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Anemia

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.

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APPROACH TO ANEMIA DR.ABDULLAH SEDAGHAT
What is CBC? Complete Blood Count : Hb, RBC, MCV, MCH, MCHC, WBC & Diff, Platelet, Reticulocyte
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
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
MCHC • Mean corpuscular hemoglobin concentration:  100   100 • It is important in diagnosis of congenital Spherocytosis (MCHC > 35) : Rbc Hb Rbc HCT
PCV or Hematocrit •57% Plasma •1% Buffy coat – WBC •42% Hct (PCV) www.drsarma.in
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. www.drsarma.in
Anaemia – First Test RETICULOCYTE COUNT % www.drsarma.in Normal Less than 2% • ‘RBC to be’ or Apprentice RBC • Fragments of nuclear material • RNA strands which stain blue
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).
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.
Types of Anaemia www.drsarma.in
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) www.drsarma.in
Red Cell Size www.drsarma.in
Anaemia Workup - MCV www.drsarma.in Microcytic MCV Normocytic Macrocytic Iron Deficiency IDA Chronic Infections Thalassemias Hemoglobinopathies Sideroblastic Anemia Chronic disease Early IDA Hemoglobinopathies Primary marrow disorders Combined deficiencies Increased destruction Megaloblastic anemias Liver disease/alcohol Hemoglobinopathies Metabolic disorders Marrow disorders Increased destruction
CLASSIFICATION • Classification by Pathophysiology • Blood Loss • Decreased Production • Increased Destruction • Classification by Morphology • Normocytic • Microcytic • Macrocytic
Anaemia Workup – 3rd Test Red cell Distribution Width – RDW www.drsarma.in RDW < 13 Mean 90 fl RDW is 13 MCV 90 fl
RDW • Red cell distribution width = anisocytosis • RDW = 11-14.5% • IDA: RDW • -thalassemia minor: NL or RDW
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 ? www.drsarma.in
Basophilic Stippling - MBAwww.drsarma.in BS occurs in Lead poisoning also
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
Basophilic stippling • lead or heavy metal poisoning • Hemolytic anemia
Elliptocytes/ovalocytes • Abnormal cytoskeletal proteins • Hereditary elliptocytosis
Howell Jolly body • Nuclear remnant - DNA • hemolytic anemia • absent or hypofunction spleen
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)
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
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
Basic chemistries • BUN, creatinine,LFT • Bilirubin, icterus = 2.5mg/dl (direct and indirect) • LDH, haptoglobin / RETIC /Coombs • Iron/TIBC • Ferritin / Hb electropheresis / • Folic acid • Vitamin B12 • Osmotic fragility • G6pd def / piruvate kinase def /
Macrocytic Anaemias A. Megaloblastic Macrocytic – B12 and Folate↓ B. Non Megaloblastic Macrocytic Anaemias 1. Liver disease/alcohol 2. Hemoglobinopathies 3. Metabolic disorders, Hypothyroidism 4. Myelodystrophy, BM infiltration 5. Accelerated Erythropoesis -↑destruction 6. Drugs (cytotoxics, immunosuppressants, AZT, anticonvulsants) www.drsarma.in
Macrocytic: RPI < 2 B12/Folate B12 Low Normal MMA High MMA Homocysteine Normal Consider Liver, Renal, Thyroid, Alcohol, Chronic dis. Consider Bone Marrow Bx Homocysteine High Folate Low
Macrocytic: RPI >= 2 Occult Blood Loss? Yes Investigate source No Coombs’ (DAT) Check for Hemolysis Peripheral smear
Macrocytic: RPI >= 2 Hemolytic Anemia Coombs’ (DAT) Positive Immune Hemolysis Drug related Hemolysis Transfusion, Infection, Cancer Negative Hemoglobinopathy, G6PD, PK, Spherocytosis, Eliptocytosis, PNH, TTP, DIC
Anaemia www.drsarma.in Hypoproliferative Hemolytic RPI < 2 RPI > 2
