This document provides information on the diagnosis of anemia. It defines anemia and outlines the grading and classification systems. It discusses the prevalence of anemia globally and in India. The clinical presentation and diagnostic workup are described. Guidelines are provided on evaluating different types of anemia based on red blood cell indices, including iron deficiency anemia, thalassemia, megaloblastic anemia, aplastic anemia, anemia of chronic disease, and hemolytic anemias. Diagnostic testing for specific conditions like sickle cell anemia and glucose-6-phosphate dehydrogenase deficiency are also reviewed. The document emphasizes the importance of anemia as a public health problem and highlights approaches to differentiate between causes of anemia.

1. Diagnosis of a case of
Anemia
Dr. Md Shahid Iqubal
Deptt Of Medicine, Nmch

2. Definition of anaemia
• Anaemia is a condition in which the number of
red blood cells or their oxygen-carrying capacity
is insufficient to meet physiologic needs, which
vary by age, sex, altitude, smoking, and
pregnancy status.
• The WHO criteria for anemia as hemoglobin (Hb)
levels <12.0 g/dL in nonpregnant women and
<13.0 g/dL in men(in adults).
• Anemia in pregnancy is defined as a hemoglobin
concentration of less than 11 g/dL .

3. DATA REPORTS
• It is a major public health problem
• Estimated prevalence of anemia in india is 42% in
women 15–59 years, 30% in men 15–59 years,
and 45% in adults >60 years.
• According to World Health Organization,
prevalence of anaemia among pregnant women
in developed countries is about 14%, whereas it is
still as high as 51% in the developing world
• The prevalence of anemia is 98% among the
pregnant females in this region of rural India.

4. Grading of anaemia
Grade of anemia Hb concentration
Mild Hb from lower limit of normal to 10g/dl
Moderate 10.0 to 7.0 g/dl
Severe <7.0 g/dl

5. Classification of anemia
• Morphological classification
• Etiological classification

6. Morphological classification of anemia
Microcytic anemia
(MCV<80fl)
Macrocytic anemia
(MCV>100fl)
Normocytic anemia
(MCV 80-100 fl)
Iron deficiency anemia Megaloblastic anemia Reticulocyte production
normal
Thalassemia Nonmegaloblastic anemia • Recent blood loss
• hemolytic anemia
Sideroblastic anemia • liver disease Reticulocyte production
deficient
Anemia of chronic disease • hemolytic anemia • Anemia of chronic
disease
• alcoholism • aplastic anemia
• myelodysplastic
syndrome
• chronic kidney disease
• hypothyroidism • hypothyroidism

7. Clinical presentation of anemia
Symptoms
• Fatigue
• Malaise
• Dyspnea and palpitation
• Syncope
• Dizziness
• Menorrhagia
• Loss of appetite

8. Diagnosis of anemia
History
• Diet history-vegeterian or nonvegeterian
• h/o-chronic blood loss(menorrhagia,hemorrhoids)
• h/o-drugs like anticancerous agents,
chloramphenicol,gold,penicillamine(aplastic anemia)
Dapsone,quinine(hemolytic anemia)
• Family history of anemia(thalassemia,sickle cell
anemia)
• h/o alcohol addiction
• h/o-renal disease,rheumatologic disease
• History of systemic symptoms like fever ,weight
loss,night sweats.
• Obstetric and menstrual history

9. examination
General examination-
• Pallor
• Icterus
• Edema
• Lymphadenopathy
• Petechiae
Systemic examination
• CVS-flow murmur,loud S1
• Chest –crepts
• P/A-splenomegaly

10. Investigation
• CBC
• Reticulocyte count
• ESR
• Peripheral blood smear
• LFT(recent viral hepatitis)
• RFT
• Iron profile
• LDH,uric acid
• Vitamin B12 and folic acid level
• Bone marrow examination
• Hg electrophoresis
• Flowcytometry
• Direct and indirect coombs test
• Screening test for hep A,B and C

11. Basic approach to diagnosis of anemia

12. Evaluation of microcytic hypochromic anemia
(50-150ng/ml)

13. Iron deficiency anemia
Cause-blood loss(menses,GI blood loss)
celiac disease,h.pylori infection
• History of pica(consumption of substances
such as ice, starch, or clay)
• koilonychia (“spoon nail”), and
glossitis(Plummer-Vinson's
syndrome) seen in severe iron
deficiency anemia

