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Microcytic hypochromic anemia
This document discusses microcytic hypochromic anemias and the laboratory approach used to diagnose them. It defines anemia and outlines the grading system used by the WHO. It then describes the clinical findings, types, and laboratory tests involved in evaluating microcytic hypochromic anemias, focusing on iron deficiency anemia and anemia of chronic disease. The key laboratory findings and bone marrow features of each condition are presented. Case studies are also included to demonstrate how the laboratory results can help arrive at a diagnosis.
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Microcytic hypochromic anemia
- 1. Dr.Nikhil Laboratory approach toMicrocytic Hypochromic anemias
- 2. Skeleton Definition ofAnemia Patient History in case of Anemia Clinical Findings of Anemia Types of Microcytic Hypochromic Anemia Laboratory Approach to Microcytic Hypochromic Anemia
- 4. Definition of Anemia Anemia : is defined as reduction in the concentration of circulating Hemoglobin below the level that is expected for healthy persons of same age and sex in the same environment. Anemia is not a disease it is a manifestation of disease.
- 5. WHO Definition ofAnemia World Health organization(WHO) has defined anemia as Hb<13.0 g/dl for men and <12.0g/dl for women For Pregnant women <11.0 g/dl .
- 6. Grading of Anemia MildAnemia Hemoglobin from lower limit of normal to 10.0 g/dl Moderate Anemia 7.0-10.0g/dl Severe Anemia <7.0 g/dl Critical Value
- 7. Clinical Findings ofAnemia
- 8. MCV Average Volumeof a single red cell. Normal range 80-100 fl. Calculated as : PCV x 10 Red cell count
- 10. RDW It isa measure of degree of variation in red cell size (Anisocytosis ) in a blood sample. Normal 11.6-14 %
- 11. Normal Range ofIron Profile S.Iron (65-180 ug/dl) in Males S.Iron (50-180 ug/dl) in Females Transferrin saturation 30 % to 50 % Total iron Binding capacity 250 to 450 ug/dl S.ferritin 50-200 ug/l
- 12. Morphological Categories ofAnemia 1)Microcytic Anemia 3)Normocytic Anemia 2)Marocytic Anemia Size of the RBC is compared with The nucleus of small lymphocyte MCV<80 fl is Microcytic MCV>100 fl is Macrocytic
- 13. •Normochromic Vs Hypochromic RBC’s •Definedby area of Central Pallor •Upto 1/3rd the Size of RBC is Normochromic •>1/3rd of RBC Size is Hypochromic
- 14. Microcytic Hypchromic anemia When the average cell size(MCV ) is reduced the anemia is called as microcytic anemia It is usually associated with hypochromia
- 15. Types Of MicrocyticHypochromic Anemia Iron Deficiency Anemia Sideroblastic Anemia Thalassemia Anemia of Chronic disease Porphyrias Lead Poisoning Congenital Atransferrinemia DMT1 Mutation Glutaredoxin5 Aceruloplasminemia
- 16. LAB APPROACHTO MICROCYTIC HYPOCHROMIC ANEMIA
- 17. Laboratory Approach toAnemia Complete Blood Count Low Hemoglobin –Anemia Abnormalities restricted to red cell series Reticulocyte count Raised Not Raised Red cell Indices Investigate for Blood loss Hemolytic anemia
- 18. Laboratory approach toanemia Complete Blood Count Low Hemoglobin –Anemia Associated abnormalities of White Blood cells and platelets Bone Marrow Examination to assess for Megaloblastic anemia ,Aplastic Anemia ,Myelodysplasia,Myelofibrosis ,myelophthsis ,Leukemia
- 20. Case presentation 1 A 29 year Old woman presents with a History of fatiguability, weakness and lethargy was found to Have a hemoglobin of 7.8 g/dl ,with a reticulocyte count of 0.4% MCV 70 fl MCH 20 pg MCHC26 g/dl RDW20 S.Iron15 ug/dl TIBC 460 ug/ dl S.ferritin15 ug/l The most likely cause of Anemia is ?
- 21. IRON DEFICIENCYANEMIA
- 22. Children (13-15yrs.): 20- 30 mg/d Pregnant women : 40 mg/d
- 23. Upper partof duodenum. Only Fe2+ (ferrous) form (reduced form) is absorbed. Fe3+ (ferric) form is not. Fe3+ (ferric) ions need to be reduced.
