Approach to anemia - Iron, Megaloblastic, Hemolytic, Autoimmune, Cytopenia, Marrow and Management - Advances, Sideroblastic

1. APPROACH TO ANEMIA
Chairperson : Dr. Kiran Havanur
Student : Dr. Basawantrao

2. Anaemia
• Decrease in the number of circulating red
blood cell mass and there by O2 carrying
capacity
• Most common hematological disorder by far
• Almost always a secondary disorder
• It is not a single disease by itself
• Need to look for the underlying cause
• Drug Rx. depends on the cause

3. Adult
male
<13
Adult
Female
<12
Pregnant
Female
<11
Newborn
<14

5. Erythron
• Erythron is the machinery of RBC production
• EPO, IL, Growth factors, Cytokines – stimulate it
• Hypoxia is strong stimulus for the Erythron
• Its functioning is influenced by
1. Normal renal production of EPO
2. A functioning Erythroid marrow
3. An adequate supply of substrates for Hb production

7. ERYTHROPOIETIN
• Glycoprotein hormone
• Produced by peritubular capillary lining of
cells in kidney
• Small amount in liver
• EPO gene regulation is by Hypoxia inducible
factor 1α
• Normal levels 10 – 25 U/l
• T1/2 – 6-9 hrs

9. Pro Erythroblast

10. Normoblast

11. Reticulocyte

12. Normal Red Cells

13. Normal Red Cells
No nucleus, Enzyme packets
Biconcave discs – Haem + Gl
Center 1/3 pallor
Pink cytoplasm (Hb filled)
Cell size 7 - 8 µ - capill. 2 µ
EM pathway, HMP
Negative charge – no phago
Na less, K more inside
100-120 days life span

14. The Factory – Bone Marrow
Sternum, pelvis, vertebrae, long
bones, skull bones, Tibia (paed)
From stem cells (pleuripotent)
75% of marrow for WBC
25% of BM for Red cells
Erythrod / Granulocyte Ratio 1:3
E:G ratio increased in Anaemia
Large white areas are marrow fat

15. Normal BM High Power

16. Hemoglobin (Hb)

20. Types of Anaemia

21. • The onset of Anaemia
• Acute versus chronic
• Clues
–Hemodynamic stability
–Previous CBC
–Overt blood loss

22. Symptoms due to Anemia
• Exertional Fatigue, Dizziness, Faintness,
Palpitations, Exertional breathlessnes
• Headache, vertigo, tinnitus, scotoma, Lack of
concentration muscular weakness

23. History
• Family History of Hemoglobinopathies, Bleeding Disorders
• History of Jaundice, Gallstones, Splenectomy and Bleeding
• Travel History
• Drug History
• Dietary History
• H/o of Blood transfusion

24. History
• History of any worm in stool and dark tarry stools, bleed per
rectum
• History of Fever – can be seen in Infections, Malignancies
and Connective tissue disorders
• Menstrual History (Defined as excessive flow – Duration
exceeds 7 days
• GI symptoms include Dysphagia Painful ulcerative lesions

26. Examination
• Pallor Palpebral conjunctiva
• Tongue, mucous membrane of mouth and pharynx ,
Nail Bed, Skin and Creases of the palms
• Nails may become Brittle and early graying of hair
• Associated Jaundice – Can be suggestive of
Hemolytic anemias, some malignancies

27. • Associated Petechiae - May suggest Bone marrow failure or
Anemia due to bleeding disorder
• Spoon shaped nails – May suggest Iron deficiency Anemia
• Chronic Leg Ulcers – Sickle cell anemias and Hereditary
spherocytosis
• Glossitis – Pernicious anemia
• Knuckle Hyperpigmentation – Megaloblastic anemia

31. PCV or Hematocrit
• 57% Plasma
• 1% Buffy coat – WBC
• 42% Hct (PCV)

32. The Three Basic Measures
Measurement Normal Range
A. RBC count 5 million 4 to 6
B. Hemoglobin 15 g% 12 to 17
C. Hematocrit 45 38 to 50

33. The Three Derived Indicies
Measurement Normal Range
A. RBC count 5 million 4 to 6
B. Hemoglobin 15 g% 12 to 17
C. Hematocrit 45 38 to 50
MCV C ÷ A x 10 = 90 fl
MCH B ÷ A x 10 = 30 pg
MCHC B ÷ C x 100 = 33%