14. Investigations
• CBC and red cell indices-↓Hb, ↓MCV, ↓MCH, ↓MCHC
• Reticulocyte count-normal or decreased
• PBS –Microcytic and hypochromic
anisocytosis and poikilocytosis
• Iron profile-ferritin decreased (<10ng/ml in women and <20ng/ml
in men)
serum iron ↓,TIBC↑
• BM biopsy-absent or ↓ staining
for iron.
Severe iron deficiency anemia
(Normal serum iron-50-150µ/dL
Normal TIBC-300-360µ/dL)

15. Thalassemia
• The thalassemia syndromes are inherited
disorders of α- or β-globin biosynthesis.
• Alpha and beta thalassemia
Alpha beta thalassemia
Silent carrier Minor
trait intermedia
Hemoglobin H Major(cooley’s anemia)
hydrops fetalis

16. Diagnosis of Thalassemia
• The diagnosis of β Thalassemia major made
during childhood.
• Minor and intermedia remains asymptomatic
• On examination – jaundice, hepatosplenomegaly,
Investigation –
• CBC- ↓MCV, ↓MCH
• Reticulocytosis
• Peripheral smear-microcytic hypochromic RBCs
with poikilocytosis ,target cells

17. Peripheral blood smear of thalassemia
Microcytic and hypochromic
resembling severe iron-deficiency
anemia. Many elliptical and
teardrop-shaped red blood cells are
noted.
Target cells have a bull’s-eye
appearance

18. Diagnosis of Thalassemia contd….
• Hb electrophoresis is diagnostic for β –
thalassemia
• HbF(α2γ2), HbA2 (α2δ2) or both increased.
• In α thalassemia trait HbA2 and HbF levels are
normal.
(Normal HbF<1%,HbA2-2.5-3.5%)
• Hb H disease have increased β tetramers.

19. Differential diagnosis of Microcytic anemia
Tests Iron Deficiency Inflammation Thalassemia Sideroblastic
Anemia
smear Micro/hypo Normal
Micro/hypo
Micro/hypo
with targeting
variable
Serum
iron(μg/dL)
<30 <50 Normal to high Normal to high
TIBC(μg/dL) >360 <300 normal normal
Percent
saturation
<10 10-20 30-80 30-80
Ferritin(μg/L) <15 30-200 50-300 50-300
Hemoglobin
pattern on
electrophoresis
Normal Normal Abnormal with
β thalassemia;
Normal

20. Evaluation of macrocytic anemia

21. Megaloblastic anemia
• Megaloblastic anemia is a term used to describe
disorders of impaired DNA synthesis in hematopoietic
cells but affects all proliferating cells.
• Due to folic acid or vitamin B12 deficiency
Diagnosis-
• In addition to sx of anemia peripheral neuropathy,
paresthesias,
Seizures and dementia may found due to vit b12
deficiency
• On examination- Jaundice or splenomegaly
• Decreased vibratory and positional sense, ataxia,

22. Investigations of megaloblastic anemia
• Increased MCV & MCH,normal MCHC
• Low RBC ,WBC,and platelets
• Peripheral smear-oval macrocytes,anisocytosis,poikilocytosis,
Hypersegmented neutrophils
• LDH and indirect bilirubin are elevated
• Raised urine urobilinogen
• Serum vitamin B12 ,or folate or both decresed
(Normal serum vit B12levels 160–200 ng/L and normal serum folate
2 -15 μg/L)
• Serum methylmalonic acid (MMA) and homocysteine (HC) are
elevated in vitamin B12 deficiency; and only HC is elevated in folate
deficiency.
• Detecting antibodies to intrinsic factor is specific for the diagnosis
of PA.

23. Peripheral smear of megaloblatic anemia
Severe megaloblastic anemia Macro-ovalocytes

24. Evaluation of normocytic anemia

25. Aplastic anemia
• Aplastic anemia is pancytopenia with bone
marrow hypocellularity.
• Inherited-fanconi anemia,dyskeratosis
congenita
• Acquired-radiation,drugs like cytotoxic
drugs,benzene,chloramphenicol,NSAIDS,sulfo
namides,gold,mercury,hydantoin,parvo
virus,hepatitis,EB virus,HIV-1

26. Diagnosis of aplastic anemia
• History-of bleeding,easy bruising,nose bleeds,heavy
menstrual flow
• Family history of hematologic ds
• Examination-petechiae and ecchymoses
• Lymphadenopathy and splenomegaly are highly atypical of
aplastic anemia. Cafe au lait spots and short stature
suggest Fanconi anemia
• MCV-increased,reticulocytes are absent or few
• Peripheral smear-shows large erythrocytes and a paucity of
platelets and granulocytes.
• Bone Marrow-only red cells,residual lymphocytes,mainly
fat
• Chromosome studies of bone marrow cells for MDS
• Flow cytometry to rule out PNH.

