This document provides an overview of how to approach and evaluate anemia. It begins by defining anemia and describing a complete blood count. It then discusses evaluating the size, hemoglobin content, and distribution of red blood cells to classify anemia as microcytic, normocytic, or macrocytic. For each type of anemia, the document lists potential causes and recommends further tests. It also covers evaluating reticulocyte count, peripheral smear, and bone marrow biopsy findings to determine if anemia is caused by blood loss, increased destruction, or decreased production of red blood cells. The goal is to systematically narrow down the cause of anemia through a series of blood tests and examinations.
Aplastic anemia is one of the stem cell disorder which leads to pancytopenia in the peripheral blood and decrease production of all cell line in bone marrow. it require bone marrow transplantation to cure the patient.
Autoimmune hemolytic anemia (or autoimmune haemolytic anaemia; AIHA) occurs when antibodies directed against the person's own red blood cells (RBCs) cause them to burst (lyse), leading to insufficient plasma concentration.
Basic approach to a case of anemia. Investigations to do and to arrive at the diagnosis. (Management not discussed). Peripheral smear findings with pictures are included.
UAEU - CMHS - Hematology-Oncology Course - MMH 302 - HONC 320. Education material for medical students - It cover basic principles of hematology and oncology, including CAR-T and gene editing. It can be used for study and review. It illustrates main principles of hematology and oncology.
Haemolysis indicates that there is shortening of the normal red cell lifespan of 120 days. There are many causes.
To compensate, the bone marrow may increase its output of red cells six- to eightfold by increasing the proportion of red cells produced, expanding the volume of active marrow, and releasing reticulocytes prematurely. Anaemia occurs only if the rate of destruction exceeds this increased production rate.
Aplastic anemia is one of the stem cell disorder which leads to pancytopenia in the peripheral blood and decrease production of all cell line in bone marrow. it require bone marrow transplantation to cure the patient.
Autoimmune hemolytic anemia (or autoimmune haemolytic anaemia; AIHA) occurs when antibodies directed against the person's own red blood cells (RBCs) cause them to burst (lyse), leading to insufficient plasma concentration.
Basic approach to a case of anemia. Investigations to do and to arrive at the diagnosis. (Management not discussed). Peripheral smear findings with pictures are included.
UAEU - CMHS - Hematology-Oncology Course - MMH 302 - HONC 320. Education material for medical students - It cover basic principles of hematology and oncology, including CAR-T and gene editing. It can be used for study and review. It illustrates main principles of hematology and oncology.
Haemolysis indicates that there is shortening of the normal red cell lifespan of 120 days. There are many causes.
To compensate, the bone marrow may increase its output of red cells six- to eightfold by increasing the proportion of red cells produced, expanding the volume of active marrow, and releasing reticulocytes prematurely. Anaemia occurs only if the rate of destruction exceeds this increased production rate.
Title: Understanding Anemia: Causes, Types, Clinical Features, and Diagnostic Investigations
Anemia is a condition characterized by a deficiency in the number or quality of red blood cells (RBCs) or hemoglobin in the blood, leading to reduced oxygen-carrying capacity. It is a prevalent global health issue affecting people of all ages, genders, and socioeconomic backgrounds. Understanding the causes, types, clinical features, and diagnostic investigations of anemia is crucial for effective management and treatment.
**Causes of Anemia:**
Anemia can result from various factors that disrupt the production, lifespan, or function of red blood cells. Some common causes include:
1. **Iron Deficiency:** Insufficient intake or absorption of iron, essential for hemoglobin synthesis, is a primary cause of anemia globally. It can stem from poor dietary intake, chronic blood loss (e.g., menstruation, gastrointestinal bleeding), or increased demand during pregnancy.
2. **Vitamin Deficiencies:** Deficiencies in vitamins such as vitamin B12 (cobalamin) or folate (vitamin B9) can impair RBC production, leading to megaloblastic anemia.