Blood Loss • Acute • Traumatic • Variety of sources • Melena, hematemesis, menometrorrhagia • Chronic • Occult bleeding • Colonic polyp/carcinonma
INCREASED DESTRUCTION •Immune Mediated •Non-immune Mediated
Increased Destruction IMMUNE MEDIATED • Cold Agglutinin • Paroxysmal nocturnal hemoglobinuria • Post mycoplasmal hemolytic anemia • Warm Agglutinin • Drug induced • Autoimmune hemolytic anemia • Transfusion reaction
Increased Destruction NON-IMMUNE MEDIATED • Extra-corpuscular • Macro-circulatory • Hypersplenism • Extracorporeal circulation • Micro-circulatory • DIC • TTP • HUS • Intra-corpuscular • RBC Wall (membrane or enzyme defects) • Heme or globin abnormalities (HbS, C)
Hypoproliferative Anaemias www.drsarma.in Failure of cell maturation Nuclear breakdown Cytoplasmic breakdown Megaloblastic Anaemia Defective DNA synthesis Folate or B12 deficiency Haem defect Globin defect Thalassemia Sickle cell AFe Phorph IDA, SA
Decreased Production • Infectious • Neoplastic • Endocrine • Nutritional Deficiency • Anemia of Chronic Disease
Decreased Production INFECTIOUS Bacterial • Tuberculosis • Viral • HIV / Parvovirus ENDOCRINE • Thyroid Dysfunction • Hypothyroidism • Erythropoietin Deficiency • Renal Failure
Decreased Production NEOPLASTIC • Leukemia • Lymphoma/Myeloma • Myeloproliferative Syndromes • Myelodysplasia NUTRITIONAL DEFICIENCY • Iron • B12 • Folate
Normocytic Anaemias 1. Chronic disease 2. Early IDA 3. Hemoglobinopathies 4. Primary marrow disorders 5. Combined deficiencies 6. Increased destruction www.drsarma.in
Normocytic – Normochromic Anemia Reticulocyte count < 1% ≥ 2.5% Wbc & Plt count Hemorrhage Hemolysis Coombs test Low Pancytopenia BMA & bx Aplastic anemia leukemia NL Pure red cell anemia BMA Congenital (DBA) VS acquired (TEC) - ve - Membrane defect - Hb pathy - Enzyme deficiency - Unstable Hb - HUS - Wilson disease - DIC + ve Autoimmune hemolytic anemia
Macrocytic: RPI < 2 Megaloblastic Anemia B12 • Inadequate absorption • Synthesized by bacteria • Meat, fish, dairy (strict vegans) • Absorbed as B12-IF complex in ileum (gastrectomy) • Ca++ and pH dependant (PPI) Folate • Inadequate intake • Synthesized by plants and micro-organism • Green leafy vege’s • Fruits • Absorbed in jejunum
Macrocytic: RPI >= 2 Hemolytic Anemia Other Lab Characteristics • RBC morphology • Serum haptoglobin • Serum LDH • Unconjugated bilirubin • Hemoglobinuria • Hemosiderinuria
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
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
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
P/E 1. Skin Pallor Jaundice Purpura Hyperpigmentation 2. Skeletal deformity 3. Eye manifestations 4. Angular cheilosis 5. Atrophic glositis 6. Microcephaly 7. Splenomegaly 8. Spoon nail
Urinalysis • Protein: light chains are not detected by dipstick • RBC • Hemoglobin
Cabot rings (RNA or protein precipitation artifact don’t confused with malaria)
Golf-ball pattern (Hb H inclusions)
Ringed Sideroblasts in BM www.drsarma.in Prussian Blue Stain
Macrocytosis -MBA www.drsarma.in
Anisocytosis - Macrocytic Anaemia www.drsarma.in
HSN - MBA www.drsarma.in
HSN - MBA www.drsarma.in
Spherocytosis www.drsarma.in
Elliptocytes www.drsarma.in Hereditary Elliptocytosis, B12 or Folate↓
Stomatocytes Slit like central pallor in RBC www.drsarma.in 1. Liver Disease 2. Acute Alcoholism 3. H Stomatocyosis 4. Malignancies
Echinocytes Evenly distributed spicules > 10 www.drsarma.in 1. Uremia 2. Peptic ulcer 3. Gastric Ca 4. PK-D Called Burr Cells
Acanthocytes 5-8 spikes of varying length, irregular intervals www.drsarma.in Called Spur Cells, Occur in A H A
Shistocytes www.drsarma.in 1. MAHA 2. Prosthetic valves 3. Uremia 4. Malignant HT Fragmented, Helmet or triangle shaped RBC
Pelger-Huet Anomaly www.drsarma.in • Inherited condition • PMN - Spectacles • Heterozygous • Homozygous fatal • Neutrophil Bands ↑ • Normal WCC • No e/o infection
