This document provides information on diagnosing and classifying anemia. It defines anemia and normal hemoglobin levels. Anemia can be classified based on mean cell volume into microcytic, macrocytic, and normocytic types. It also describes approaches to investigating anemia based on mean cell volume. The diagnostic workup of anemia includes a complete blood count, blood smear, reticulocyte count, iron, B12 and folate levels. Physical exam may reveal pallor or signs of B12 deficiency. The cause of anemia is then determined based on laboratory results and clinical clues.

1. A diagnostic approach to
anemia
Dr Nighat majeed
Assistant professor
Medical unit 11
SIMS/SHL Lahore

2. Definition
Anemia refers to a state in which level of
hemoglobin in blood is below the normal
range appropriate for age and sex.
Anemia is present in adults if the hematocrit
is less than 41% (hemoglobin < 13.5 g/dL)
in males or less than 37% (hemoglobin < 12
g/dL) in females.

3. Anemia
• For adult men, a hemoglobin level less than 13.0
g/dl (grams per deciliter) is diagnostic of anemia,
and for adult women, the diagnostic threshold is
below 12.0 g/dl.
• Normal red cell count is 6.9 million/mm6
in women
and 6.3 million/mm6
in men.
• Normal red cell volume in men is 32+ 6.5 ml/kg in
men and 25 + 6.5 ml/kg in women.

4. Peripheral blood smear microscopy of a patient
with iron-deficiency anemia

6. Classification
Decreased production
• Hemoglobin synthesis: iron deficiency,
thalassemia, anemia of chronic disease.
• DNA synthesis: megaloblastic anemia.
• Stem cell: aplastic anemia, myeloproliferative
leukemia.
• Bone marrow infiltration: carcinoma,
lymphoma.
• Pure red cell aplasia.

7. Classification
Increased destruction
1-Blood loss
2-Hemolysis
(intrinsic)
• Membrane: hereditary spherocytosis,
elliptocytosis.
• Hemoglobin: sickle cell, unstable hemoglobin.
• Glycolysis: pyruvate kinase deficiency, etc
• Oxidation: glucose-6-phosphate dehydrogenase
deficiency.

8. Classification
Hemolysis
(extrinsic)
• Immune: warm antibody, cold antibody.
• Microangiopathic: thrombotic.
thrombocytopenic purpura, hemolytic-uremic
syndrome, mechanical cardiac valve, paravalvular
leak.
• Infection: clostridial.
• Hypersplenism.

9. Classification
Classification of anemias by mean cell
volume.
1-Microcytic(MCV<80)
• Iron deficiency.
• Thalassemia.
• Anemia of chronic disease.

10. Classification
2-Macrocytic(MCV>100)
Megaloblastic
• Vitamin B12
deficiency.
• Folate deficiency.
Nonmegaloblastic
• Myelodysplasia, chemotherapy.
• Liver disease.
• Increased reticulocytosis.
• Myxedema.

11. Classification
3- Normocytic(80<MCV<100)
• Many causes.

12. History
Iron deficiency anemia
Blood loss
• Gastrointestinal
• Menstrual
• Blood donation

13. History
Iron deficiency anemia
• Deficient diet.
• Decreased absorption.
• Increased requirements. (Pregnancy, Lactation)
• Hemoglobinuria.
• Iron sequestration.
• Pulmonary hemosiderosis.

14. History
B12 deficiency anemia
• Abdominal or intestinal surgery that affects
intrinsic factor production or absorption.
• A diet low in vitamin B12 (for example, a strict
vegetarian diet that excludes all meat, fish, dairy
products, and eggs).
• Chronic alcoholism.

15. History
B12 deficiency anemia
• Crohn's disease.
• Infection with the fish tape worm.
• Intestinal malabsorption disorders.
• Pernicious anemia, which is caused by the
destruction of intrinsic factor by the immune
system.

16. History
Folate deficiency
anemia
•Alcoholism.
• (which interferes with the
• Absorption of folate).
•Eating overcooked food.
• Malabsorption diseases.
•Poor diet.
•Pregnancy.

17. History
Past medical history
• May reveal a disease which is known to be
associated with anemia, such as rheumatoid
arthritis, or previous intestinal surgery causing
malabsorption.