3. **Chronic Diseases:** Conditions like chronic kidney disease, inflammatory disorders (e.g., rheumatoid arthritis), and infections can disrupt erythropoiesis (RBC production) or accelerate RBC destruction, causing anemia.
4. **Hemolytic Disorders:** Inherited or acquired conditions that increase the breakdown (hemolysis) of red blood cells, such as sickle cell disease, thalassemia, or autoimmune hemolytic anemia, can result in anemia.
5. **Bone Marrow Disorders:** Diseases affecting the bone marrow, including leukemia, myelodysplastic syndromes, and aplastic anemia, can lead to decreased RBC production and anemia.
**Types of Anemia:**
Anemia is classified based on the underlying mechanism or etiology, leading to several types:
1. **Iron-Deficiency Anemia:** Characterized by low iron levels, resulting in decreased hemoglobin synthesis and microcytic (small-sized) RBCs.
2. **Megaloblastic Anemia:** Caused by impaired DNA synthesis in RBC precursors due to deficiencies in vitamin B12 or folate, leading to macrocytic (large-sized) RBCs.
3. **Hemolytic Anemia:** Occurs due to increased RBC destruction, either intravascularly (within blood vessels) or extravascularly (outside blood vessels), leading to various subtypes like autoimmune hemolytic anemia, hereditary spherocytosis, and sickle cell disease.
4. **Anemia of Chronic Disease:** Associated with chronic inflammation, infections, or malignancies, leading to impaired iron metabolism and decreased RBC production.
5. **Aplastic Anemia:** Results from bone marrow failure, leading to decreased production of all blood cell types, including RBCs.
**Clinical Features of Anemia:**
The clinical presentation of anemia can vary depending on its severity, underlying cause, and individual factors. Common clinical features include:
anemia is a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues. Having anemia, also referred to as low hemoglobin, can make you feel tired and weak. There are many forms of anemia, each with its
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
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The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
2. What is CBC?
Complete Blood Count :
Hb, RBC, MCV, MCH, MCHC, WBC & Diff, Platelet,
Reticulocyte
3. Anemia
• RBC mass
• ed level of Hb more than 2SD of mean normal of Hb
according to age
Age Hb level
• New born <13 gr/dl
• 2-3 months < 9 FT
< 7 premature
• 6m-2y <9.5
• 2y – 6 years old <10.5
• 6 – 12 y/o <11.5
• >12 y/o Male < 14
Female < 12
4. MCV
• Mean corpuscular volume: 100 (fl)
• Age: 2-10 y/o MCV= Age (year) + 70
• Age ≥ 10 y/o MCV < 80: Microcytosis
MCH
• Mean corpuscular hemoglobin: 100 (Pg)
• More sensitive than MCV
• MCH 25- 27 hypochromia
Rbc
HCT
5. MCHC
• Mean corpuscular hemoglobin concentration:
100 100
• It is important in diagnosis of congenital
Spherocytosis (MCHC > 35)
:
Rbc
Hb
Rbc
HCT
7. The Three Basic
Measures
Measurement Normal Range
A. RBC count 5 million 4 to 6
B. Hemoglobin 15 g% 12 to 17
C. Hematocrit 45 38 to 50
A x 3 = B x 3 = C - This is the rule of thumb
Check whether this holds good in given results
If not -indicates micro or macrocytosis or hypochro.
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8. Anaemia – First Test
RETICULOCYTE COUNT %
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Normal
Less than 2%
• ‘RBC to be’ or Apprentice RBC
• Fragments of nuclear material
• RNA strands which stain blue
9.
10.
11. The reticulocyte count
(kinetic approach)
• Increased reticulocytes (greater than 2-3% or
100,000/mm3 total) are seen in blood loss and
hemolytic processes, although up to 25% of
hemolytic anemias will present with a normal
reticulocyte count due to immune destruction of red
cell precursors.