Tear Drop Cells www.drsarma.in 1. Myelofibosis 2. Infiltration of BM 3. Tumours of BM 4. Thalassemia
Hair on end - Thalassemia Major www.drsarma.in
Sickle Cell Anaemia www.drsarma.in
Copyright ©2002 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2002;2002:100325 Figure 1. Note the profound central pallor of the hypochromic and microcytic RBC
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 
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
Copyright ©2002 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2002;2002:100344 Figure 5. This patient has hereditary elliptocytosis
Copyright ©2001 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001:100248 No Caption Found
Hemolytic anemias •Acanthocytes •Spurr cells- end stage liver disease- fatal prognosis •Burr cells •Uremia, PK deficiency •Target cells •High degree (30-100%) Hg CC, Hb EE, Hb SC, S-β-thal
Hemolytic anemias •RBC enzyme defects •G6PD deficiency-X linked, NSHA, Favism, Spot test •Pyruvate kinase and other enzyme defects •Autosomal recessive, for most •Chronic hemolytic anemia •Specific enzyme assays •Intravascular hemolysis •Serum haptoglobin •Urine hemosiderin-useful 1-3 weeks after episode of intravascular hemolysis
Copyright ©2001 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001:100226 Figure 1. Note the "bite cells" and the cells with "blisters" and dense cross-bonded hemoglobin
Hemolytic anemias •Causes of chronic intravascular hemolysis •Cardiac abnormalities, usually prosthetic valve •PNH •PNH- paroxysmal nocturnal hemoglobinuria •Sucrose hemolysis test •Acid serum hemolysis test (Ham’s test) •Flow cytometry for CD55, CD59
Copyright ©2001 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001:100231 Figure 2. Note the hypersegmented neutrophil (7-8 lobes)
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
Basophilic stippling •Precipitated RNA •lead or heavy metal poisoning •ETOH abuse •Hemolytic anemia
Burr cells •Altered lipid in cell membrane •artifact •Uremia •Renal failure •gastric CA •transfused old blood
Elliptocytes/ovalocytes •Abnormal cytoskeletal proteins •Hereditary elliptocytosis
Howell Jolly body •Nuclear remnant - DNA •hemolytic anemia •absent or hypofunction spleen
Schistocyte/helmet cells •Fragmented (mechanical or phagocytosis) •DIC •TTP •HUS •Vasculitis •prosthetic heart valve •severe burns
Sickle cells •Molecular aggregation of Hgb-S •SS, SC, S-thal •rarely S-trait
NRBC •Common in newborn •severe degree of hemolysis
Spherocyte •Absent central palor •look smaller •Hereditary spherocytosis •immune hemolytic anemia
Stomatocyte •Mouth like •Membrane defect •Smear artifact •Hereditary stomatocytosis •Liver disease
Target cells •Increased redundancy of membrane •hemoglobinopathies •thalassemia •liver disease
Tear drop cells •Distorted drop shaped •Smear artifact •myelofibrosis •promyeloblastic leukemia •space occupying lesions of marrow
Sideroblastic anemia •Accumulation of mitochondrial iron in erythroblasts •Hereditary •Drugs - INH, lead, zinc, alcohol, chloramphenicol, cycloserine, plavix •Hypothermia •Confirm w/ BM Bx
Anemia of chronic disease •Infections: TB, SBE, osteo, chronic UTI or pyelo, fungal •Malignancy: mets, leukemia, lymphoma, myeloma •Chronic inflammatory disorders: RA, SLE, Sarcoid, collagen vascular disease, polymyalgia rheumatica, chronic hepatitis, decubitus ulcer
Coombs’ positive with Spherocytes Autoimmune hemolytic anemia Warm AIHA •Abrupt onset •IgG •Anti-Rh, e, C, c, LW, U •Jaundice •Splenomegaly •SLE, CLL, Lymphoma •Drugs: methyl-dopa, mefenamic acid, cimetidine, cefazolin Cold AIHA •Insidious onset •IgM, complement •Anti-I, I, Pr •Cold agglutinin titer •Absent jaundice •Mycoplasma •Virus