27. Anemia of chronic kidney disease
• Primarily due to decreased endogenous EPO
production
• Other causes are-Diminished red blood cell
survival, Bleeding diathesis
• Iron deficiency
• Hyperparathyroidism/bone marrow fibrosis
• Chronic inflammation
• Folate or vitamin B12 deficiency
• Comorbid conditions: hypo-/hyperthyroidism,
pregnancy,

28. Diagnosis Anemia of chronic kidney disease
• cbc-normal MCV
• Reticulocyte count-normal
• PBS-normocytic,normochromic,echinocytes
(burr cell)

29. Hemolytic anemia
• Abnormality intrinsic to red cells-
1. Hereditary spherocytosis
2. Sickle cell disease
3. Thalassemia
4. G-6PD deficiency
• Abnormality extrinsic to red cells
1. Immune
2. Mechanical

30. Evaluation of hemolytic anemia

31. Diagnosis of hemolytic anemia
• General examination- Jaundice, pallor
• Other physical findings Splenomegaly; bossing of skull
• Hemoglobin level From normal to severely reduced
• MCV, MCH Usually increased
• Reticulocytes Increased
• Bilirubin Increased (mostly unconjugated)
• LDH Increased
• Haptoglobin Reduced to absent
• direct Coombs test [DAT] is an indicator of the presence of
antibodies attached to RBC.
• The indirect Coombs test indicates the presence of free antibody in
the plasma.
• A peripheral blood smear-in Intravascular hemolysis may show red
cell fragmentation (i.e., schistocytes,helmet cells)

32. Hereditary Spherocytosis
• Autosomal dominant
• Jaundice,splenomegaly,gall stones
• MCHC increased
• Peripheral smear-normocytic,spherocytes
• Screening test-osmotic fragility test
• Definitive dx by molecular studies of gene

33. Sickle cell anemia
• Due to point mutation in 6th place of beta
chain ,glutamic acid→valine
• On deoxygenation sickle cells are formed
Clinical presentation
• Vaso-occlusive crisis-acute chest
syndrome,pain crisis
• Aplastic crisis-by parvovirus B19
• Hemolytic crisis-gall stones
• infections

34. Diagnostic testing of sickle cell anemia
• Reticulocytosis,bilirubin
(indirect↑,LDH↑,leukocy
tosis,thrombocytosis
• Peripheral smear shows
sickle shaped RBCs,target
cells and howell-jolly
bodies

35. Diagnostic testing of sickle cell anemia
Sickling test
Sickling and solubility test –screening test of sickle cell anemia

36. Diagnostic testing of sickle cell anemia
• HPLC- Hb analysis by high performance liquid chromatography
homozygote
heterozygote

37. Glucose-6-phosphate dehydrogenase deficiency
• X-linked disorder
• Reduced activity of G6PD
• Inability to remove H2O2
• Accumulated H2O2 leads to oxidation of
hemoglobin with precipitation of globin chains
• May Present as neonatal jaundice
• Incresed bilirubin and Hemoglobinuria.

38. Peripheral smear of G6PD
• On Peripheral smear-bite cells and heinz
bodies (precipitated Hb within RBCs).

39. Autoimmune Hemolytic Anemia
 Warm antibody AIHA-by an IgG autoantibody
• Lymphoma,CLL,collagen vascular ds
 Cold antibody AIHA-by an IgM autoantibody
• Seen in cold agglutinin ds,mycoplasma EB virus
 Diagnosis-
• reticulocytosis,elevated LDH, and indirect
hyperbilirubinemia.
• Peripheral blood smear may show spherocytes, occasional
fragmented RBCs,
• Positive DAT(direct coombs test)
• Warm AIHA: IgG +and/or C3+
• Cold AIHA: IgG-and C3+

40. Take home message
• Anemia is one of the important cause of morbidity and
mortality in women.
• Iron deficiency anemia is the most common type of anemia
• Iron deficiency in adult male means GI blood loss until
proven otherwise.
• Hb electrophoresis is diagnostic for thalassemia
• Megaloblastic anemia may present as pancytopenia
• Reticulocytosis present in hemolytic anemia
• Microcytic hypochromic –iron deficiency anemia
• Macrocytic-megaloblastic anemia
• Normocytic normochromic-hemolytic anemia

41. THANK YOU!