18. History
Family history
• Haemolytic anemias such as the
haemoglobinopathies and heriditary spherocytosis
may be suspected from family history.Ask about
anemia, jaundice, gallbladder disease,
splenectomy in blood relatives.
• Pernicious anemia may also be familial.

19. History
• Dug history
• Aspirin and anti-inflammatory drugs, may cause
the blood loss.
• Drugs like chloramphenicol can cause aplastic
anemia.
• Radiation, chemotherapy, or infection can cause
bone marrow aplasia.

20. History
Dietary history
• Alcohol intake, causes folic acid deficiency.
• Vegetables are deficient in B12.
• Assess the dietary intake of iron and folate.
• Lead exposure is toxic to the bone marrow,
leading to fewer red blood cells. Lead poisoning
occurs in adults from work-related exposure and
in children who eat paint chips. Improperly glazed
pottery can also taint food and liquids with lead.

21. History
• A feeling of weakness or fatigue in general
or during exercise, general malaise and poor
concentration.
• Dyspnoea.
• Heart failure.
• Sweating.
• Palpitation.

22. Physical examination
• Pallor (pale skin, mucosal linings and nail beds).
• Cheilosis.
• koilonychia.
• Pica, the consumption of non-food based items
such as dirt, paper, wax, grass, ice, and hair, may
be a symptom of iron deficiency, although it
occurs often in those who have normal levels of
hemoglobin.

23. Physical examination
• Jaundice.
• Periphral neuropathy.(B12 deficiency)
• Dementia.(B12 deficiency)
• Signs of subacute combined degeneration of cord.
(B12 deficiency)

24. Diagnosis
• complete blood counts is the first blood tests in
the diagnosis of an anemia.
• Examination of a stained blood smear

25. Diagnosis
In modern counters, four parameters
• (RBC count).
• Hemoglobin concentration.
• MCV and RDW are measured.
• Allowing others (hematocrit, MCH and MCHC)
to be calculated, and compared to values adjusted
for age and sex.

26. Diagnosis
Reticulocyte counts.
• A reticulocyte count is a quantitative measure of
the bone marrow's production of new red blood
cells.
• The reticulocyte production index is a calculation
of the ratio between the level of anemia and the
extent to which the reticulocyte count has risen in
response.

27. Diagnosis
• Other tests: ESR, ferritin, serum iron, transferrin,
RBC folate level, serum vitamin B12, hemoglobin
electrophoresis, renal function tests.
• When the diagnosis remains difficult, a bone
marrow examination allows direct examination

28. In v e s tig a tio n o f a n e m ia w ith n o rm a l o r lo w M cv
In v e stig a te
F e d e ficie n t
F e rritin (lo w )
B e ta T h a la s s e m ia tria t
In c re a s e d H B A 2
A lp h a th a las s e m ia triat
N o rm a l H B A 2
H B e le ctro p h o re s is
T a rg e t ce ll b a s o p h ilic s tip p lin g
L o w M C V
H y p o c h ro m ia
S id ero b la s tic
B o n e m arro w
D im o rp h ic
o r ch e c k iro n s to re s
If H B < 8 g /l co n s id e r b o n e m arro w
if fe rritin is n o rm al o r h ig h
a n em ia o f ch ro n ic d is e a s e
C o n s id e r fe rritin )
N o n s p e c ific
N o rm a l o r lo w retic u lo c yte c o u n t
M C V n o rm a l(7 6 -9 8 fl) o r lo w (< 7 6 fl)

29. In vestig ation o f anem ia w ith hig h M C V
In vestig ate cau se D ru gs cyto toxic ag ent
F o late B 12
H yperseg m en ted n eutro ph ils
L iver fun ctio n test
T arget cell
sto m ato cytes
S id ero b lastic
A n em ia
B o ne m arrow
D im o rph ic
M yelo dysp lasia
M arrow
D ysp lasia cyto p en ia
h aem o lysis
b leed ing
p o lych ro m asia
h ig h retics
N o rm al or low reticulo cyte co u nt
B lo od film and reticulo cyte co u nt
M C V H igh (>98 fl) C lin ical clu es

30. THANKU