The Ambulatory medicine Resident topic review) at Chiang Mai university

1. Patama Gomutbutra
Consultant : Lect. Lalita Norasetthada
Anemia
Ambulatory setting

2. Challenge of anemia in real life

3. Case
• A Thai male 74 year-old UD: HT, DLP,Gouty arthritis
• CC: Transient loss of conscious and palpitate
• PI : progressive fatigue for a month. Dyspnea on exertion.
No fever
No orthopnea or PND
No bone pain
No passing bloody stool
No passing dark urine

4. • PH:
• Never be hospitalized before.
• Social history:
• Social drinker
• No smoking
• FH:
• Grand children has ‘blood disease’ that need to receive blood
every 2 months
• His wife died last month from multiple organ failure

5. Physical exam
• An old man with alert and oriented
• VS BP 103/80 PR 97/min
• HEENT : mild pale conjunctivae, no icteric sclerae
• Heart : regular, SEM gr II all valvular area
• Lungs : clear , equal breath sound
• Abd : No hepatospleenomegaly
• Ext : No pitting edema
• PR : No melena

7. • Corrected RC = 6.62 X (18.3 /45) = 2.68

9. TS = SI/TIBC = 16.5%

11. Hb-typing 1 day after the patient received PRC 2 u

12. Which mechanism is the major contributor
for anemia in this patient
•A. Low iron intake
•B. Occult blood lost
•C. Bone marrow failure
•D. Extravascular hemolysis
•E. Inflammatory reactant-Hepcidin

13. PBS
• Hypochromic microcytic. Anisopoikilocyte 2+ ,No nRBC
• Increased polychromasia
Imp: Thallasemia trait with occult blood lost

14. Further work up for occult blood loss
•Stool occult blood positive
•EGD & Colonoscopy
• Mild gastritis
•Internal hemorrhoid

15. Hb < 12 for female
Hb < 13 for male
Low MCV <80
High RCLow RC
Normal MCV 80-100
High RC
Low RC
High MCV >100
High RCLow RC
MCV, RC
!
Adapted from Norasettada L et al. 2013
! !
Hemolysis ?
- LDH
- Bilirubin
w Indirect bilirubin
- Haptoglobin (likely intravas)
SI/TIBC high
• Lead poisoning
• Sideroblastic
Hb typing normal
• PNH
• IDA w Iron
suppl
Bi/pancytopenia
• Aplastic
• MDS
• BM infiltrate
Coomb’s positive
• AIHA (E)
Megaloblastic :
hypersegmented neutrophil
• B12 def
• Folic def
SI/TIBC low <20
• Iron def
anemia
• ACD
• Thal trait
Hb typing abn
• Thalasemia
major
Occult bleeding ?
Pure anemia
• Endocrine
Thyroid, AI
• BM defect
MM, PRCA
Non megaloblastic
• Liver disease/Alcohol
• Hypothyroid
• BM defect
Coomb’s negative
• MAHA (I )
• G-6-PD (I )
• Malaria (I)
• Spherocytosis(E)
!

16. Challenge of anemia in OPD
When PBS (usually the must) is not available
•Hemoglobin problem? -> MCV
•RBC production -> RC, Abs reti
•Hemolysis -> LDH, DB, Haptoglobin
•Iron status -> SI/TIBC, Ferritin
•Anisocytosis -> RDW
•Thailand -- Thalassemia land

17. MCV < 80

18. Corrected reticulocyte count
= %RC x Hb pt / 45
• < 1%= poor RBC production
• > 3%= increase RBC production
• 1-3% Need correlate with degree of anemia

19. Absolute reticulocyte count
= corrected RC X RBC
• < 25,000 /mm3 (25x10^9/L) = poor RBC production
• > 100,000 /mm3 (100x10^9/L) = increase RBC production
• 25,000 -50,000 need correlate with degree of anemia
ie abs reti 30,000 (1.2 times) in Hb drop from 12 -> 6 (2 times)
= poor RBC production

20. Hemolysis
• LDH increase
• Increase dominant indirect bilirubin (> 1/3 of TB)
• Haptoglobin decrease or absent -> likely intravascular
hemolysis

21. Free Hb
bind to
Haptoglobin

22. Accumulate PTP intermediate = Porphyrias (Greek – Purple)
Acute intermittent porphyria Porphyria cutanea tada
Lack of Protoporphyrin
lead to excess iron
= Sideroblastic anemia (Greek – iron)
Fe
PTP

23. • Feritin is the best indicator for
Iron storage status
cut point 100
sens = 70 %
spec = 95 %
• TIBC is Transferin ‘seeking for Fe’
Lower Fe -> Higher TIBC
(SI/TIBC)
350 ug/dl
100 ug/dl
50 ug/dl 300 ug/dl

24. Note : Iron deficiency concert
•SI decrease
and
•TIBC increase
and
•Feritin decrease

25. RDW = Level of varies in size (anisocytosis)
Normal range of RDW-CV
< 16-18 %
Why divide by MCV ?
= To fair with higher upper limit
of RBC population

26. Thallasemia minor/ trait
• Hb normal or mildly reduced
• MCV reduced
• Hb electrophoresis
• HbA2: <5 % (<3.5 = alpha , > 3.5 = beta)
• Hb F: < 5 %
• HbCS 1-2%
• Not cause of significant hemolytic anemia
• PBS- milder anisopoikilocytosis. No nRBC

27. Exercise case
A 25 year old waiter with recurrent pulmonary TB
and long term Isoniazid treatment
• Hb = 3.8
• MCV = 72
• RC corrected = 1.7
• RDW = 22
• SI = 246 (50-150)
TIBC = 254 (250-450)
Feritin = 446 (27-224)
• TB/DB = 1.0/0.2
What is the most likely diagnosis
A. Iron def anemia
B. Thallasemia
C. Anemia of chronic disease
D. Sideroblastic anemia
E. Lead poisoning