• Retic counts are most helpful if extremely low
(<0.1%) or greater than 3% (100,000/mm3 total).
12. The reticulocyte count
• To be useful the reticulocyte count must be adjusted for
the patient's hematocrit. Also when the hematocrit is
lower reticulocytes are released earlier from the marrow
so one can adjust for this phenomenon. Thus:
• Corrected retic. = Patients retic. x (Patients Hct/45)
• Reticulocyte index (RPI) = corrected retic.
count/Maturation time
(Maturation time = 1 for Hct=45%, 1.5 for 35%, 2 for
25%, and 2.5 for 15%.)
• Absolute reticulocyte count = retic x RBC number.
15. Workup – Second Test
• The next step is ‘What is the size of RBC’ ?
• MCV indicates the Red cell volume (size)
• Both the MCH & MCHC tell Hb content of RBC
• If the RPI is 2 or less
• We are dealing with either
• Hypoproliferative anaemia (lack of raw material)
• Maturation defect with less production
• Bone marrow suppression (primary/ secondary)
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18. CLASSIFICATION
• Classification by Pathophysiology
• Blood Loss
• Decreased Production
• Increased Destruction
• Classification by Morphology
• Normocytic
• Microcytic
• Macrocytic
19. Anaemia Workup – 3rd Test
Red cell Distribution Width – RDW
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RDW < 13
Mean 90 fl
RDW is 13
MCV 90 fl
20. RDW
• Red cell distribution width = anisocytosis
• RDW = 11-14.5%
• IDA: RDW
• -thalassemia minor: NL or RDW
21. Anaemia Workup - 4th Test
Peripheral Smear Study
• Are all RBC of the same size ?
• Are all RBC of the same normal discoid shape ?
• How is the colour (Hb content) saturation ?
• Are all the RBC of same colour/ multi coloured ?
• Are there any RBC inclusions ?
• Are intra RBC there any hemo-parasites ?
• Are leucocytes normal in number and D.C ?
• Is platelet distribution adequate ?
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23. RBC morphology
• 7-9 m with 1/3 central palor
• Lifespan of 110-120 days
• About the size of nucleus of normal lymphocyte
• Poikilocytosis & Anisocytosis
26. Howell Jolly body
• Nuclear remnant - DNA
• hemolytic anemia
• absent or hypofunction
spleen
27. HISTORY
AGE: Nutritional iron deficiency is never responsible for
anemia in term infants before 6 months of age; rarely seen in
premature infants before the time that they have doubled their
birth weight.
Anemia occurring in the neonatal period is generally the result
of recent blood loss, isoimmunization, or initial manifestation of
a congenital hemolytic anemia or congenital infection
Anemia first detected at 3 to 6 months of age suggests a
congenital disorder of hemoglobin synthesis or hemoglobin
structure
Gender: Consider X-linked disorders in males (G6PD
deficiency, pyruvate kinase deficiency)
28. History
Drug: Oxidant-induced hemolytic anemia, phenytoin (Dilantin)-
induced megaloblastic anemia, drug-induced aplastic anemia
Infectious: Hepatitis-induced aplastic anemia, infection-induced
red cell aplasia, hemolytic anemia
Inheritance: Family history of anemia, jaundice, gallstones, or
splenomegaly
Diarrehia: Suspect small bowel disease with malabsorption of
folate or vitamin BIz. Suspect inflammatory bowel disease with
blood loss. Suspect exudative enteropathy with blood loss
29. History
Neonatal: A history of hyperbilirubinemia in the
newborn period suggests the presence of congenital
hemolytic anemia, such as the hereditary spherocytosis
of G6PD deficiency. Prematurity predisposes to the