34. MENTZERS INDEX
• MCV/RBC
• >13 - S/O IRON DEFICIENCY ANEMIA
• 11-13 - INDETERMINATE
• <11 - THALASSEMIA TRAIT

35. RETICULOCYTE COUNT %
• Reticulocytes are immature RBC
• ‘RBC to be’ or Apprentice RBC
• Fragments of nuclear material
• RNA strands which stain blue
• Normal Less than 2%

39. Reticulocytes
Leishman’sSupravital

40. Mean Cell Volume (MCV)
• RBC volume (rather) is measured by
• The Mean Cell Volume or MCV and RDW
Microcytic
< 80 fl
MCV
Normocytic Macrocytic
80 -100 fl > 100 fl
< 6.5 µ 6.5 - 9 µ > 9 µ

41. Anaemia Workup - MCV
Microcytic
MCV
Normocytic Macrocytic
Iron Deficiency IDA
Chronic Infections
Thalassemias
Hemoglobinopathies
Sideroblastic Anemia
Chronic disease
Early IDA
Hemoglobinopathies
Primary marrow disorders
Combined deficiencies
Increased destruction
Megaloblastic anemias
Liver disease/alcohol
Hemoglobinopathies
Metabolic disorders
Marrow disorders
Increased destruction

42. Red cell distribution width
• RDW measures range of variation of red cell
volume
• Normal range is 11.5 to 14.5 %
• It is measure of anisocytosis
• Usually elevated in deficiency of Iron, Folate,
B12
• Usually normal in Hemoglobinopathy

43. RBC Size – Anisocytosis
Different sizes of RBC

45. Peripheral Smear Study
• Are all RBC of the same size ?
• Are all RBC of the same normal discoid shape ?
• How is the colour (Hb content) saturation ?
• Are all the RBC of same colour/ multi coloured ?
• Are there any RBC inclusions ?
• Are intra RBC there any hemo-parasites ?
• Are leucocytes normal in number and D.C ?
• Is platelet distribution adequate ?

46. Normal CBC

47. Hypoproliferative Anaemias
Failure of cell
maturation
Nuclear
breakdown
Cytoplasmic
breakdown
Megaloblastic Anaemia
Defective DNA synthesis
Folate or B12 deficiency Haem defect Globin defect
Thalassemia
Sickle cell AFe Phorph
IDA, SA

48. Microcytic Hypochromic Anaemia
Serum Ferritin
< 33 pmol / l 33-270 pmol / l > 270pmol / l
Not IDA, Other Mi A
TIBC
HIGH N or ↓
BM Fe +-
Iron Deficiency Anaemia IDA

49. Microcytic Anaemias
MCV < 80 fl Serum Iron TIBC BM Perls stain
Iron Def. Anemia ↓↓ ↑↑ 0
Chronic Infection ↓↓ ↓↓ + +
Thalassemia ↑↑ N + + + +
Lead poisoning N N + +
Sideroblastic ↑↑ N + + + +

50. IDA – Special Tests
Iron related tests Normal IDA
Serum Ferritin (pmo/L) 33-270 < 33
TIBC (µg/dL) 300-340 > 400
Serum Iron (µg/dL) 50-150 < 30
Saturation % 30-50 < 10
Bone marrow Iron ++ Absent

51. IDA
• Microcytic MCV < 80 fl, RBC < 6 µ
• RDW Widened and shift to left
• Hypochromic MCH < 27 pg, MCHC < 30%
• RPI < 2
• Serum ferritin Very low < 30 (p mols/L)
• TIBC Increased > 400 (µg/dL)
• Serum Iron Very low < 30 (µg/dL)
• BM Fe Stain Absent Fe
• Response to Fe Rx. Excellent

52. IDA
• Look for occult blood loss – 2 days non veg. free
• Pica and Pagophagia
• Absorption of Haem Iron > Fe++ > Fe+++
• Food, Phytates, Ca, Phosphate, antacids ↓absorption
• Ascorbic acid ↑absorption
• Oral iron Rx. always is the best

53. • FeSO4 is the best. Reserve parenteral Rx.
• Packed cell transfusion in emergency
• Continue Fe Rx at least 2 months after normal Hb
• 1 gram ↑in Hb every week can be expected
• Always supplement protein for the Globin component

54. IDA -CBC

55. Microcytic Hypochromic - IDA

56. Severe Hypochromia

57. Ringed Sideroblasts in BM
Prussian Blue Stain

58. Target Cells
1. Liver Disease
2. Thalassemia
3. Hb D Disease
4. Post splenectomy

59. Hair on end - Thalassemia Major

60. Macrocytic Anaemias
• Megaloblastic Macrocytic – B12 and Folate↓
• Non Megaloblastic Macrocytic Anaemias
1. Liver disease/alcohol
2. Hemoglobinopathies
3. Metabolic disorders, Hypothyroidism
4. Myelodystrophy, BM infiltration
5. Accelerated Erythropoesis -↑destruction
6. Drugs (cytotoxics, immunosuppressants, AZT,
anticonvulsants)

