication. Dr. Monika Nema
  21. 21. Dr. Monika Nema
  22. 22. •Shortness of breath •Palpitation •Decreased work or exercise tolerance •Fatigue •Weakness Dr. Monika Nema
  23. 23. Pica ( Abnormal eating pattern ) is striking symptom of iron deficiency anemia. Dr. Monika Nema
  24. 24.  Iron deficiency usually arises from chronic blood loss.  The major cause in younger women is menstruation.  In non menstruating women and in men, the most common source is gastrointestinal hemorrhage. (esophageal varices,hiatus hernia, peptic ulcer,gastritis,neoplasm ,hook worm infestation) Dr. Monika Nema
  25. 25.  Inadequate dietary intake of iron  Defective absorption of iron (Achlorhydriya, Gastric surgery, Celiac disease, Duodenal bypass, Drugs, Tannins, Phytate, Bran) Dr. Monika Nema
  26. 26.  Increased requirements of iron (Pregnancy, Infancy, Lactation)  Inadequate presentation to erythroid precursors (Atransferrinemia, Atransferrin receptor antibodies)  Abnormal iron balance (Aceruloplasminemia, Autosomal dominent hemochromatosis due to mutation in ferroportin) Dr. Monika Nema
  27. 27.  Is an inherited autosomal recessive blood disease which results in reduced synthesis or no synthesis of one of the globin chains that make up hemoglobin causing the formation of abnormal hemoglobin molecules leading to anemia.  Thalassemia is a quantitative problem. Dr. Monika Nema
  28. 28.  Thalassemia minor patients are usually asymptomatic. Diagnosis is made through evaluation of positive family history. Dr. Monika Nema
  29. 29. These are group of disorders of varying aetiology in which marrow shows marked dyserythropoiesis & intra mitochondrial accumulation of Fe in erythroid precursors Dr. Monika Nema
  30. 30.  In sideroblastic anemia, majority of patient exhibits manifestations of iron overload.  Abnormal glucose tolerance, cardiac arrhythmia and congestive heart failure can occur. Dr. Monika Nema
  31. 31.  In case of Lead poisoning, There can be occupational history of inhaling fumes in industry. Ingestion of lead based paint chips by children. Ingestion of contaminated herbs and food supplements. Gasoline sniffing in addicted person. Dr. Monika Nema
  32. 32. A. Chronic inflammation  Rheumatoid arthritis  systemic lupus erythematosis  Crohn’s disease B. Chronic infection  Tuberculosis  Urinary tract disease  HIV infection  Bacterial endocarditis  pneumonia C. Neoplasm  Carcinoma  Lymphoma  Myeloma Dr. Monika Nema
  33. 33.  Anemia is related to decrease in release of iron from macrophage to plasma  Reduced RBC lifespan  Inadequate erythropoietin response to anemia, caused by effects of cytokine such IL-1, TNF on erythropoiesis  Hepcidin released by the liver in response to inflammation.  Hepcidin functions to regulate (inhibit) iron transport across the gut mucosa, thereby preventing excess iron absorption and maintaining normal iron levels within the body. Hepcidin also inhibits transport of iron out of macrophages (where iron is stored) Dr. Monika Nema
  34. 34.  The clinical manifestation vary widely in anemia of chronic disease because of its association with so many diseases.  Usually, the signs and symptoms of the underlying disorder overshadow those of the anemia. Dr. Monika Nema
  35. 35. In the hands, the skin of the palms first becomes pale, but the creases may retain their usual pink color until the Hb concentration is less than 7 g/dl. Is a sign of anemia. The pallor associated with anemia is best detected in the mucus membrane of mouth, the conjunctiva, lips and the nail beds Dr. Monika Nema
  36. 36. Site Findings Nails Flattening, Koilonychia Tongue Soreness, Mild papillary atrophy, Absence of filiform papillae Mouth Angular stomatitis Hypopharynx Dysphagia,Esophageal varices Stomach Achlorhydria,Gastritis Koilonychia Dr. Monika Nema
  37. 37. Gums in lead poisoning. Lead lines are shown in gums of this patient suffering from lead poisoning Dr. Monika Nema
