The diagnosis is vitamin B12 deficiency (pernicious anemia). The neurologic findings can be explained by the fact that severe B12 deficiency can damage the dorsal and lateral columns of the spinal cord, leading to decreased vibratory sense, loss of position sense in the joints, and possibly ataxia. This is because B12 is essential for myelin formation and maintenance in the nervous system. The next step would be to measure the patient's serum B12 level and consider treatment with parenteral B12 injections if deficient.

1. DR HASEEB AHMED BHATTI
MBBS, MD (USA)

2. Definition
• Anemia is a condition in which the number of RBCs
or their oxygen-carrying capacity(Hb content) is
insufficient to meet physiologic needs, which vary by
age, sex, altitude, smoking, and pregnancy status
• For diagnosis and further evaluation Hb values:
• <13 g/dL in adult males.
• <12.0 g/dL in adult females.
o Hgb = expression of amount (g/dL).
o Hct = expression of volume (% or decimal fraction).
o RBC = expression of number (#/mm3).
WHO recommendations

3. Anemia: Special Populations
• Higher Hb/HCT:
o Patients living at high altitudes
o Smokers and patients living in air pollution areas
o Endurance athletes have increased HCT
• Lower Hb/HCT:
o African-Americans have 0.5 to 1 g/dl lower Hb than
do Caucasians
o Elderly (slowed erythropoiesis)
o Pregnant women (hemodilution)

4. Normal erythropoiesis
© Dr. Haseeb Ahmed Bhatti

5. © Dr. Haseeb Ahmed Bhatti

6. Normal Iron cycle
© Dr. Haseeb Ahmed Bhatti

7. Mechanism of anemia
• Any process that can disrupt the normal life span of a
red blood cell may cause anemia. Normal life span of a
red blood cell is typically around 120 days. Red blood
cells are made in the bone marrow.
• Anemia is caused essentially through two basic
pathways. Anemia is caused by either:
1. a decrease in production of red blood cells or
hemoglobin, or
2. an increase in loss or destruction of red blood cells.

8. Pathophysiologic
Classification
I. Anemia due to blood loss
a. Acute post haemorrhagic anemia
b. Anemia due to chronic blood loss
II. Anemia due to impaired red cell formation
a. Cytoplasmic maturation defects
-Deficient haem synthesis : Iron deficiency anemia
-Deficient globin synthesis : Thalassaemic syndromes
b. Nuclear maturation defects
Vitamin B12 & /or Folic acid deficiency : Megaloblastic anemia 6
© Dr. Haseeb Ahmed Bhatti

9. Pathophysiologic
Classification
c. Defect in stem cell proliferation & differentiation
1. Aplastic anemia
2. Pure red cell aplasia
d. Bone marrow failure due to systemic diseases
(anemia of chronic disorders)
1. Anemia of inflammation/infections, disseminated
malignancy.
2. Anemia in renal disease
3. Anemia due to endocrine & Nutritional deficiences
4. Anemia in liver disease
© Dr. Haseeb Ahmed Bhatti

10. Pathophysiologic
Classification
e. Bone marrow infiltration
1. Leukaemias
2. lymphomas
3. Multiple myeloma
f. Congenital anemia
1. Sideroblastic anemia
2. Congenital dyserythropoietic anemia.
III. Anemia due to increased red cell destruction (hemolytic
anemias)
1. Intracorpuscular defect (erythrocyte defects- membrane
abnormalities, metabolic disturbances, disorders of hemoglobin)
2. Extracorpuscular defect (abnormal elements in vascular bed that
“attack” RBCs)
© Dr. Haseeb Ahmed Bhatti

11. Morphology Classification
• Microcytic (MCV <80 µ3):
o Iron deficiency, thalassemia, chronic
disease/inflammation, sideroblastic anemia, lead
poisoning.
• Normocytic (MCV 80-100 µ3):
o Acute blood loss, chronic disease, hypersplenism,
bone marrow failure, hemolysis.
• Macrocytic (MCV >100 µ3):
o B12 or folate deficiency, hemolysis with
reticulocytosis, chemotherapy, hypothyroidism, MDS.

12. 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

13. CLINICAL FEATURES
© Dr. Haseeb Ahmed Bhatti

14. Physical examination
• Pallor (may be jaundiced– think hemolytic)
• Tachycardia, bounding pulses
• Systolic flow murmur
• Glossitis
• Angular cheilosis
• Decreased vibratory sense/ joint position sense
(B12 deficiency, w/ or w/o hematologic changes)
• Ataxia, positive Romberg sign (severe B12/folate
deficiency)

15. Preliminary investigations:
Complete blood count (CBC), red cell indices,
white blood cell count, and differential, and
platelet count
Absolute reticulocyte count
Serum ferritin level
Serum transferrin saturation (TSAT)
Serum vitamin B12 and folate levels
© Dr. Haseeb Ahmed Bhatti