- 25. Regulation of Absorption Hepicidin protein plays important role in Iron Absorption . It decreases iron absorption by binding to ferroportin. So, when Plasma Levels of iron are High hepicidin expression increases and when plasma levels of iron are low Hepicidin expression is decreased .
- 26. Transport and deliveryto target sites Fe3+ is carried as transferrin in Blood to various tissues. Transferrin is a β-Glycoprotein it is circulated in Blood Bone Marrow & Liver are the Major sites of Iron Utilization. Liver uses it for Heme proteins and Enzymes Synthesis
- 27. Plasma Transferrin &TIBC Plasma Iron is transferrin Bound . Average Levels of Transferrin are 300 mg % Normally this transferrin can bound a maximum of 300 ug/dl of iron. This therefore becomes Total Iron Binding capacity However under normal Physiological conditions ,transferrin remains only 30 % saturated with Bound Iron. Hence Normal Transferrin saturation is 30 %
- 28. Storage of Iron-Ferritin Ferritin is indicator of Body Iron stores. In deficiency state Iron is released from ferritin by the macrophages mainly in the Liver and spleen
- 29. Iron Deficiency Anemia Most Common Nutritional Deficiency in the world Etiology : 1) Dietary Deficiency 2) Blood loss – causes of Gastrointestinal lesion leading to Blood loss are as follows :
- 30. Etiology of Irondeficiency anemia Peptic ulcer Hiatal Hernia Alcoholic Gastritis Excessive Salicyclate ingestion Carcinoma Colon Hookworm infestation Hemorrhoids Menstruation in women of Child bearing age
- 31. Etiology of Irondeficiency anemia 3) Malabsorption After gastrectomy Atrophic gastritis Achlorhydria 4) Increased requirements: In pregnancy Children less than 5 years Elderly Women of reproductive age group and Adolescents
- 32. Patho-physiology of IDA Stage1 : During Iron Depletion (No Functional effect ) Iron Stores are Exhausted indicated by decrease in S.ferritin No Anemia Erythrocyte Morphology is normal Red cell distribution width is Elevated Abnormal RDW can be the first Hematologic indication of a developing Iron deficiency in non anemic patients.
- 33. Patho-physiology of IDA Stage2 : The second stage of Iron deficiency is characterized by iron deficient erythropoeisis There is insufficient iron to insert into the protoporphyrin ring to form heme. As a result protoporphyrin accumulates in the cell and complexes with zinc to form ZPP. Bone marrow sideroblasts are absent Macrophage iron is not seen Anemia and Hypochromia are still not detectable but RBC’s can become slightly microcytic
- 34. Patho-physiology of IDA Stage3 : Long standing negative iron flow eventually leads to the last stage of Iron deficiency. Blood loss can shorten the time for this stage to develop All laboratory tests for Iron status becomes markedly abnormal. The most significant finding is classic microcytic hypochromic anemia
- 36. Clinical findings ofIDA Insidious onset Clinical symptoms of anemia Fatigue Dyspnea Tachycardia Other symptoms : Koilonychia Glossitis Pharyngeal webs Pica syndrome : Unusual craving for ingesting unnatural items
- 37. Lab findings inIron Deficiency anemia Peripheral smear shows Anisocytosis and poikilocytosis Anisocytosis – important early sign Leading to Raised Red cell distribution width. Red blood cells are microcytic smaller than the nucleus of small lymphocyte Erythrocytes are Hypochromic with a Increased central Pallor Elliptocytic and pencil shaped forms can be present
- 38. Peripheral blood pictureof IDA
- 39. Iron Deficiency Anemia Leukocyte count –Usually normal Mild Granulocytopenia can be seen in long standing cases Recent large Volume hemorrhage leads to neutrophilic leukocytosis. Due to parasitic infestation , Eosinophilia can be seen Thrombocytes : Thrombocytosis is frequently seen
- 40. Transferrin The principalsource of Iron for hemoglobin production is carried by the transferrin, Iron transport protein in plasma. When transferrin saturation with Iron is less than 15% ,RBC Production rate decreases and Hypochromic, microcytic cells are manufactured. This stage is known as Iron Deficient erythropoeisis
- 41. Serum transferrin receptorassay STfR assay is useful in differentiating Iron deficiency anemia and anemia of chronic disease STfR-F index Serum transferrin receptor = STfR/Log of ferritin Patients with Iron deficiency have a mean STfR over twice that of normal individuals . STfR in Anemia of chronic disease is similar to normal individuals.
