The document discusses anemias and their classification. It begins by defining anemia and noting that it is a reduction in red blood cells (RBCs) or hemoglobin. Anemias are classified based on RBC size and hemoglobin content as hypochromic microcytic, normocytic, or macrocytic. Causes can include blood loss, decreased production, or increased destruction. A thorough diagnostic approach considers the patient's history, physical exam findings, and lab tests to determine the underlying cause of the anemia. Complete blood count, RBC indices, reticulocyte count, and peripheral smear help characterize the anemia. Identifying associated symptoms and risk factors provides clues to facilitating diagnosis

1. The Anemias
Professor Dr. Salah Al-Zuhairy, MD.

2. Introduction
 The study of the blood has a long history.
 Humankind probably always has been
interested in the blood because it is likely
that even primitive peoples realized that loss
of blood, if sufficiently great, was associated
with death.
 In biblical references, to shed blood meant to
kill.

3. Introduction
Anemia :
 It is a reduction of the RBC volume or hemoglobin
concentration below the range of values occurring in
healthy persons.
 It is a reduction of the RBC volume or hemoglobin
concentration below -2SD for age, race and sex.
 In certain pathologic states, anemia may be present
when the hemoglobin level is within the normal range:
 cyanotic cardiac diseases
 pulmonary disease
 hemoglobin with an abnormally high affinity for oxygen
is present.

4.  A reduction in the amount of circulating
hemoglobin decreases the oxygen-carrying
capacity of the blood
 But few clinical disturbances occur until the
hemoglobin level < 7–8 g/dL.
 Anemia is not a specific entity
 It is the result of many underlying pathologic
processes.
 Anemia is a common complication of many
disorders and may accentuate organ
dysfunction.
Introduction

5. Introduction
It is important for pediatricians to recognize
that:
 RBC size changes with age
 MCV variations in childhood
 It is essential to review the appearance of
RBCs on a peripheral blood smear
 The presence of polychromatophilia, which
usually correlates with the degree of
reticulocytosis, indicates that the marrow is
able to respond to RBC loss or destruction.

6. Introduction:COMPLETE BLOOD COUNT
Hb Concentration (g/dl)
Hematocrit (PCV) (%)
MCV (fl)
MCH (pg)
MCHC (g/dl)
RBC Count (…x106/ mm3 )
RDW (%)
WBC Count (…x103/ mm3 )
Neutrophil ( % )
lymphocyte ( % )
Monocyte ( % )
Basophil ( % )
Eosinophil ( % )
Platelet Count (…x103/ mm3 )
Reticulocyte Count ( % )

7. Introduction: COMPLETE BLOOD COUNT
Normal Values

8. Introduction: Normal values

9. Introduction: Reticulocyte Production Index
• RPI corrects the retics for the degree of anaemia
• RPI indicates whether bone marrow is responding
appropriately to anemia
• RPI= Retic x Hb(O) x 0.5 / Hb(n)
• RPI > 3 increased production (hemolysis or blood loss)
• RPI < 3 decreased production or ineffective production for
the degree of anaemia
• Reticulocytopenia—acute onset of anemia, antibody
mediated destruction, BM disease , or failure.

10. Anemias are classified based on the size and hemoglobin
content of the cells
1. Hypochromic, microcytic anemia: is caused by an
inadequate production of hemoglobin.
 The most common causes of this type of anemia are
iron deficiency and thalassemia.
2. Normocytic anemia: are associated with a systemic
illness that impairs adequate marrow synthesis of
RBCs.
3. Macrocytic anemia: are associated with vitamin B12
and folic acid deficiencies
Classification

11.  Anemias may occur from increased destruction (hemolysis).
 Hemolytic diseases are mediated either by:
1. Intrinsic disorders of the RBC:
 Memebrane defect :Hereditary spherocytosis and Hereditary
elliptocytosis.
 Enzyme deficiencies : G6PD deficiency and pyruvate kinase
deficiency
2. Extrinsic disorders to the RBC: Immune-mediated
hemolysis
 Extravascular Hemolysis: when RBCs coated with antibodies
or complement are phagocytosed by the RE system
 Intravascular Hemolysis: when antibody binding leads to
complement fixation and lysis of RBCs.
Classification