Coombs’ positive with Spherocytes Other immune hemolytic anemia Alloantibody hemolytic anemia •Transfusion reaction •Feto-maternal incompatibility (Kleihauer-Betke test) Drug related Hemolytic anemia •Toxic immune complex (drug+Ab+C3) - Quinine, Quinidine, Rifampin, INH, Sulfonamides, Tetracyclin •Hapten formation (anti-IgG) - PCN, methicillin, ampicillin
Coombs’ Negative Hemolytic anemia •Episodic - G6PD def., PNH •Hemoglobinopathy - Sickle, crystals or target cells •Elliptocytosis •Spherocytosis •DIC, TTP
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
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
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
Coombs’ Negative Hemolytic Anemia Hemoglobinopathy continues HbC disease •Mild hemolysis •Splenomegaly •Lysine substitution •HbC crystals “bar of gold” •Hgb electrophoresis HbSC disease •Sickle and SC crystals “Washington monument” •Less crises •More retinopathy/aseptic necrosis
Coombs’ Negative Hemolytic Anemia Paroxysmal Nocturnal Hemoglobinuria •Rare chronic condition •Recurrent abdominal pain, vomiting, headaches, eye pain, thrombophlebitis •Episodic Hgb in urine, Hemosiderinuria •Abnormal cell membrane - increased lysis by complement •Screening - Sucrose hemolysis test •Confirm - Acid hemolysis test (Ham’s test)
Coombs’ Negative Hemolytic Anemia Fragmented RBC’s & Thrombocytopenia TTP-HUS •Thrombocytopenia •Microangiopathic hemolytic anemia •Neurologic symptoms and signs •Renal failure •Fever •Idiopathic - 37 % Drug-associated - 13 % Autoimmune disease - 13 % Sepsis - 9 % Pregnancy - 7 % Bloody diarrhea - 6 % Hematopoietic cell transplantation - 4 % DIC •Depletion of clotting factor (TTP – normal) •Thrombocytopenia •Bleeding (64%) •Renal dysfunction (25%) •Hepatic dysfunction (19%) •Respiratory dysfunction (16%) •Shock (14%) •Thromboemboli (7%) •Central nervous system involvement (2%) •Sepsis, trauma, malignancy
IDA Summary •MicrocyticMCV < 80 fl, RBC < 6 µ •RDWWidened and shift to left •HypochromicMCH < 27 pg, MCHC < 30% •RPI< 2 •Retic. countMay be > 2 % •Serum ferritinVery low < 30 (p mols/L) •TIBCIncreased > 400 (µg/dL) •Serum IronVery low < 30 (µg/dL) •BM Fe StainAbsent Fe •Response to Fe Rx.Excellent www.drsarma.in
Anaemia of Chronic Disease •Thyroid diseases •Malignancy •Collagen Vascular Disease •Rheumatoid Arthritis •SLE •Polymyositis •Polyarteritis Nodosa www.drsarma.in • IBD – Ulcerative Colitis – Crohn’s Disease • Chronic Infections – HIV, Osteomyelitis – Tuberculosis • Renal Failure
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 www.drsarma.in
Tests Used to Diagnose Hemolysis .1Reticulocyte count .2Combined with serial Hb .3Serum LDH .4Serum bilirubin .5Haptoglobin .6Urine hemosiderin .7Hemoglobinuria www.drsarma.in
Findings in Hemolytic Anaemia www.drsarma.in Reticulocyte count and RPI Increased Serum Unconjugated Bilirubin Increased Serum LDH 1: LDH 2 Increased Serum Haptoglobin Decreased Urine Hemoglobin Present Urine Hemosiderin Present Urine Urobilinogen Increased Cr 51 labeled RBC life span Decreased
Tests to define the cause of hemolysis .1Hemoglobin electrophoresis .2Hemoglobin A2 (βeta-Thalassemia trait) .3RBC enzymes (G6PD, PK, etc) .4Direct & indirect antiglobulin tests (immune) .5Cold agglutinins .6Osmotic fragility (spherocytosis) .7Acid hemolysis test (PNH) .8Clotting profile (DIC) www.drsarma.in

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Anemia

  • 1.
  • 2.
    What is CBC? CompleteBlood 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 corpuscularvolume:  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 corpuscularhemoglobin concentration:  100   100 • It is important in diagnosis of congenital Spherocytosis (MCHC > 35) : Rbc Hb Rbc HCT
  • 6.
    PCV or Hematocrit •57%Plasma •1% Buffy coat – WBC •42% Hct (PCV) www.drsarma.in
  • 7.