16. © Dr. Haseeb Ahmed Bhatti

17. Fe++ deficiency anemia
• Most commonly due to chronic bleeding and
erythropoiesis limited by iron stores that have been
depleted
• May be dietary (pica, lack of meat/ vegetables, other)
• Iron balance is very close in menstruating women, so
Fe++ deficiency is not uncommon with no other source of
bleeding
• Determine the underlying cause

18. Labs
• Iron and ferritin will be low
• TIBC (total iron binding capacity) will be high,
since iron stores are not saturating their binding
sites on transferrin
• Reduced RBC counts (definition of anemia)
• Microcytosis & hypochromia are hallmarks, but
early Fe++ may be normocytic (± hypochromic)
• Usually, MCH and MCHC will both be low
(whereas in macrocytic anemia, the MCH may
be normal while the MCHC is low, because of
the larger cell size)

19. 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   

20. © Dr. Haseeb Ahmed Bhatti

21. Treatment
• Iron, oral in most cases, parenteral in cases of
malabsorption
• All forms of iron are constipating; the amount of
constipation directly relates to the amount of elemental
iron delivered
o If intolerant of FeSO4 (cheapest), reduce the dose, rather than switching form
o Start 325 mg QD, increase slowly to TID
• Grey/black iron stools vs tarry stools
• Avoid tea with iron, encourage citrus fruits
• Follow up the cause of the iron deficiency!

22. Anemia of chronic disease
• Normocytic anemia with ineffective
erythropoiesis (reduced reticulocyte count)
• May be normochromic or hypochromic
• Results from
o Chronic inflammation (e.g. rheumatologic disease):
Cytokines released by inflammatory cells cause
macrophages to accumulate iron and not transfer it to
plasma or developing red cells (iron block anemia)
o Renal failure (erythropoietin from kidneys)
o Endocrine (e.g. hypothyroid)
o Hepatic disease
• Bone marrow suppression (EPO is elevated)

23. Treatment
• Correct or manage underlying disease when possible
o May need EPO injection ($$$$)
• EPO is the treatment of choice for anemia of renal failure
• In bone marrow deficiency/malignancy, treat if possible,
remove precipitating drugs, may require BMT

24. Macrocytic anemia with ineffective
erythropoiesis
• Low/normal reticulocyte count, macrocytosis
• Most common is folate/B12 deficiency
o Dietary: folate far more common, B12 may occur in
strict vegans
o Pernicious anemia: lack of B12 protection in stomach
and gut
o Poor uptake in terminal ileum (e.g. in Crohn’s
disease)
o B12 and folate are essential for cell maturation and
DNA synthesis, erythrocytes end up large, usually
normochromic, since iron is not lacking
• Other: drugs, toxins, myelodysplasia

25. MCV > 115 fl DDX Folate or B12 Deficiency
Folic Acid
Deficiency
B12 Deficiency
Peripheral smear & BM
morphology
Same Same
Dietary Cause Common, in 3-
4 months
Rare, except pure
vegans, 3-4 yrs
Drugs interfering with
absorbtion
Dilantin, oral
contraceptives
Omeprazole
(Prilosec)
Neurologic findings No May be present
Methylmalonic acid level Normal Elevated
Schilling test Useful for
etiology
Obtain after Rx

26. Folate deficiency
• Folate intake is usually dietary, and may be deficient with
low fresh fruit & vegetable intake
• Folate supplementation of bread prevents neural tube
defects in pregnancy
• PE may include neurological effects if severe deficiency

27. 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)

28. B12 deficiency
• Less common, usually caused by absorption
problems, rather than dietary deficiency
• B12 needs Intrinsic Factor for protection from
degradation in gut
o Produced by parietal cells of stomach, protects
through gut for uptake at terminal ileum
o Pernicious anemia from immune attack of IF
production
o EtOH-related gastritis can affect IF production, and
liver disease may also contribute to macrocytosis

29. Neurological effects
• Deficiency results in damage to dorsal columns
(sensory) and lateral columns (motor) of spinal
cord
• Decreased vibration sense and position sense of
joints detectable, and may affect gait, etc.
• May have positive Romberg’s test
• Severe effects may include ataxia and dementia

30. Labs
• Folate and B12 levels
• Schilling test may be useful to establish etiology
of B12 deficiency
o Assesses radioactive B12 absorption with and without exogenous IF
• Other tests if pernicious anemia is suspected
o Anti- parietal cell antibodies, anti-IF antibodies
o Secondary causes of poor absorption should be sought (gastritis, ileal
problems, ETOH, etc.)