  38. 38. Dr. Monika Nema
  39. 39.  Most microcytic anemia are due to deficient hemoglobin synthesis often associated with iron deficiency or impaired iron use. Dr. Monika Nema
  40. 40. Erythrocytes:  If symptoms of anemia are the presenting complain, the blood hemoglobin is usually 8 g/dl or lower.  MCV – decreased. (Microcytic)  MCH- decreased. (Hypochromic)  Anisocytosis- Important early sign . Leading to raised Red Cell Distribution Width.  Few pencil cells, few target cells can be seen. Dr. Monika Nema
  41. 41. Dr. Monika Nema
  42. 42. Leukocytes:  Usually normal in number.  Mild graulocytopenia is seen in long standing cases.  Recent large volume hemorrhage leads to Neutrophilic Leukocytosis.  Due to parasitic infestation, Eosinophilia can be seen. Thrombocytes:  Thrombocytosis is usually seen. Dr. Monika Nema
  43. 43. Dr. Monika Nema
  44. 44. The normal film shows little variation in red cell size The iron deficient cells shows variations in size (anisocytosis) and shape (poikilocytosis), as well as microcytosis (low average cell size) and hypochromia (increased central pallor). Dr. Monika Nema
  45. 45.  Usually normocytic normochromic anemia is seen.  Hypochromia is more common than microcytosis.  Microcytosis in anemia of chronic disease is usually not as striking as that commonly associated with iron deficiency anemia. Dr. Monika Nema
  46. 46.  In iron deficiency anemia, hypochromia follows microcytosis.  Whereas in anemia of chronic disease, hypochromia preceeds microcytosis. Dr. Monika Nema
  47. 47. Normocytic picture Microcytic picture Dr. Monika Nema
  48. 48. Dr. Monika Nema
  49. 49.  It is a measure of amount of iron bound to transferrin.  Shows diurnal variation Highest in morning and lowest in evening.  Influenced by recent ingestion and absorption of iron medication.  Normal value : 0.6-1.7 microgram/L. Dr. Monika Nema
  50. 50.  The principal source of iron for hemoglobin production is that carried by transferrin, the iron transport protein in plasma.  When transferrin saturation with iron is less than 16%, RBC production rate decreases and hypochromic,microcytic cells are manufactured. This state is known as iron deficient erythropoiesis.  Normal transferrin saturation is 16-50%. Dr. Monika Nema
  51. 51.  It is indirect measurement of transferrin in terms of amount of iron it will bind.  Shows slight fluctuation.  Normal value : 2.5-4.0 microgram/L. Dr. Monika Nema
  52. 52.  Disulphide linked transmembrane protein that facilitates entry of transferrin bound iron into cells. Dr. Monika Nema
  53. 53.  Ferritin is chiefly intracellular iron storage protein.  Serum ferritin is glycosylated and contains little or no iron.  In most circumstances, Serum ferritin is proportional to total body iron stores.  Not influenced by recent iron therapy.  Normal : Male – 15-300 microgram/L. Female – 15-200 microgram/L. Dr. Monika Nema
  54. 54.  Ferritin levels are the single best serum measure of storage iron.  Serum ferritin level in patient with anemia of chronic diseases may increase dispropotinately relative to increase in iron stores, probably because ferritin is an Acute phase reactant.  This phenomenon complicates diagnosis of Iron deficiency anemia when it co-exists with inflammatory disease. Dr. Monika Nema
  55. 55. Dr. Monika Nema
  56. 56.  Total iron binding capacity – Increased in iron deficiency anemia Decreased in anemia of chronic disease.  Erythrocyte sedimentation rate is found to be elevated in anemia of chronic disease owing to its inflammatory etiology. Dr. Monika Nema
  57. 57.  Cellularity – increased  Erythroid hyperplasia  Micronormoblastic reaction  Normoblast are smaller  Late micronormoblast demonstrates persistent basophilia and fraying of cytoplasmic borders indicating lack of complete hemoglobinization  Myelopoiesis – Normal  Megakaryopoiesis – Normal  Depleted bone marrow iron Dr. Monika Nema