early development of iron deficiency
Diet:Document sources of iron, vitamin BIz, folic
acid, or vitamin E in the diet. A history of pica,
geophagia, or pagophagia suggests the presence of iron
deficiency
48. Microcytic hypochromic
anemia
1. IDA
2. or thalassemia trait
3. Sideroblastic anemia
4. Anemia of chronic disease
5. Lead poisoning
6. Copper deficiency
7. Malnutrition
49. DDX of Microcytosis
Iron deficiency anemia Familial telangiectasia (OWR)
idiopathic pulmonary
hemosiderosis, PNH
- thalassemia No simple test, trial of iron therapy
- thalassemia Thal minor - elevated Hb A2 if not
iron deficient
Anemia of chronic disease MCV 75-82; inadequate
erythropoietin response
Hb CC African-American, splenomegaly,
mild anemia MCV 65, many target
cells
Hb EE Southeast Asian, no anemia or
minimal anemia. MCV 65 many
target cells
50. Approach to Dx
• Hx- age,sex,pica,infection, duration, onset, subjacent
illness, blood loss (GI, menstruation, surgery…), diet,
medications, toxic exposure, occupation, Family Hx,
Social Hx
• PE- complete exam including skin (jaundice, petechiae),
HEENT, Abdomen (hepatosplenomegally), lymphatics,
rectal, and pelvic
71. Lab Test for DDx of Common Microcytic Hypochromic Anemias
Iron
Deficiency
Thalassemia
Minor
Chronic
Disease
Scrum Iron N or
TIBC N or N or
% Iron
Saturation
(< 10%) N or
Serum Feritin
FEP N
72. Hemolytic anemias
•Coomb’s test direct negative, indirect positive = delayed
transfusion reaction
•Hereditary spherocytosis
•Osmotic fragility test: fresh and incubated
•Autosomal dominant, spectrin decreased, splenectomy
•Sickle cells
•Sickledex- solubility screening test for hgb S
•Cellulose acetate electrophoresis necessary to define AS, SS, SC, S-
thal etc
•Elliptocytes
•Most are not anemic or have compensated hemolytic process
•10-15% have chronic hemolytic anemia
80. RBC morphology
•7-9 m with 1/3 central palor
•Lifespan of 110-120 days
•About the size of nucleus of normal lymphocyte
•Poikilocytosis & Anisocytosis
97. Coombs’ Negative Hemolytic Anemia
Membrane Defects
Spherocytosis
•Common among Northern
European
•Autosomal dominant
•Decreased spectrin
•Osmotic fragility test
•Autohemolysis test
Elliptocytosis
•90% with no clinically
significant hemolysis
•Abnormal membrane
protein
98. Coombs’ Negative Hemolytic Anemia
Deficiency of RBC Enzymes
Pyruvate Kinase Def.
•Severe anemia in
newborns
•Adults symptomatic
•Jaundice
•Splenomegaly
•Fluorescent screening test
•Quantitative test
G6PD Def.
•X-linked
•Mediterranean, African
American, and Asian
•Oxidant drugs – ASA, quinine,
primaquine, chloroquine,
sulfacetamide, sulfamethoxazole,
nitrofurantoin, chloramphenicol,
procainamide, quinidine
•Infections
•Quantitative test
99. Coombs’ Negative Hemolytic Anemia
Hemoglobinopathy
HbS disease
•Valine substitution for
Glutamic acid at the 6th
position of b-chain
•Sickle crises
•Severe anemia
•Screening test - Na
Metabisulfite solubility
•Hgb electrophoresis
105. Hemolytic Anaemia
Anemia of increased RBC destruction
– Normochromic, normocytic anemia
– Shortened RBC survival
– Reticulocytosis – due to ↑ RBC destruction
Will not be symptomatic until the RBC life span is
reduced to 20 days – BM compensates 6 times
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106. Tests Used to Diagnose Hemolysis
.1Reticulocyte count
.2Combined with serial Hb
.3Serum LDH
.4Serum bilirubin
.5Haptoglobin
.6Urine hemosiderin
.7Hemoglobinuria
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