Approach to Anemia

1. Approach to Anemia
Hb < 13 M ; < 12 F

3. Pathophysiology
↓ O2 delivery-
Fatigue, DOE, S/S Hyperdynamic state (Bounding pulse)
palpitation
Severe cases - Lethargy, confusion, CCF, Angina, Arrhythmia,
AMI
Vol depletion –
Easy fatigability, Lassitude, Muscle cramps
Postural dizziness, lethargy, syncope, ↓ BP, Shock, Death

4. Normal peripheral blood smear
High power view of a normal peripheral blood smear. Several platelets (black arrows) and a normal
lymphocyte (blue arrow) can also be seen. The red cells are of relatively uniform size and shape.
The diameter of the normal red cell should approximate that of the nucleus of the small
lymphocyte; central pallor (red arrow) should equal one-third of its diameter.

5. Causes – Kinetic approach → ↓ RBC production
↑ RBC destruction
Morphologic approach

6. ↓ Effective RBC production
1.Lack of nutrients B12, Fe
2.Marrow disorders→
-- ↓RBC precursors – AA, Pure RBC aplasia, Marrow
infiltration
-- Marrow supression – Drugs, chemo, irradiation
3.Low level of Trophic hormones- EPO

7. 4. Infection, inflammation or malignant disorder
↓ availability of Iron ↓absorption from GIT
↓ release of Iron from macrophages
↓ Level of EPO
5. Ineffective erythropoiesis – Megaloblastic, α and β Thal,
MDS, Sideroblastic anemia

8. ↑ Destruction of circulating RBC
Inherited Hemolytic anemia – Hereditary Spherocytosis, SCD,
Thal major
Acquired Hemolytic anemia- Autoimmune Coombs positive
HA, TTP, Malaria,
Enlarged spleen – Hypersplenism, PNH

9. Morphologic approach
Macrocytic – MCV > 100ft
Folate, B12 deficiency
Drugs – Zidovidine, Hyroxyurea
MDS, Acute Leukemia
Alcohol Liver Disease

10. Microcytic MCV < 80 ft
↓ Iron availability
Inflammation,
↓ cu
Acquired – Lead, sideroblastic
↓ Globin prodn – Thal , Hbpathies

11. Microcytic hypochromic red cells in iron deficiency anemia
Peripheral smear at two different magnifications from a patient with iron deficiency shows small (microcytic) red
cells with a thin rim of pink hemoglobin (hypochromic); occasional "pencil" shaped cells are also present. Normal
red cells are similar in size to the nucleus of a small lymphocyte (arrow) and central pallor should equal about one-
third of its diameter; thus, many hypochromic and microcytic cells are present in this smear.

12. Normocytic – MCV 80 to100 ft
Systemic disorders
CKD
Cardio renal syndrome
Cancer Associated

13. IDA - ↓ Ferritin, ↑ TIBC, ↓ S iron
α or β Thal minor – Minimum anaemia, F/H Negative
splenomegaly
PS shows - Microcytic Hypochromic, Target, Tear Drop,
Basophil Stippling
↑ RBC count, Iron stores Normal or ↑ , Hb A2 ↑
Inflammation - ↓ Fe, ↓ TIBC, Ferritin – N

14. Beta thalassemia trait
Peripheral smear from a patient with beta thalassemia trait. The field shows numerous hypochromic and microcytic
red cells (thin arrows), some of which are also target cells (blue arrows).

15. Teardrop-shaped red blood cells (dacrocytes)
This peripheral smear from a patient with bone marrow fibrosis shows numerous teardrop-shaped red cells

17. Evaluation – Is patient bleeding now or past
Evidence of ↑ RBC destn (Intra /
Extra Vasc)
Is bone marrow suppressed
Is patient Iron deficient
Deficient in Folate or Vit B12

18. History
Recent loss of appetite, Weight loss, fever, night
sweats ,
Tarry stool
Drugs Aspirin, NSAID
H/o Transfusion, liver disease

19. Physical Examination
↑ HR, ↑ RR, Fever, Postural ↓ BP
Jaundice, Pallor (palm, nail bed, face, conjunctiva)
LN, Hepatosplenomegaly
Bone(Sternum) tender – (Infilt- CML, MM)

20. Laboratory
RBC indices –
MCV 80- 100; > 115 – B12/FA
MCH 27.5-33.2 ; ↓ IDA
Thal:↑Macrocytosis
MCHC 31-33 ↓ like MCV, MCH:
↑ cong / Acq Spherocytosis

21. Reticulocytes
↑ - Hemolysis / Blood loss
↓ - Reduced marrow ; ↓ Response to anaemia
↓ Retic count + Pancytopenia – AA
↓ Retic count + Normal WBC, Platelets – Pure RBC
aplasia

22. WBC
↓ TLC – AA, Marrow suppression, Hypersplenism ↓
B12
↑ TLC- Infection, Inflammation, Carcinoma
DLC - ↑ Polymorphs- Infect
↓ Abs Lymphocytes - HIV / Following steroid

23. Peripheral smear
Hypersegmented neutrophils-
> 5% with 5 lobes or >1 Polymorph with > 6 Lobes

24. Megaloblastic blood picture
Peripheral blood smear showing a hypersegmented neutrophil (seven lobes) and macroovalocytes, a pattern that
can be seen with cobalamin or folate deficiency.

31. THAT’S ALL FOR TODAY…….

33. Hemolysis – Retic, Abnormal shape, ↑ LDH, ↑ Indirect
Bilirubin, ↓ Heptoglobin
↑ LDH, ↓ Hepto- 90% specific for diagnosis; NLDH + > 25
Hepto 92% sens to rule out
Intravasc Hemolysis – Plasma, Urine Hb, Urinary
hemosidrin PNH

34. Marrow - ↑Retic – Erythroid Hyperplasia
↓Retic Erythroid Hyperplasia Ineffective
erylhropoiesis
Indication – Pancytopenia, blast cells → AA,
MDS, Marrow replacement
Myeloprolifn

35. Hemolytic – Intra / Extra corpuscular defect
Intravasc – Direct trauma – March Hguria
Sheer stress – Mech Heart Valve
Heat – Thermal burn
Complement induced lysis Parox cold Hburia
Osmotic – Hypotonic soln
Bact toxin , ↑ Cu

36. Approach- Rapid onset pallor
Jaundice - ↑ Indurest Bilirubin
Pigmentory gall stone
Splenomegaly, spherocytosis
↑ LDH, ↓ Heploglobin
Coomb +, ↑ Retic