This document provides an overview of practical approaches to anemia. It discusses various causes of anemia including decreased or increased destruction of red blood cells. It classifies anemias based on mean corpuscular volume and provides case examples to demonstrate diagnostic approaches. Key learning points emphasize the importance of a rational diagnostic workup for anemia and identifying cases that need specialist attention. The document also cautions that transfusion is not always the only treatment for anemia.

1. Seasons’ Greetings from
Dept.Of Medicine,
Bharati hospital

2. ANEMIA PRACTICAL APPROACH
Dr Arundhati Diwan

3. ‘It is often the physician and not the anemia
that is refractory’

4. Causes of anemia
Decreased production of RBCs
 Aplastic anemia/pure red cell aplasia/
Myelodysplasia
 Infiltration of marrow: malignancies (hematologic/
secondaries), fibrosis, granulomas
 Nutritional deficiencies: iron, folate/B12
Increased destruction/ loss of RBCs
 Hemolytic anemia
 Hemorrhage

5. Iron deficiency
Thalassemia
Congenital
sideroblastic anemia
Lead poisoning
MICROCYTIC MACROCYTIC NORMOCYTIC
CLASSIFICATION BASED ON MCV
(Normal MCV: 80- 100 fl)
Megaloblastic anemia
MDS
Aplastic anemia
Hypothyroidism
Liver disease
Anemia chronic disease
Malignancies
Hemolytic anemias

6. Case
 24 year lady 38 weeks pregnant
 1st ANC visit: Hb 8 g WBC: 5000 Plt 4 lakhs
 Physician consulted, advises IV iron sucrose,
1000 mg
 Pt follows up late, 2nd trimester. Hb 8.5. Oral iron
and folate continued
 3rd trimester: Hb 7.5g.
 Hb electrophoresis done:Thal trait

7.  Husband advised to undergo testing, refuses
as his Hb has always been 14g
 Subsequently checks Hb electrophoresis:Thal
trait

8. Concept learnt
 One must know when NOT to use iron
 Look at MCV when checking hemogram
 All ANC patients in the 1st ANC visit –
complete blood count must be checked (at
least by GPs if not the Gynecologist).

9.  Hb 4.8gm%
 RBC 1.5 million
 MCV 65
 RDW 26
 Diagnosis: Iron deficiency
 Hb: 10 g%
 RBC 5.5 million
 MCV 65
 RDW 12
 Diagnosis: Thalassemia trait

10. Case 2
30 year lady referred for refractory iron def anemia
 2 years ago: Hb: 6g WBC: 5000 Plt: 4.5 lakhs
 MCV 60, serum ferritin 2ng (15 -150)
 Receives 3 units of blood, started on oral iron 1 tab
daily for 3 months.
 Now presents with Hb 7 g
 No menorrhagia, no bleeding history
 Diagnosis?
 Inadequate dose of iron

11. Concept to be revised
 Dose of oral iron: 180 mg per day of elemental iron
 Dose of IV iron: (14 – pt Hb) x body weight x 2.4 + 500
mg
 Iron sucrose is available as 50 and 100 mg amp. Check
the strength and not number of ampoules
 Unless appropriate dose if given and dietary advise
strictly given, patient will continue to have ‘refractory
anemia’

12.  There is no role of IM iron (iron dextran) today.
 Use oral iron whenever possible
 Most side effects of oral iron (constipation) are
transient
 Use iron sucrose if: non compliant patient,
intolerable side effects, malabsorption
 Iron sucrose can be administered in your clinic,
no anaphylaxis known. Allergies may develop
 DO NOT use > 200 mg at a time, administer over
an hour

13. KOILONYCHIA
&
ATROPHIC
GLOSSITIS

14. Angular
cheiliosis

15. RERCURRENT IRON DEFICIENCY
Compliance,absorption,pan supari—Tanic acid,Gutkha,Tea drinking

16. Pica(pervertedeatinghabits)Latin
meaningbird
 The habitual ingestion of unusual substances
 earth, clay (geophagia)
 laundry starch (amylophagia)
 ice (pagophagia), tomatophagia
 Usually is a manifestation of iron deficiency and
is relieved when the deficiency is treated