61. Anemia - Macrocytic (MCV > 100)
– Macrocytic anemias may be asymptomatic
until the Hb is as low as 6 grams
– MCV 100-110 fl must look for other causes of
macrocytosis
– MCV > 110 fl almost always folate or B12
deficiency

62. Macrocytosis of Alcoholism
• 25-96% of alcoholics
• MCV elevation usually slight (100-110 fl)
• Minimal or no anemia
• Macrocytes round (not oval)
• Neutrophil hyper segmentation absent
• Folate stores normal

63. DRUGS CAUSING MEGALOBLASTICANEMIA
 Folate antagonists (e.g., methotrexate)
 Purine antagonists (e.g., 6-mercaptopurine)
 Pyrimidine antagonists (e.g., cytosine arabinoside)
 Alkylating agents (e.g., cyclophosphamide)
 Zidovudine (AZT, Retrovir)
 Trimethoprim
 Oral contraceptives
 Nitrous oxide
 Arsenic

64. Megaloblastic Hematopoiesis
Marrow failure due to
• Disrupted DNA synth. & ineffective erythropoesis
• Giant precursors (Megaloblasts)
• Nuclear : Cytoplasmic dyssynchrony in marrow
• Neutrophil hyper segmentation & macro ovalocytes
• Anemia (and often leukopenia & thrombocytopenia)
• Almost always due to B12 or folate deficiency

65. Pernicious Anaemia - Tongue
Bald, smooth, lemon
yellowish red tongue

66. Megaloblastic anemia

67. Megaloblastic anemia

68. Anisocytosis - Macrocytic Anaemia

69. Basophilic Stippling

70. Megalocyte in PS

71. Megaloblast (BM)

72. Normocytic Anaemias
• Chronic disease
• Early IDA
• Hemoglobinopathies
• Primary marrow disorders
• Combined deficiencies
• Increased destruction
• Anaemia of investigations

73. Anaemia of Chronic Disease
• Thyroid diseases
• Malignancy
• Collagen Vascular Disease
– Rheumatoid Arthritis
– SLE
– Polymyositis
– Polyarteritis Nodosa
• IBD
– Ulcerative Colitis
– Crohn’s Disease
• Chronic Infections
– HIV, Osteomyelitis
– Tuberculosis
• Renal Failure

75. • Anaemia is usually mild and non-progressive, rarely less than
9 gm/dL.
• Anaemia is never severe
• Anaemia resolves when underlying cause is treated.
• Anaemia of chronic inflammation is not responsive to
haematinics like iron, folate, vitamin B12.
• Transfusion is rarely indicated.
• Higher doses of Epo is required to treat ACD than for the
therapy of renal anaemia.

76. Anemia due to renal disease:
• This is of normochromic and normocytic type.
• This is due to lack of secretion of erythropoietin
and suppression of its production by toxins.
• Causes
• EPO in Different renal diseases
• Don’t correct Hb more than 11to12gm%

77. ‘Dimorphic’ Anaemia
• Folate & Fe deficiency (pregnancy, alcoholism)
• B12 & Fe deficiency (PA with atrophic gastritis)
• Thalassemia minor & B12 or folate deficiency
• Fe deficiency & hemolysis (prosthetic valve)
• Folate deficiency & hemolysis (Hb SS disease)
• Peripheral smear exam is critical to assess these
• RDW is increased very much

78. Poikilocytosis
Different Shapes of RBC

79. Hemolytic Anaemia
Anemia of increased RBC destruction
– Normochromic, normocytic anemia
– Shortened RBC survival
– Reticulocytosis – due to ↑ RBC destruction
Will not be symptomatic until the RBC life span is
reduced to 20 days – BM compensates 6 times

80. Tests Used to Diagnose Hemolysis
1. Reticulocyte count
2. Combined with serial Hb
3. Serum LDH
4. Serum bilirubin
5. Haptoglobin
6. Urine hemosiderin
7. Hemoglobinuria

81. Findings in Hemolytic Anaemia
Reticulocyte count and RPI Increased
Serum Unconjugated Bilirubin Increased
Serum LDH 1: LDH 2 Increased
Serum Haptoglobin Decreased
Urine Hemoglobin Present
Urine Hemosiderin Present
Urine Urobilinogen Increased
Cr 51 labeled RBC life span Decreased