    The Three Basic Measures MeasurementNormal 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. www.drsarma.in
  • 8.
    Anaemia – FirstTest RETICULOCYTE COUNT % www.drsarma.in Normal Less than 2% • ‘RBC to be’ or Apprentice RBC • Fragments of nuclear material • RNA strands which stain blue
  • 11.
    The reticulocyte count (kineticapproach) • 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.
  • 14.
  • 15.
    Workup – SecondTest • 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) www.drsarma.in
  • 16.
  • 17.
    Anaemia Workup -MCV www.drsarma.in Microcytic MCV Normocytic Macrocytic Iron Deficiency IDA Chronic Infections Thalassemias Hemoglobinopathies Sideroblastic Anemia Chronic disease Early IDA Hemoglobinopathies Primary marrow disorders Combined deficiencies Increased destruction Megaloblastic anemias Liver disease/alcohol Hemoglobinopathies Metabolic disorders Marrow disorders Increased destruction
  • 18.
    CLASSIFICATION • Classification byPathophysiology • Blood Loss • Decreased Production • Increased Destruction • Classification by Morphology • Normocytic • Microcytic • Macrocytic
  • 19.
    Anaemia Workup –3rd Test Red cell Distribution Width – RDW www.drsarma.in RDW < 13 Mean 90 fl RDW is 13 MCV 90 fl
  • 20.
    RDW • Red celldistribution 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 ? www.drsarma.in
  • 22.
    Basophilic Stippling - MBAwww.drsarma.in BSoccurs in Lead poisoning also
  • 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
  • 24.
    Basophilic stippling • leador heavy metal poisoning • Hemolytic anemia
  • 25.
  • 26.
    Howell Jolly body •Nuclear remnant - DNA • hemolytic anemia • absent or hypofunction spleen
  • 27.
    HISTORY AGE: Nutritional irondeficiency 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 hemolyticanemia, 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 historyof 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
  • 30.
    Basic chemistries • BUN,creatinine,LFT • Bilirubin, icterus = 2.5mg/dl (direct and indirect) • LDH, haptoglobin / RETIC /Coombs • Iron/TIBC • Ferritin / Hb electropheresis / • Folic acid • Vitamin B12 • Osmotic fragility • G6pd def / piruvate kinase def /
  • 31.
    Macrocytic Anaemias A. MegaloblasticMacrocytic – B12 and Folate↓ B. Non Megaloblastic Macrocytic Anaemias 1. Liver disease/alcohol 2. Hemoglobinopathies 3. Metabolic disorders, Hypothyroidism 4. Myelodystrophy, BM infiltration 5. Accelerated Erythropoesis -↑destruction 6. Drugs (cytotoxics, immunosuppressants, AZT, anticonvulsants) www.drsarma.in
  • 32.
    Macrocytic: RPI <2 B12/Folate B12 Low Normal MMA High MMA Homocysteine Normal Consider Liver, Renal, Thyroid, Alcohol, Chronic dis. Consider Bone Marrow Bx Homocysteine High Folate Low
  • 33.
    Macrocytic: RPI >=2 Occult Blood Loss? Yes Investigate source No Coombs’ (DAT) Check for Hemolysis Peripheral smear
  • 34.
    Macrocytic: RPI >=2 Hemolytic Anemia Coombs’ (DAT) Positive Immune Hemolysis Drug related Hemolysis Transfusion, Infection, Cancer Negative Hemoglobinopathy, G6PD, PK, Spherocytosis, Eliptocytosis, PNH, TTP, DIC
  • 35.
  • 36.
    Blood Loss • Acute •Traumatic • Variety of sources • Melena, hematemesis, menometrorrhagia • Chronic • Occult bleeding • Colonic polyp/carcinonma
  • 37.
  • 38.
    Increased Destruction IMMUNE MEDIATED •Cold Agglutinin • Paroxysmal nocturnal hemoglobinuria • Post mycoplasmal hemolytic anemia • Warm Agglutinin • Drug induced • Autoimmune hemolytic anemia • Transfusion reaction
  • 39.
    Increased Destruction NON-IMMUNE MEDIATED •Extra-corpuscular • Macro-circulatory • Hypersplenism • Extracorporeal circulation • Micro-circulatory • DIC • TTP • HUS • Intra-corpuscular • RBC Wall (membrane or enzyme defects) • Heme or globin abnormalities (HbS, C)
  • 40.