17. Hypothyroidism
 Can mimic anemia
 TSH

18.  71 yr male, k/c/o DM
 Presented with weakness, fatigue, anorexia
 Diagnosed to have Anemia since 2 yrs
Received adequate iron, B12, FA supplements
with some improvement

19.  Hb- 6.1, TLC-12750, Plt- 463000
MCV- 68
PBS- MCHC, anisocytosis
Retic- 4.5, LDH- 400, Ferritin- 6.21
HAM, DCT- negative
Stool OB- Positive on two occasions
USG abdo, CXR- Normal

20.  Upper GI scopy- normal
 Colonoscopy- Two colonic pedunculated
polyps
 HPE- Low grade dysplasia

21.  Capsule Endoscopy- large ulcerative lesion in
ileum with active bleeding
 CT abdomen-10 cm ileal wall thickening with
large ulcerative exophytic growth

22.  Underwent resection anastomosis
 HPE- Invasive adenocarcinoma with single
nodal metastasis (T3 N1 M0)
 Now on chemo

23.  40 year male, symptomatic anemia since 3 months
 Physical examination : normal
 Hb: 5g% MCV: 110
 TLC: 2800, N40 L50, M5, E5
 Plt: 50,000
 Retic: 1%
 BM: Hypercellular, erythroid hyperplasia with
megaloblastic maturation, myeloids adequate with
megaloblastic changes, megakaryocytes seen
Impression: Megaloblastic anemia

25. Diagnosis of megaloblastic
anemia
 Macrocytic anemia with mild leucopenia and
thrombocytopenia
 Knuckle pigmentation – prominent finding
 PBS showing macro ovalocytosis,
hypersegmented neutrophils
 High LDH
 Bone marrow examination not required

26. Macrocytic anemia
LDH
HIGH
Megaloblastic anemia
(PBS must be suggestive)
NORMAL
MDS/ Aplastic anemia
Bone marrow

27. Myelodysplastic
syndrome
 Production of structurally and functionally
defective hemopoietic cells.
 Peripheral blood cytopenia BM:
hypercellular with dysplastic changes.
 May be impossible to distinguish
occasionally from megaloblastic anemia.
 Treatment: BMT, lenalidomide/
thalidomide, erythropoietin.

28.  65 year lady presented with weakness,
lethargy
 Clinically had just palpable spleen, no other
findings
 Hb: 7 -9 g%, WBC: 2000 – 3000, Plt: 50 –
75,000
 LDH normal, LFTs, RFTs normal
 USG abdomen: mild splenomegaly

29.  1 hematologist starts treatment with
Lenalidomide (drug used to treat MDS)
 Toxicity to Lenalidomide, pt sees another
hematologist who sees all reports, changes to
Thalidomide
 Pt does not respond (blood counts remain
same)
 Treatment changed to erythropoietin + G CSF
 Good improvement noted in Hb and WBC
 After 3 months spleen JP

30.  Suddenly admitted with massive
hematemesis
 UGI scopy done: Grade 4 varices
 Dictum:
 . Hypersplenism can occurWITHOUT
significant splenomegaly

31.  Pancytopenia with splenomegaly – UGI scopy
indicated to rule out portal hypertension
 Final diagnosis: Hypersplenism

32. Case
 25 year man, admitted for malaria. PBS MP, optimal
negative. Has jaundice. DD: Leptospirosis
 Treated for malaria 3 times in past by different
physicians. Also has had 2 episodes of jaundice in
past
 Referred for mild anemia. Has splenomegaly 3 cm
 Hb: 9g WBC: 6000 Plt 3 lakhs
 MCV: 90
 PBS reported normal

33.  Bilirubin: 4 mg Direct: 0.8, Indirect: 3.2. SGPT,
SGOT,Alk phos normal
 Reticulocyte count: 10%
 LDH: 800
 PBS reviewed: Spherocytes
 Diagnosis: Hereditary spherocytosis