82. Tests to define
the cause of hemolysis
1. Hemoglobin electrophoresis
2. Hemoglobin A2 (βeta-Thalassemia trait)
3. RBC enzymes (G6PD, PK, etc)
4. Direct & indirect antiglobulin tests (immune)
5. Cold agglutinins
6. Osmotic fragility (spherocytosis)
7. Acid hemolysis test (PNH)
8. Clotting profile (DIC)

83. Hyperactive BM – Skull
Hemolytic Anaemia

84. Spherocytosis

85. Elliptocytes
Hereditary Elliptocytosis, B12 or Folate↓

86. Polychromasia - Spherocytosis

87. Sickle Cell Anaemia

88. Autosplenectomy - SS
Normal spleen is 8 to 12 cm

89. Howell-Jolly Bodies
Absence of Splenic function; Nuclear chromatin in RBC

90. MAHA
Micro Angiopathic Hemolytic Anaemia

91. Micro Angiopathic Hemolytic Anaemia

92. Shistocytes
1. MAHA
2. Prosthetic
valves
3. Uremia
4. Malignant HT
Fragmented, Helmet or triangle shaped
RBC

94. ANEMIA DUE TO IMPAIRED BONE
MARROW RESPONSE
Red blood cell aplasia
Aplastic anemia
Myelodysplasia
Leukemias
Myelophthisic anemia
Marrow infiltration
Myeloma
Congenital Dyserythropoietic Anemias

95. Aplastic Anaemia
1. Chloramphenicol
2. Carbimazole
3. Sulfonamides
4. Phenytoin
5. Anti Ca drugs

96. Tear Drop Cells
1. Myelofibosis
2. Infiltration of
BM
3. Tumours of BM
4. Thalassemia

97. Normal BM High Power
E : G = 1 : 3

98. Shift in E : G Ratio
E : G = 2 : 1

99. BM - Aplastic Anaemia

100. Myelofibrosis

101. Stomatocytes
Slit like central pallor in RBC
1. Liver Disease
2. Acute Alcoholism
3. H Stomatocyosis
4. Malignancies

102. Echinocytes
Evenly distributed spicules > 10
1. Uremia
2. Peptic ulcer
3. Gastric Ca
4. PK-D
Called Burr Cells

103. Acanthocytes
5-8 spikes of varying length, irregular intervals
Called Spur Cells, Occur in A H A

104. ↓
HB
RETIC COUNT

112. CONDITION SERUM
IRON
TIBC FERRITIN COMMENT
Iron deficiency ↓ ↑ ↓ Responsive to iron
Chronic
inflammation
↓ ↓  Unresponsive to iron
Thalassemia major ↑ N N
Reticulocytosis and
indirect
bilirubinemia
Lead poisoning N N N Basophilic stippling of
RBCs
Sideroblastic anemia ↑ N  Ring sideroblasts in
marrow

113. ↓
HB

114. RPI <2.5 RPI >2.5
• Anemia of
chronic disease
• CKD
• Acute Bloodloss
• Leukemia
• Approach to
Pancytopenia
• Approach to
Hemolytic
anemia

115. ↓
HB
RETIC COUNT

119. Take Home message
• If Hb% is low – Do not start on Iron straight away
• All investigations to be drawn before starting Hematinics or
blood transfusion
• Ask for CBC, Hematocrit – Derive MCV, MCH, MCHC
• Order for Reticulocyte count – Is RPI < 2.5 % or > 2.5%
• Thoroughly look for blood loss – acute / chronic / occult
• Is it hypo-proliferative or hemolytic or hemorrhagic
anaemia

120. • If hypo proliferative – Microcytic or Macrocytic? (MCV,
RDW)
• If microcytic – IDA or others – Spl. Iron tests, BM Iron
• If macrocytic – Megaloblastic (B12, FA) or Normoblastic
BM
• If normocytic – Anaemia of chronic Disease – Liver, Ca
• Peripheral smear study for RBC size, shape, colouration
etc.
• If retic. count is ↑- Hemolytic work up; Hb
electrophoresis, special tests

121. REFERENCES
• Harrison’s Principles of Internal Medicine 20th
edition
• The Washington’s Manual of Medical
Therapeutics 34th edition
• Robbins & Cotran Pathologic Basis of Disease, 8th
edition
• Wintrobe’s Clinical Hematology 13th edition