31. Treatment– supplementation
• Do NOT correct folate levels unless B12 is OK
o Correction of folate deficiency will correct hematologic
abnormalities without correcting neurological
abnormalities
o Check B12 and correct first
• B12 usually 1000 mg I.M. q month
o B12 stores take a long time to deplete; missed doses
are not usually a problem
o Oral supplementation is gaining support; usually
effective in pernicious anemia (1-2 mg PO QD)
• Reticulocyte count should respond in 1 wk

32. Normochromic, normocytic anemia
with effective erythropoiesis
• INCREASED reticulocyte count
• Acute blood loss
o Very acutely, with hypovolemia, may have normal
blood counts, will become anemic with volume
replenishment
• Hemolytic anemia
o Increased reticulocyte production cannot keep pace
with loss of RBCs peripherally

33. Hemolytic Anemia
• Intrinsic RBC causes
o Membranopathies: hereditary spherocytosis
o Enzymopathies: G6PD
o Hemoglobinopathies: Sickle cell disease
• Extrinsic causes
o Immune mediated: Autoimmune (drug, virus, lymphoid
malignance) vs Alloimmune (transfusion reaction)
o Microangiopathic (TTP)
o Infection (Malaria)
o Chemical agents (spider venom)
© Dr. Haseeb Ahmed Bhatti
Inadequate number of RBCs caused by premature destruction
of RBCs

34. Immune hemolytic anemia
• IgG or IgM labeled as “warm” or “cold”
o Antibodies on RBC result in hemolysis
• Usually acute, often with jaundice
• May be drug-induced
• Cold hemolytic anemia often post-infectious,
generally not severe, worsens with exposure of
periphery to cold temperatures

35. Diagnosis of Hemolysis
• Symptoms depend on degree of anemia (ie, rate of
destruction)
• Clinical features: anemia, jaundice, reticulocytosis,
high MCV & RDW, elevated indirect bili, elevated
LDH, low haptoglobin, positive DAT/Coomb’s (AIHA)
• Acute intravascular hemolysis: fever, chills, low
back pain, hemoglobinuria
• Smear: polychromatophilia, spherocytosis &
autoagglutination

36. Copyright ©2001 American Society of Hematology. Copyright restrictions may apply.
Schrier, S. ASH Image Bank 2001;2001:100214
Figure 1. Note the dense microspherocytes and the macrocytes with
polychromasia

37. Special cases of hemolytic anemia
• Glucose-6 Phosphate Dehydrogenate deficiency
o More common in African and Mediterranean
populations
o Lack of RBC enzyme makes cells very sensitive to
oxidative stress (infection, certain drugs eg. penicillin,
quinidine, quinine, rifampin)
o Treatment: avoid triggers if possible, especially
inciting drugs

38. Sickle cell disease
• African background, Autosomal recessive
• Abnormal hemoglobin (HBS) causes change in
RBC shape(sickle or crescent), resulting in
constant RBC destruction by the spleen,
functional asplenia, susceptible to infection
• Arterial occlusion leads to infarcts, pain crises,
acute chest syndrome, stroke, MI
• Keep hydrated, treat pain, take infection
seriously

39. © Dr. Haseeb Ahmed Bhatti

40. Thalassemias
• Decreased production of normal hemoglobin polypeptide
chains.
• Classified according to hemoglobin chain that is affected
(α,β,γ,δ)
• Common, variable severity of hemolysis
• Characterized by hypochromic microcytic red cells (MCV
markedly decreased while MCHC only slightly
decreased)
• Beta Thalassemia most common in this country and can
be suspected if electrophoresis shows a compensatory
increase in Hb A2 and/or F (fetal). (Note: Hb A2
generally does not increase above 10%)

41. Case Studies

42. Anemia
Case Study #1
A 72 year old
male has the
CBC findings
shown.
Peripheral
RBCs are
hypochromic
& microcytic.

43. Anemia
Case Study #1
• What test would you order for this
patient?
• A-Hemoglobin Electrophoresis
• B-Retic count
• C-Stool for occult blood
• D-B12 Assay
• E-Bone marrow biopsy

44. Anemia
Case Study #1
• Two questions:
o What is your diagnosis?
o What is the next step for this patient?

45. Anemia
Case Study #1
• Answers
o Question 1
• Likely Iron Deficiency Anemia
o Question 2
• Colonoscopy

46. Anemia
Case Study #2
A 48 year old male
has become
progressively more
fatigued at the end
of the day. This has
been going on for
months. In the past
month he has noted
paresthesias with
numbness in his
feet. A CBC
demonstrates the
findings shown.

47. Anemia
Case Study #2
A peripheral blood
smear (the slide is
representative of
this condition)
shows red blood
cells displaying
macro- ovalocytosis
and neutrophils with
hypersegmentation.

48. Anemia
Case Study #2
Which of the following tests would be most useful to
determine the etiology?
A. Hemoglobin electrophoresis
B. Reticulocyte count
C. Stool for occult blood
D. Vitamin B12 assay
E. Bone marrow biopsy

49. Anemia
Case Study #2
• Questions:
• What is the diagnosis from these findings?
• How do you explain the neurologic findings?

50. Anemia
Case Study #2
• Answers:
o Question 1
• This is a macrocytic (megaloblastic) anemia. The neurologic findings
suggest vitamin B12 deficiency (pernicious anemia).
o Question 2
• The B12 deficiency leads to degeneration in the spinal cord
(posterior and lateral columns).

51. Thank you
© Dr. Haseeb Ahmed Bhatti
An approach to diagnosis of anemia
https://youtu.be/aupUH6ONmQg