    Hypoproliferative Anaemias www.drsarma.in Failure of cell maturation Nuclear breakdown Cytoplasmic breakdown MegaloblasticAnaemia Defective DNA synthesis Folate or B12 deficiency Haem defect Globin defect Thalassemia Sickle cell AFe Phorph IDA, SA
  • 41.
    Decreased Production • Infectious •Neoplastic • Endocrine • Nutritional Deficiency • Anemia of Chronic Disease
  • 42.
    Decreased Production INFECTIOUS Bacterial • Tuberculosis •Viral • HIV / Parvovirus ENDOCRINE • Thyroid Dysfunction • Hypothyroidism • Erythropoietin Deficiency • Renal Failure
  • 43.
    Decreased Production NEOPLASTIC • Leukemia •Lymphoma/Myeloma • Myeloproliferative Syndromes • Myelodysplasia NUTRITIONAL DEFICIENCY • Iron • B12 • Folate
  • 44.
    Normocytic Anaemias 1. Chronicdisease 2. Early IDA 3. Hemoglobinopathies 4. Primary marrow disorders 5. Combined deficiencies 6. Increased destruction www.drsarma.in
  • 45.
    Normocytic – Normochromic Anemia Reticulocytecount < 1% ≥ 2.5% Wbc & Plt count Hemorrhage Hemolysis Coombs test Low Pancytopenia BMA & bx Aplastic anemia leukemia NL Pure red cell anemia BMA Congenital (DBA) VS acquired (TEC) - ve - Membrane defect - Hb pathy - Enzyme deficiency - Unstable Hb - HUS - Wilson disease - DIC + ve Autoimmune hemolytic anemia
  • 46.
    Macrocytic: RPI <2 Megaloblastic Anemia B12 • Inadequate absorption • Synthesized by bacteria • Meat, fish, dairy (strict vegans) • Absorbed as B12-IF complex in ileum (gastrectomy) • Ca++ and pH dependant (PPI) Folate • Inadequate intake • Synthesized by plants and micro-organism • Green leafy vege’s • Fruits • Absorbed in jejunum
  • 47.
    Macrocytic: RPI >=2 Hemolytic Anemia Other Lab Characteristics • RBC morphology • Serum haptoglobin • Serum LDH • Unconjugated bilirubin • Hemoglobinuria • Hemosiderinuria
  • 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 Irondeficiency 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
  • 51.
    P/E 1. Skin Pallor Jaundice Purpura Hyperpigmentation 2.Skeletal deformity 3. Eye manifestations 4. Angular cheilosis 5. Atrophic glositis 6. Microcephaly 7. Splenomegaly 8. Spoon nail
  • 52.
    Urinalysis • Protein: lightchains are not detected by dipstick • RBC • Hemoglobin
  • 53.
    Cabot rings (RNA orprotein precipitation artifact don’t confused with malaria)
  • 54.
  • 55.
  • 56.
  • 57.
  • 58.
  • 59.
  • 60.
  • 61.
  • 62.
    Stomatocytes Slit like centralpallor in RBC www.drsarma.in 1. Liver Disease 2. Acute Alcoholism 3. H Stomatocyosis 4. Malignancies
  • 63.
    Echinocytes Evenly distributed spicules> 10 www.drsarma.in 1. Uremia 2. Peptic ulcer 3. Gastric Ca 4. PK-D Called Burr Cells
  • 64.
    Acanthocytes 5-8 spikes ofvarying length, irregular intervals www.drsarma.in Called Spur Cells, Occur in A H A
  • 65.
    Shistocytes www.drsarma.in 1. MAHA 2. Prostheticvalves 3. Uremia 4. Malignant HT Fragmented, Helmet or triangle shaped RBC
  • 66.
    Pelger-Huet Anomaly www.drsarma.in • Inheritedcondition • PMN - Spectacles • Heterozygous • Homozygous fatal • Neutrophil Bands ↑ • Normal WCC • No e/o infection
  • 67.
    Tear Drop Cells www.drsarma.in 1.Myelofibosis 2. Infiltration of BM 3. Tumours of BM 4. Thalassemia
  • 68.
    Hair on end- Thalassemia Major www.drsarma.in
  • 69.
  • 70.
    Copyright ©2002 AmericanSociety of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2002;2002:100325 Figure 1. Note the profound central pallor of the hypochromic and microcytic RBC
  • 71.