- 42. Iron Profile inIron deficiency anemia S.Iron decreased <30ug/dl S.ferritin decreased <15 ug/l TIBC Increased Pecrentage transferrin saturation <15 %
- 43. Bone Marrow Featuresof Iron Deficiency Anemia Cellularity – Increased Erythroid Hyperplasia Micronormoblastic reaction Normoblast are smaller Late Micronormoblast demonstrates persistent basophilia and fraying of cytoplasmic borders indicating lack of Hemoglobinization Myelopoeisis –Normal Megakaryopoeisis –Normal Depleted Bone marrow iron
- 44. BONE MARROW FEATURESOF IRON DEFICIENCY ANEMIA
- 45. Bone Marrow Featuresof Iron Deficiency Anemia
- 46. Bone Marrow Featuresof Iron Deficiency Anemia
- 49. Case presentation2 A 25 year old lady on treatment for Rheumatoid arthritis Has the following Laboratory Findings: Hb-9g/dl MCV-50fl Ferritin -220 ug/dl TIBC -240 ug/dl. S.Iron -30 ug/dl What is the likely diagnosis ?
- 50. Anemia of chronicdisease Also called as Anemia of inflammation or anemia of infection. Most frequent form of anemia in Hospitalized patients. Definition : Impaired red cell production associated with chronic diseases that produces systemic inflammation.
- 51. Anemia of chronicdisease Conditions associated with Anemia of Chronic Disorders Category Conditions Chronic infection (after 1-2 months ) of sustained infection Pulmonary infections Subacute Bacterial endocarditis Pelvic inflammatory disease Osteomyelitis Chronic urinary tract infection Chronic fungal disease Tuberculosis
- 52. Anemia of chronicdisease Conditions associated with Anemia of Chronic Disorders Category Conditions Chronic Non infectious inflammation Rheumatoid arthritis Rheumatic Fever Systemic Lupus erythematosus Sterile abscess Regional enteritis Ulcertaive colitis
- 53. Anemia of chronicdisease Other causes Malignant Neoplasm Alcoholic Liver Disease Congestive Heart failure Thrombophlebitis Ischaemic Heart disease Severe tissue trauma Thermal Injury Fractures
- 54. Pathophysiology of ACD Causes are Multifactorial. Block in release of iron from macrophages due to increased Hepcidin. Cytokine inhibition of Erythropoetin production. Direct Cytokine inhibition of Erythropoeisis. Shortened erythrocyte survival.
- 55. Pathophysiology of ACD Block in iron release from macrophages is mediated by hepcidin which is produced in response to IL-6 and other inflammatory cytokines released in anemia of chronic disease. Decreased Erythropoetin production and direct suppression of erythropoiesis by cytokines. Shortened erythrocyte survival :due to non specific macrophage activation.
- 56. PathoPhysiology of ACD Disorders associated with Anemia of chronic disease enhance phagocytic activity of macrophages Activated macrophages are sensitive to slight alteration in red cells and causes their premature destruction.
- 57. PathoPhysiology of ACD Release of Iron from macrophages is inhibited leads to hypoferremia (Low serum Iron) and less iron is available to erythroid precursors. This causes iron deficient erythropoiesis despite sufficient storage iron
- 58. Clinical Findings ofAnemia of Chronic Disease Signs and symptoms are those of underlying disorders Anemia develops during first 1-2 months of illness Clinical manifestation may vary widely in anemia of chronic disease because of its association with so many diseases.
- 59. Laboratory Findings ofAnemia of chronic disease Peripheral Blood Erythrocytes are usually Normocytic Normochromic MCV<85 fl But long standing cases can present as microcytic Hypochromic White blood cell and platelet count are normal.
- 60. Iron studies S.iron–Normal to decreased TIBC –Normal to decreased Transferrin saturation – normal to decreased Increased S.ferritin
- 61. Bone Marrow Examination Increased myeloid: erythroid ratio because of decrease in erythroid precursors Proportion of younger erythroblast increases. Sideroblasts <30% Macrophages appears to have increased hemosiderin in the form of coarse iron aggregates
- 62. BONE MARROW FEATURESOF ANEMIA OF CHRONIC DISEASE Bone Marrow aspirate demonstrate an increased iron staining in a fragment representing Increased marrow iron stores. Normal Iron staining is shown in histiocytes for comparison.