34. Learning lesson
Anemia with jaundice = hemolytic anemia if
the raised bilirubin is indirect, especially if
splenomegaly present

35. Transfusion in anemia
 Patient hemodynamically unstable
 Medications are not available to control
anemia
 On going bleeding

36. Learning Points
 Most anemias can be diagnosed by rational
approach.
 Not all anemias are nutritional in original
 Important to identify which anemia needs
specialist attention early
 Transfusion is not the only answer to
treatment of anemia

37. Hb 9.7,TLC 3800
 ESR 111,platelets 32000

39. Rheumatoid Arthritis:
Ulnar Deviation and MCP Swelling An across-the-room
diagnosis
 Prominent ulnar
deviation in the right
hand
 MCP and PIP swelling
in both hands
 Synovitis of left wrist

40. RA: Anemia
• Clues of impending disaster
• High risk for NSAID gastropathy
• Presentation suggestive of blood loss
 Pale, dizzy, weak
 Tachycardia, low blood pressure
• No evidence of flare in RA to explain recent
symptoms of increased fatigue

41. Hemolytic facies- chipmunk
facies

42. Patient History
 Acute or chronic
 H/o Medication/Drug
G6PD
AIHA
 Family history
 Concomitant medical illnesses
 Clinical presentation

43. Case
 3 yr old male child presenting with
pallor,jaundice
 Severe pain of long bones, fever
 CBC-anemia,reticulocytosis,increased WBC
 LAB - LDH -600 u/L (normal upto 200)
S.bilirubin- 5mg%
Unconjucated-3.6 mg %

44.  SICKLE CELL ANEMIA

45. CASE
 6 yr old sindhi child presenting with severe
pallor,jaundice growth delay
 “Chipmunk facies”,hepatosplenomegaly+
 H/o recurrent blood transfusions
 CBC-Hb -3gm%, MCV-58 fl(Nl-86-98),
-MCH- 19pg (nl-28-33)

46. CASE
 45 yr old male came to OPD in a remote PHC
with burning micturation.
 Urine R/M shows numerous pus cells.
 UTI diagnosed & medical officer gave
Cotrimoxazole 2 bd X 5days
 1 wk later,pt developed severe
pallor,palpitation,jaundice
 Lab- increased LDH, S.BILIRUBIN,RETIC COUNT
 P.B.S- shows bizarre poikilocytes.

47. Diagnosis?
 G-6PD DEFICIENCY

48. Consecutive urine samples from another patient.
Variation in the severity of hemoglobinuria within hours.

49. Renal dysfunction serum
creatinine
 Rx iron ,Erythropoietin

50. Case
 58/M
 Presented with backache
 Urea 58, Creat 2.4
15-03-2016AJK 50

51. 15-03-2016AJK 51

52. 15-03-2016AJK 52
Case 8

54. Clinical features ofAplastic anemia
 Red cells : anemia
 White Cells: Fever, sepsis
 Platelets: bleeding

55. Typical case
 Hb: 4g%
 WBC: 1500/cmm
 Platelet: 10,000
 LDH: normal

56. 15 yr male
Hb: 12 g%
TLC: 4000
DLC: N40, L60
Plt: 15,000
15 yr male
Hb: 12 g%
TLC: 800
DLC: N10, L90
Plt: 2,00,000

57.  Hb: 8g%, TLC: 800, Plt: 1,50,000
 History- fever since 1 month, joint pains since
15 days, visited local GP, received injections
and tablets- fever and joint pains subsided
completely, patient now feels well

58. BM
 Moderately hypocellular
 Normal erythroids
 Myeloid hypoplasia
 Megs- adequate
Whats the next step?

59.  Wait for few weeks, monitor blood counts
weekly
 Likely diagnosis: Partially treated acute
lymphoblastic leukemia

60. ThankYou

61. Thank you
Thank You