12. • Age : Iron deficiency is rare without
blood loss before 6 mo in term infants.
• Family History & Genetics:
1. X-linked: G6PD deficiency.
2. Autosomal dominant: Spherocytosis
3. Autosomal recessive : Sickle cell diseases ,
Fanconi anemia
4. Family member with early age of
cholecystectomy or splenectomy
5. Ethnicity: Thalassemia; G6PD deficiency.
Diagnostic Approach:
History

13. • Diarrhoea:
Malabsorption of Vitamin B12 / E /Fe.
Inflammatory bowel diseases, and
anemia of chronic disease with or
without blood loss.
Milk protein intolerance induced blood
loss.
Intestinal resection: Vitamin B12
deficiency.
Diagnostic Approach:
History

14. • Infections:
Giardia: iron malabsorption (IDA)
Intestinal bacterial overgrowth: Vitamin B12
deficiency.
EBV, CMV, Parvovirus: Bone marrow suppression.
Mycoplasma, Malaria: Hemolysis.
Hepatitis: Aplastic anemia.
Endocarditis, HIV: Anemia of chronic disease, or
hemolysis.
Diagnostic Approach:
History

15. • Nutrition:
Cows milk diet: Iron deficiency
Strict vegetarian: B12 deficiency.
Goats milk: Folate deficiency.
Pica: Plumbism, Iron deficiency.
Cholestasis, malabsorption: Vitamin E
deficiency.
Diagnostic Approach:
History

16. • Drugs:
G6PD: Oxidants (sulfa, primaquine, henna)
Immune mediated hemolysis: Penicillin
Bone marrow suppression : Chemotherapy.
Phenytoin: Increase folate requirement
Diagnostic Approach:
History

17. • Fever: Acute infection, collagen vascular disease
• Jaundice: Hemolysis
• Petechia & Purpura: Bleeding tendency
• Hypertension &edema: Renal disease (HUS)
• HSM and LAP: Infiltrative disease, malignancies.
• Growth failure or poor weight gain: Anemia of chronic
disease or organ failure
• Examine stool for blood
• Examine urine for hemoglobinuria
Physical exam reveals presence
and potential causes of anaemia

18. Skin:
 Hyperpigmentation, café au lait spots: Fanconi anemia
 Jaundice: hemolysis
 Petechia & purpura: BM infiltration, or aplasia
 Erythematous rash: Parvovirus, EB virus
 Butterfly rash: SLE
 Vitiligo: Vit-B12 deficiency.
Physical Findings in Anaemia

19. Head:
 Frontal bossing: Thalassemia major
 Microcephaly: Fanconi anemia
Physical Findings in Anaemia

20. Eyes:
 Microphthalmia: Fanconi anemia
 Retinopathy: Sickle cell disease
 Optic atrophy: Osteopetrosis
 KF ring: Wilson disease
Ears:
 Deafness: Osteopetrosis
Physical Findings in Anaemia

21. Mouth:
 Glossitis: B12 deficiency, iron deficiency.
 Angular stomatitis: Iron deficiency.
 Pigmentation: Peutz Jeghers syndrome.
 Telangiectasia: Osler Weber Rendu syndrome
Physical Findings in Anaemia

22.  Chest:
o Cardiac murmur: Endocarditis, prosthetic valve
hemolysis
 Abdomen:
 Hepatomegaly: Hemolysis, infiltrative
processes , chronic disease, hemangioma,
cholecystitis
 Splenomegaly : Hemolysis, SCD, thalassemia,
malaria, EBV, portal hypertension
 Kidney anomaly: Pelvic/absent kidney
Physical Findings in Anaemia

23. Extremities:
 Absent thumb: Fanconi anemia
 Spoon nails: Iron deficiency
 Dystrophic nails: Dyskeratosis congenita
 CNS:
• Irritable, apathy: Iron deficiency.
• Peripheral neuropathy: Lead poisoning
• Ataxia, post.column signs: B12 deficiency
• Stroke: Sickle cell anemia
 Short stature: Fanconi anemia, Malnutrition
Physical Findings in Anaemia

24. Thank You