    Lab Test forDDx 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 testdirect 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
  • 73.
    Copyright ©2002 AmericanSociety of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2002;2002:100344 Figure 5. This patient has hereditary elliptocytosis
  • 74.
    Copyright ©2001 AmericanSociety of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001:100248 No Caption Found
  • 75.
    Hemolytic anemias •Acanthocytes •Spurr cells-end stage liver disease- fatal prognosis •Burr cells •Uremia, PK deficiency •Target cells •High degree (30-100%) Hg CC, Hb EE, Hb SC, S-β-thal
  • 76.
    Hemolytic anemias •RBC enzymedefects •G6PD deficiency-X linked, NSHA, Favism, Spot test •Pyruvate kinase and other enzyme defects •Autosomal recessive, for most •Chronic hemolytic anemia •Specific enzyme assays •Intravascular hemolysis •Serum haptoglobin •Urine hemosiderin-useful 1-3 weeks after episode of intravascular hemolysis
  • 77.
    Copyright ©2001 AmericanSociety of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001:100226 Figure 1. Note the "bite cells" and the cells with "blisters" and dense cross-bonded hemoglobin
  • 78.
    Hemolytic anemias •Causes ofchronic intravascular hemolysis •Cardiac abnormalities, usually prosthetic valve •PNH •PNH- paroxysmal nocturnal hemoglobinuria •Sucrose hemolysis test •Acid serum hemolysis test (Ham’s test) •Flow cytometry for CD55, CD59
  • 79.
    Copyright ©2001 AmericanSociety of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001:100231 Figure 2. Note the hypersegmented neutrophil (7-8 lobes)
  • 80.
    RBC morphology •7-9 mwith 1/3 central palor •Lifespan of 110-120 days •About the size of nucleus of normal lymphocyte •Poikilocytosis & Anisocytosis
  • 81.
    Basophilic stippling •Precipitated RNA •leador heavy metal poisoning •ETOH abuse •Hemolytic anemia
  • 82.
    Burr cells •Altered lipidin cell membrane •artifact •Uremia •Renal failure •gastric CA •transfused old blood
  • 83.
  • 84.
    Howell Jolly body •Nuclearremnant - DNA •hemolytic anemia •absent or hypofunction spleen
  • 85.
    Schistocyte/helmet cells •Fragmented (mechanicalor phagocytosis) •DIC •TTP •HUS •Vasculitis •prosthetic heart valve •severe burns
  • 86.
    Sickle cells •Molecular aggregationof Hgb-S •SS, SC, S-thal •rarely S-trait
  • 87.
  • 88.
    Spherocyte •Absent central palor •looksmaller •Hereditary spherocytosis •immune hemolytic anemia
  • 89.
    Stomatocyte •Mouth like •Membrane defect •Smearartifact •Hereditary stomatocytosis •Liver disease
  • 90.
    Target cells •Increased redundancyof membrane •hemoglobinopathies •thalassemia •liver disease
  • 91.
    Tear drop cells •Distorteddrop shaped •Smear artifact •myelofibrosis •promyeloblastic leukemia •space occupying lesions of marrow
  • 92.
    Sideroblastic anemia •Accumulation of mitochondrialiron in erythroblasts •Hereditary •Drugs - INH, lead, zinc, alcohol, chloramphenicol, cycloserine, plavix •Hypothermia •Confirm w/ BM Bx
  • 93.
    Anemia of chronic disease •Infections:TB, SBE, osteo, chronic UTI or pyelo, fungal •Malignancy: mets, leukemia, lymphoma, myeloma •Chronic inflammatory disorders: RA, SLE, Sarcoid, collagen vascular disease, polymyalgia rheumatica, chronic hepatitis, decubitus ulcer
  • 94.
    Coombs’ positive withSpherocytes Autoimmune hemolytic anemia Warm AIHA •Abrupt onset •IgG •Anti-Rh, e, C, c, LW, U •Jaundice •Splenomegaly •SLE, CLL, Lymphoma •Drugs: methyl-dopa, mefenamic acid, cimetidine, cefazolin Cold AIHA •Insidious onset •IgM, complement •Anti-I, I, Pr •Cold agglutinin titer •Absent jaundice •Mycoplasma •Virus
  • 95.
