Anaemia is defined as a low blood haemoglobin level below the normal range based on age and sex. Common causes include iron, folate or B12 deficiency, bleeding, bone marrow disorders, and haemolysis. Clinical features depend on severity and cause, and may include fatigue, palpitations, and signs of heart failure in severe cases. A combination of blood tests, medical history, and physical examination can help identify the underlying cause.

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.