- 63. CRITERIA FOR GRADINGIRON STORES Grade Criteria 0 No Iron Granules observed 1+ Small granules, seen only in oil immersion lens 2+ Few small granules seen with low power lens 3+ Numerous small granules in all marrow particles 4+ Large granules in small clumps 5+ Dense, large clumps of granules 6+ Very large granules obscuring marrow details Normal Marrow = 1+ to 3+
- 64. For Diagnosis ofAnemia of chronic disease Evidence of chronic disease (Raised ESR),Raised CRP Mild to moderate anemia, red cells normocytic normochromic, in late stages presents as microcytic hypochromic Low S.Iron, Low TIBC , Low transferrin saturation S.ferritin Normal or Increased S.Hepicidin High
- 65. Case 3 A33 yr old patient on ATT with following laboratory investigations Increased S.iron Increased transferrin saturation Increased ferritin Normal TIBC What is the most likely diagnosis ?
- 66. Sideroblastic Anemia Mutationsthat affect the first enzyme step in Heme synthesis, formation of δ-aminolevulinic acid result in sideroblastic anemia
- 67. Causes of Sideroblasticanemia Hereditary Acquired primary refractory anemia with ringed sideroblasts Secondary Hematological malignancies – Myeloproliferative disorders , multiple myeloma ,Acute Myeloid leukemia M6 type Drugs-Isoniazid ,pyrazinamide ,cycloserine . Alcoholism Lead poisoning Others – Collagen disorders ,Carcinoma
- 68. Pathogenesis of sideroblasticanemia Impaired Heme synthesis in Mitochondria Defective heme synthesis is associated with increased Iron uptake Protoporphyrin link up with iron fails to occur and excess iron is deposited in mitochondria
- 69. Peripheral Blood pictureof Sideroblastic anemia Poikilocytosis. Moderate to severe anemia A Dimorphic picture –Normocytic and hypochromic Dual population of normocytes and microcytes Hypochromic microcytes more common in hereditary form of Sideroblastic anemia Erythrocytes can contain pappenheimer bodies (Iron deposits)-Basophilic granules of iron inside RBC. Basophilic stippling can be seen in any of Sideroblastic anemia resulting from aggregated ribosomes
- 70. Iron profile insideroblastic anemia S.Iron Increased Normal or Increased TIBC Increased S.ferritin Increased Transferrin saturation levels
- 71. Bone Marrow findingsin Sideroblastic anemia Erythroid hyperplasia Erythroblast –poorly hemoglobinized with scanty irregular cytoplasm Macrophages contain increased amount of storage iron Ringed sideroblasts >40% are erythroblast with iron granules that encircle one third or more of the nucleus
- 72.
- 73. Case 4 A5 yr old child with chronic anemia not responding to Iron therapy ? Diagnosis ?
- 74. Thalassemia Definition : Thalassemias are heterogeneous group of Inherited disorders of Hemoglobin characterised by reduced or absent production of one of the globin chains Thalassemia is a quantitaive disorder Thalassa Greek word means Great sea First observed in Mediterranean sea
- 75. Classification of Thalassemia 1)Based on type of globin chain that is deficiently synthesized 2) Clinical expression of disease Classification according to the type of globin chain which is deficiently synthesised : The two most common types are α and β Thalassemia Classification According to Clinical severity : β Thalassemia classified on the basis of severity of anemia into three types : thalassemia major ,thalassemia minor and thalassemia intermedia
- 76. α Thalassemiaare Hb Bart’s ,Hydrops fetalis syndrome ,HbH disease ,Thalassemia trait and Silent carrier. Classification of Thalassemia
- 77. Molecular Basis ofThalassemia β Thalassemia are caused by point mutations. while most of the α thalassemias result from gene deletions.
