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Approach To A Patient With Anemia
1. Anemia can be classified based on MCV as microcytic, normocytic, or macrocytic. Laboratory data and physical exam findings help determine the underlying cause. 2. Automated hematology analyzers use electrical impedance and light scattering to count and characterize blood cells from a sample. This provides rapid results but still requires confirming abnormal findings on a peripheral smear. 3. A thorough history, physical exam, and initial lab work can help establish a differential diagnosis and guide further testing for a patient presenting with anemia.
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Approach To A Patient With Anemia
- 1. Approach To APatient With Anemia Dr. Mohammad Usman Shaikh Assistant Professor, Aga Khan University Hospital.
- 2. Hematology • Study ofblood forming tissue and circulating blood component • Clotting factors • Blood groups • CBC and smear examination regardless of specialty • Accessible, close proximity to tissues, often provide some information • Important for accurate diagnosis and therapeutics choices
- 3. Manual Versus Automation Feasibility: Workload: •Depend on number of samples per day • Less than 20 samples, prefer manual method • Tertiary care hospital setting in western hospitals, CBC is mandatory for consultation. • Rapid analysis • Require only an appropriate blood sample. • Measure 8-25 variables, no equivalent manually.
- 4. Principles of Automation •Electrical Impedance • Light scattering
- 5. Electrical Impedance Detection &measurement of changes in electrical resistance produced by cells as they passes via a small aperture Electrical resistance between two electrodes, or impedance in current leads to the formation of pulses
- 6. A stream ofcells passes through aperture across which electrical current is applied. Each cell that passes alters electrical impedance and can thus be counted and sized. Good Pulse Diluent stream
- 7. Sensing Zone Red Blood Cells ElectricalImpedance Oscilloscope Oscilloscope Each time a cell passes a pulse is produced. The pulse height is proportional to Cell volume Animation by M.A.Ghauri
- 8. Light Scattering O-3 deg (relativesize) Light Scatter estimates relative cell size based on forward scatter - that is a measurement of cross-sectional diameter Laser
- 9. Hemogram/ Histogram • Visualrepresentation of what was counted at the aperture. • Verify a count that has a typical pattern according to the reference ranges • Alert for possible interfering particles and abnormalities
- 11. Hematological Variables onAutomation RBC Hb, HCT, MCV, MCH, MCHC, RBC count, RDW WBC Total count, differential and absolute count Platelet Total count Others: Nucleated RBC, reticulocyte count flags
- 12. Anemia – Definition: lowHemoglobin and hematocrit – Results from a wide variety of disorders
- 13. Anemia • Laboratory datais more informative when considered in the context of history and physical examination
- 14. Approach to Anemia •History: – Family history– inherited causes such as thalassemia, sickle cell anemia, G6PD deficiency and hereditary spherocytosis. – In most of these cases morphological findings of smear are diagnostic • B symptoms • Systemic or other chronic disorders
- 15. History • Drug history: •History of blood loss • Clinically: Degree of pallor, with or without icterus, angular stomatitis and glossitis, koilonychia, lymphadenophathy and hepatoslenomegaly
- 16. Koilonychia Physical Examination: helps todirect the clinician to the cause of anemia Iron deficiency: koilonychia, glossitis, ang ular stomatitis.