    Coombs’ positive withSpherocytes Other immune hemolytic anemia Alloantibody hemolytic anemia •Transfusion reaction •Feto-maternal incompatibility (Kleihauer-Betke test) Drug related Hemolytic anemia •Toxic immune complex (drug+Ab+C3) - Quinine, Quinidine, Rifampin, INH, Sulfonamides, Tetracyclin •Hapten formation (anti-IgG) - PCN, methicillin, ampicillin
  • 96.
    Coombs’ Negative Hemolytic anemia •Episodic- G6PD def., PNH •Hemoglobinopathy - Sickle, crystals or target cells •Elliptocytosis •Spherocytosis •DIC, TTP
  • 97.
    Coombs’ Negative HemolyticAnemia 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 HemolyticAnemia 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 HemolyticAnemia 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
  • 100.
    Coombs’ Negative HemolyticAnemia Hemoglobinopathy continues HbC disease •Mild hemolysis •Splenomegaly •Lysine substitution •HbC crystals “bar of gold” •Hgb electrophoresis HbSC disease •Sickle and SC crystals “Washington monument” •Less crises •More retinopathy/aseptic necrosis
  • 101.
    Coombs’ Negative HemolyticAnemia Paroxysmal Nocturnal Hemoglobinuria •Rare chronic condition •Recurrent abdominal pain, vomiting, headaches, eye pain, thrombophlebitis •Episodic Hgb in urine, Hemosiderinuria •Abnormal cell membrane - increased lysis by complement •Screening - Sucrose hemolysis test •Confirm - Acid hemolysis test (Ham’s test)
  • 102.
    Coombs’ Negative HemolyticAnemia Fragmented RBC’s & Thrombocytopenia TTP-HUS •Thrombocytopenia •Microangiopathic hemolytic anemia •Neurologic symptoms and signs •Renal failure •Fever •Idiopathic - 37 % Drug-associated - 13 % Autoimmune disease - 13 % Sepsis - 9 % Pregnancy - 7 % Bloody diarrhea - 6 % Hematopoietic cell transplantation - 4 % DIC •Depletion of clotting factor (TTP – normal) •Thrombocytopenia •Bleeding (64%) •Renal dysfunction (25%) •Hepatic dysfunction (19%) •Respiratory dysfunction (16%) •Shock (14%) •Thromboemboli (7%) •Central nervous system involvement (2%) •Sepsis, trauma, malignancy
  • 103.
    IDA Summary •MicrocyticMCV <80 fl, RBC < 6 µ •RDWWidened and shift to left •HypochromicMCH < 27 pg, MCHC < 30% •RPI< 2 •Retic. countMay be > 2 % •Serum ferritinVery low < 30 (p mols/L) •TIBCIncreased > 400 (µg/dL) •Serum IronVery low < 30 (µg/dL) •BM Fe StainAbsent Fe •Response to Fe Rx.Excellent www.drsarma.in
  • 104.
    Anaemia of Chronic Disease •Thyroiddiseases •Malignancy •Collagen Vascular Disease •Rheumatoid Arthritis •SLE •Polymyositis •Polyarteritis Nodosa www.drsarma.in • IBD – Ulcerative Colitis – Crohn’s Disease • Chronic Infections – HIV, Osteomyelitis – Tuberculosis • Renal Failure
  • 105.
    Hemolytic Anaemia Anemia ofincreased 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 www.drsarma.in
  • 106.
    Tests Used toDiagnose Hemolysis .1Reticulocyte count .2Combined with serial Hb .3Serum LDH .4Serum bilirubin .5Haptoglobin .6Urine hemosiderin .7Hemoglobinuria www.drsarma.in
  • 107.
    Findings in Hemolytic Anaemia www.drsarma.in Reticulocytecount and RPI Increased Serum Unconjugated Bilirubin Increased Serum LDH 1: LDH 2 Increased Serum Haptoglobin Decreased Urine Hemoglobin Present Urine Hemosiderin Present Urine Urobilinogen Increased Cr 51 labeled RBC life span Decreased
  • 108.
    Tests to define thecause of hemolysis .1Hemoglobin electrophoresis .2Hemoglobin A2 (βeta-Thalassemia trait) .3RBC enzymes (G6PD, PK, etc) .4Direct & indirect antiglobulin tests (immune) .5Cold agglutinins .6Osmotic fragility (spherocytosis) .7Acid hemolysis test (PNH) .8Clotting profile (DIC) www.drsarma.in