  58. 58. Dr. Monika Nema
  59. 59. Bone marrow aspirate demonstrating increased iron staining in a fragment representing increased marrow iron stores. . This finding is present in a patient with anemia of chronic disease. Normal iron staining in histiocytes is shown for comparison Dr. Monika Nema
  60. 60. Grade Criteria 0 No iron granules observed 1+ Small granules in reticulum cells, seen only in oil immersion lens 2+ Few small granules seen with low power lens 3+ Numerous small granules in all marrow particles 4+ Large granules in small clumps 5+ Dense, large clumps of granules 6+ Very large granules, obscuring marrow details Normal Marrow =1+ To 3+ Dr. Monika Nema
  61. 61.  Red cell count is increased.  MCV –decreased.  MCH- decreased.  MCHC- normal or slightly decreased.  Reticulocytes are generally increased to twice the normal number and have been found to correlate with hemoglobin level. Dr. Monika Nema
  62. 62. Dr. Monika Nema
  63. 63. Target cells Dr. Monika Nema
  64. 64. Basophilic stippling in thalassemia. Dr. Monika Nema
  65. 65. Dr. Monika Nema
  66. 66. Findings Thalassemia minor Iron deficiency anemia Anisocytosis Mild or absent Early and prominent finding Microcytosis More severe Less severe Dr. Monika Nema
  67. 67. Dr. Monika Nema
  68. 68.  Mentzer index= Mean cell volume Red cell count Value greater than 14 is found in iron deficiency anemia whereas value less than 12 is seen in thalassemia trait disorder. Value between 12-14 is considered indeterminate. Dr. Monika Nema
  69. 69.  Calculated as MCV x MCH Red cell count >371: normal 321-370: iron def.=> trial of iron for 1 mo. 251-320: Mixed iron def. & minor thalassemia => trial of iron & folate then check CBC & Hb elect <250 : Minor thalassemia =>check Hb elect. Sensitivity =99% , Specificity=86% Dr. Monika Nema
  70. 70.  Calculated as MCV x MCH Red cell count x MCHC >13: Normal 10.5-13: Iron deficiency 8-10.5: Mixed iron def & minor thalassemia. <8 : Minor thalassemia Note : Sensitivity=99% , Specificity=93% Dr. Monika Nema
  71. 71.  HbF Electrophoresis  High performance liquid chromatography  DNA analysis Dr. Monika Nema
  72. 72.  Hb A 2 ranges 3.5 to 7.0 %  Hb F ranges 1 – 3 % Dr. Monika Nema
  73. 73.  Hypercellular  Erythroid hyperplasia  M:E ratio 1:5  Dyserythropoisis  Myelopoisis and megakaryopoisis are normal  Bone marrow iron increased Dr. Monika Nema
  74. 74. Top and bottom panels show bone marrow aspirate and biopsy, respectively, from a case of thalassemia trait. The bone marrow has increased numbers of erythroid precursors (a low myeloid to erythroid ratio) related to the increased peripheral RBC destruction in this disease. Dr. Monika Nema
  75. 75.  Peripheral smear: microcytic hypochromic ,anisopoiklocytosis ,few cell show basophilic stippling,WBC and platelet normal.  Serum iron and percent transferrin saturation increased  Bone marrow: hypercellular,normoblastic or micronormoblastic reaction with vacuolation in cytoplasm, sideroblast , megakaryopoisis and normal myelopoisis. Dr. Monika Nema
  76. 76. Sideroblastic anemia. Normocytic cells are present, along with a minor population of microcytic, hypochromic erythrocytes possessing a thin rim of cytoplasm. Occasional teardrop cells are visible. Dr. Monika Nema
  77. 77. Dr. Monika Nema
  78. 78. In Sideroblastic anemia. Numerous ringed sideroblasts are seen in this marrow aspirate smear stained for iron. They are normoblasts with ≥10 iron-containing granules in the cytoplasm encircling at least one- third of the nucleus. Dr. Monika Nema
  79. 79. Peripheral blood film demonstrating coarse basophilic stippling. Normocytic or microcytic anemia may be present. Dr. Monika Nema
  80. 80. Dr. Monika Nema
  81. 81. Dr. Monika Nema
  82. 82. PRESENTED BY :- DR.MONIKA NEMA Dr. Monika Nema