- 17. Glossitis B12 deficiency: decrease vibrationand postural sense Folate deficiency: glossitis, sign of malabsorption, alcohol abuse and pregnancy
- 18. Angular stomatitis Angular stomatitis: nonspecific, can be seen in iron deficiency, B12 and folate deficiency
- 19. Lymphadenophathy • Bone marrow failure/infiltration:fever, Petechiae, lymphadenophathy, splenomegaly and sternal tenderness
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- 24. Classification of Anemiaon the Basis of MCV Less than 76fl --- microcytic Iron deficiency Thalassemia Anemia of chronic disease Sideroblastic anemia and lead poisoning MCV between 76 to 96 fl Anemia of chronic disease Acute blood loss Chronic renal failure Anemia due to infiltration Aplastic anemia
- 25. Classification of Anemiaon the Basis of MCV • MCV more than 96fl – Macrocytic anemia • Megaloblastic: B12 and folate deficiency • Non megaloblastic: – Hemolysis – MDS – Hypothyroidism – Liver disease
- 26. Etiological Classification ofAnemia: • Increase destruction 1-Hemolytic anemia inherited and acquired • Impaired Production 2-Anemia due to bone marrow failure states 3-Nutritional deficiencies 4-Anemia due to infiltrative disorders 5-Anemia of chronic disorders
- 27. Hemoglobin: 3.5 gm/dl HCT:12% MCV: 57 fl MCH: 18 pg TLC: 22,000 Platelets: 155,000
- 30. Hemoglobin: 4.5 gm/dl HCT:14% MCV: 56 fl MCH: 20 pg TLC: 6,000 Platelets: 600,000
- 32. NORMOCYTIC NORMOCHROMIC ANEMIA MCVbetween 76 to 96 fl • Anemia of chronic disease • Acute blood loss • Chronic renal failure • Anemia due to infiltration • Aplastic anemia
- 33. Hemoglobin: 8 gm/dl HCT:25% MCV: 84 fl MCH: 27 pg TLC: 5000 Platelets: 205,000
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- 35. Sickle Cell Disease •Rare in Pakistan (Balochistan), common in Middle East, and up to 40% trait in Central Africa • Qualitative globin chain defect; Homozygous inheritance • Deoxy Hb S--- tendency to aggregate--- sickle cell • Increase blood viscosity --- vascular stasis---tissue damage + RBC membrane damage • Sickling depend on Hb S concentration • Hb S <50%, usually no symptoms • Hb F---confer protection • Hb: 5-11 g/dl, Normocytic normochromic, Target cells, reticulocytosis, Increase WBC & Platelets
- 36. Hemoglobin: 7.0 gm/dl HCT:22% MCV: 89 fl MCH: 28 pg TLC: 22,000 Platelets: 20,000
- 39. Acute Leukemia • Presentingcount • Age • Cytogenetics
- 40. Hemoglobin: 5.0 gm/dl HCT:16% MCV: 93 fl MCH: 26 pg TLC: 500 Platelets: 11,000 Pancytopenia Cellular Vs hypocellular
- 44. Chronic Leukemias • Cytogeneticsfor CML • CLL workup and staging
- 45. Hemoglobin: 5.0 gm/dl HCT:16% MCV: 93 fl MCH: 26 pg TLC: 500 Platelets: 11,000 Pancytopenia Cellular Vs hypocellular
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- 48. • Hemoglobin: 9.5gm/dl HCT: 30% MCV: 99 fl TLC: 2200 Platelets: 10,000 Blood culture: gram negative rods
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- 51. Macrocytic Anemia • MCVmore than 96fl – Macrocytic anemia • Megaloblastic: B12 and folate deficiency • Non megaloblastic: – Hemolysis – MDS – Hypothyroidism – Liver disease
- 52. Hemoglobin: 6.0 gm/dl HCT:19% MCV: 110 fl MCH: 36 pg TLC: 2,800 Platelets: 45,000
- 54. Hemoglobin: 7.5 gm/dl HCT:23% MCV: 100 fl MCH: 28 pg MCHC 36% TLC: 5000 Platelets: 100,000
- 60. Reticulocyte • Reticulocyte: largerthan normal RBC • RNA and Golgi remnants, Ribosome, maturation take another 24 to 48 hours in the blood circulation
- 63. Conclusions • Peripheral bloodsmear examination and reporting is one of the most important aspect of hematology. • It is diagnostic in many hematological and non hematological disorders. • It is cost effective and non invasive and helps the clinicians in further diagnostic workup