- 78. Clinical features ofAlpha Thalassemia Pallor Weakness Fatigue Hepatosplenomegaly Heart defects Hb barts syndrome can cause complications in pregnancy
- 79. Clinical Features ofβ-Thalassemia Thalassemia Major Age of presentation : 6months -9 months Progressive pallor and Jaundice Cardiac failure Hepatosplenomegaly Bouts of Fever and Diarrhoea Feeding problems
- 80. Clinical Features ofβ- Thalassemia By childhood Growth retardation Transfusion dependent Changes in skeletal system
- 81. Skeletal Changes CHIPMUNKFACIES(HEMOLYTIC FACIES) Frontal bossing,maxillary hypertrophy,depression of nasal bridge, malocclusion of teeth PARAVERTEBRAL MASSES Broad expansion of Ribs at vertebral attachment PATHOLOGICAL FRACTURES Cortical thinning Premature fusion of epiphysis –Short stature
- 82. Clinical features ofthalassemia Intermedia Moderate pallor ,usually maintains Hb>6gm% Less transfusion dependent Skeletal changes Progressive Splenomegaly Growth Retardation Longer survival than Thalassemia Major
- 83. Usually asymptomatic Mild Pallor ,No jaundice No Growth retardation No Skeletal abnormalities ,No Hepatomegaly May Present as Iron deficiency Anemia Unresponsive/refractory to Iron therapy Normal life expectancy Clinical features of thalassemia Minor
- 84. LABORATORY DIAGNOSIS Hb-Reduced(3-9 g/dl) RBC count Increased WBC, Platelets –Normal RBC Indices –MCV,MCH and MCHC Reduced RDW Normal
- 85. Laboratory Findings PeripheralBlood examination : Microcytic hypochromic RBC’s Anisocytosis Poikilocytosis Plenty of target cells Howell jolly bodies Basophilic stippling Nucleated red cells.
- 86. Target cells Peripheralpicture of Thalassemia minor
- 87. Basophilic stippling Peripheral pictureof Thalassemia minor
- 88. Bone marrow Findingsin thalassemia Bone marrow examination shows Erythroid hyperplasia Myeloid : Erythroid ratio reversed (Normal 3:1) Increased Bone marrow iron
- 89. S.IRON studies S.IronNormal S.Ferritin Normal Percentage Saturation Normal Normal TIBC
- 90. SCREENING TEST NESTROFTTEST Naked eye single tube red cell osmotic fragility test Most common screening test Blood sample is collected in test tube and normal saline is added (0.35%) A plain white paper with a black line is placed behind the test tubes After 30 minutes interpretation will be : A Black line is seen in normal individual.
- 91. No Blackline seen is indicator of Thalassemia
- 92. Other Parameters TotalBilirubin and Indirect Bilrubin is Increased Haptoglobin and Hemopexin depleted Free erythrocyte Protoporphyrin Normal
- 93. Special test Diagnosisis confirmed by Hemoglobin electrophoresis This characteristically shows elevated HbF in Thalassemia Major. Increased HbA2 in β-Thalassemia minor
- 94.
- 96. Thalassemia minor vsiron deficiency anemia Findings Thalassemia minor Iron deficiency anemia Anisocytosis Mild or absent Early and prominent finding Microcytosis More severe Less severe
- 97. Mentzer index Mentzerindex=Mean cell volume/Red cell count Value greater than 13 is found in iron deficiency anemia whereas value less than 13 is seen in thalassemia trait disorder.
- 98. Differential diagnosis ofMicrocytic anemia Iron deficiency Anemia Anemia of Chronic Disease Thalassemia (α or β) Sideroblastic Anemia S.Iron Reduced Reduced Normal Raised S.TIBC Raised Reduced Normal Normal S.Ferritin Decreased Raised Normal Raised Iron in Bone Marrow Absent Present Present Present RDW Increased Normal Normal Normal Percentage Transferrin saturation Reduced Reduced Normal Raised Free Erythrocyte Protoporphyrin Raised Raised Normal Raised
- 100. Summary Iron DeficiencyAnemia is the most common nutritional deficiency In Iron Deficiency Anemia TIBC is Increased. In Anemia of Chronic Disease TIBC is Decreased. In sideroblastic anemia TIBC Normal In Thalassemia Iron studies will be Normal
- 101. References Mckenzie S.ClinicalLaboratory Hematology 3rd Edition.Pearson Education : New Jersey;2015.p200-268 Wintrobe’s clinical Hematology 11th Edition.Lippincott and Wilkins: USA;2004,p.972-976 Kumar V.Robbins and Cotran Pathologic Basis of disease 9th Edition.RELX Pvt.Ltd;2015.p629-650 Kawathalkar S.Essentials of Clinical Pathology 2nd ed.New Delhi:Jaypee Brothers Medical publishers (p) Ltd;2018.p213-216. Google Images www.ncbi.nilm.nih.
- 102.
Editor's Notes
- #23 Transfer of iron to fetus occurs mainly in the last trimester. Therefore during this period , diet should contain surplus amount of iron.
- #38 De
- #90 In beta thalassaemia major multiple blood transfusions, ineffective erythropoiesis and increased gastrointestinal iron absorption lead to iron overload in the body. ... Results: 87.4% of the beta thalassaemia major patients showed very high ferritin levels.