Anemia, dr yasmin husseiny

Anemia
By
Dr/ Yasmin Husseiny
Lecturer of family
medicine
YASMIN HUSSEINY, 2022

List
The referral criteria for a
case with anemia
Identify
Screening and patient
education for anemia
Highlight
The clinical approach for
anemia
Determine
The diagnostic criteria for
each type
Identify classification of anemia
Identify Epidemiology of anemia
Define Anemia

Definition
Anemia is a condition in which the number of red blood cells or the
hemoglobin concentration within them is lower than normal.
Diagnosed when hemoglobin (Hb) level <12 g/dL in females and
<14 g/dL in males or, alternatively, as an Hb level <12.5 g/dL in
adults. (WHO)
It is the most common hematologic disorder seen in general
medical practice.

HB level in children

Epidemiology
Anemia is a serious global public health problem that
particularly affects young children and pregnant women.

Global anemia prevalence (WHO)
Population group Prevalence of anemia
Percent 95% CI
Preschool-age children 45.7-49.1
school-age children 25.4 19.9-30.9
Pregnant women 39.9-43.8
Non-pregnant women 30.2 28.7-31.6
Men 8.6-16.9
Elderly 23.9 18.3-29.4
47.4
41.8
12.7

Prevalence in Egypt (DHS,2015)
 Children aged 6 month-< 5 years
More than one in four young children in Egypt suffers
from some degree of anemia.
Children Aged 5-19 Years
Girls aged 5-19 years are somewhat more likely than boys
in the age group to be anemic (21% and 18%,
respectively).
Ever-married Women Aged 15-49
25% of women were classified as anemic.

Clinical presentation

Clinical presentation
Symptoms are a function of the
severity and the speed of onset of the
anemia.
Rapid onset of anemia, with little
time for the compensatory
mechanisms to act = More symptoms

Hemoglobin Electrophoresis
Hgb A1: 95–98%
Hgb A2: 2–3%
Hgb F:
–Newborn: 50–80%
–6-month-old: 1–2%
–Adult: 0.8–2%
Hgb C, S, or E: 0%

Classification of anemia
Based on cause
Blood loss
Inadequate
production of
normal blood
cells
Excessive
destruction of
blood cells

Based on morphology
Microcytic Normocytic Macrocytic

Microcyticanemia

Causes of microcytic anemia
Iron deficiency anemia
Thalassemia
Anemia of chronic disease
Sideroblastic anemia
Lead poisoning
Hereditary spherocytosis

 Iron deficiency is the most common nutritional disorder
worldwide and accounts for approximately one-half of
anemia cases.
Iron deficiency anemia can result from inadequate iron
intake, decreased iron absorption, increased iron demand,
and increased iron loss.

Diagnosis
1. Complete Blood Count (CBC)
 can be helpful to determine the
MCV.
 Although iron deficiency is the most
common cause of microcytic
anemia, up to 40 percent of patients
with iron deficiency anemia will
have normocytic erythrocytes.
 iron deficiency should still be
considered in all cases of anemia
unless the mean corpuscular volume
is greater than 95 μm3 (95 fL).

Diagnosis
2. Serum ferritin level:
 Ferritin reflects iron stores and is the most accurate test in
diagnosis. Levels below 30 ng/mL are consistent with a
diagnosis of iron deficiency anemia and levels greater than
100 ng/ml exclude it.
Ferritin is also an acute phase reactant and can be elevated
in patients with chronic inflammation or infection. In
patients with chronic inflammation, iron deficiency anemia
is likely when the ferritin level is less than 50 ng/mL

Diagnosis
In patients with no inflammatory states and in whom the
ferritin level is indeterminate 31 to 99 ng per mL, further
tests can be performed to ascertain iron status. Values
consistent with iron deficiency include a low serum iron
level, low transferrin saturation, and a high total iron-
binding capacity.
Soluble transferrin receptor and erythrocyte
protoporphyrin testing, or bone marrow biopsy can be
considered if the diagnosis remains unclear.

Evaluation

Treatment

Underlying cause
Patients with an underlying condition that
causes iron deficiency anemia:
should be treated or referred to a subspecialist
(e.g., gynecologist, gastroenterologist) for
definitive treatment.

Oral iron therapy (dose)
The dosage of elemental iron required to treat iron
deficiency anemia in adults is 120 mg per day for three
months
The dosage for children is 3 mg per kg per day, up to 60
mg per day.

Oral iron therapy (follow up)
An increase in hemoglobin of 1 g per dL after one
month of treatment shows an adequate response to
treatment and confirms the diagnosis.
In adults, therapy should be continued for three
months after the anemia is corrected to allow iron stores
to become replenished.

Oral iron therapy
Adherence to oral iron therapy can be a barrier to
treatment because of GI adverse effects such as
epigastric discomfort, nausea, and constipation.
These effects may be reduced when iron is taken with
meals, but absorption may decrease by 40 percent.

Oral iron therapy
Medications such as proton pump inhibitors and
factors that induce gastric acid hypo-secretion (e.g.,
chronic atrophic gastritis, recent gastrectomy or
vagotomy) are associated with reduced absorption of
dietary iron and iron tablets.

Parenteral iron therapy
Parenteral therapy may be used in patients who cannot
tolerate or absorb oral preparations.
The most common indications for intravenous therapy
include GI effects, worsening symptoms of inflammatory
bowel disease, unresolved bleeding, renal failure–induced
anemia treated with erythropoietin, and insufficient
absorption in patients with celiac disease.

Iron Therapy: Formulations and Dosing

Monitoring
There are no standard recommendations for follow-up
after initiating iron therapy; however, one suggested
course is to recheck CBC every three months for one
year.
If HB and RBCs indices remain normal, one additional
CBC should be obtained 12 months later.
No further follow-up is necessary if the patient is
asymptomatic, and the hematocrit level remains normal.

Blood transfusion
Transfusion is recommended in pregnant women with
hemoglobin levels of less than 6 g per dL because of potentially
abnormal fetal oxygenation resulting in non-reassuring fetal
heart tracings, low amniotic fluid volumes, fetal cerebral
vasodilation, and fetal death.
If transfusion is performed, two units of packed red blood cells
should be given, then the clinical situation should be reassessed
to guide further treatment.

Thalassemia

Epidemiology
Approximately 5 % of the world’s population has a globin
variant, but only1.7 % has alpha or beta thalassemia trait.
Thalassemia affects men and women equally and occurs in
approximately 4.4 of every 10,000 live births.
Thalassemia is most common in persons of
Mediterranean, African, and Southeast Asian descent.

Patho physiology

Diagnosis (family history AR)

Diagnosis

Clinical recommendations (AAFP)
Persons with beta thalassemia major require chelation therapy for iron
overload. (A)
Persons with beta thalassemia major require periodic lifelong blood
transfusions to maintain hemoglobin levels higher than 9.5 g per dL (95 g
per L) and sustain normal growth. (B)
Persons with anemia from thalassemia trait should not take iron
supplements unless they have coexistent iron deficiency. (C)
Persons at risk of having a child with thalassemia should be offered
preconception genetic counseling. (C)

The most common diseases that can cause anemia are:
Any type of infection (HIV)
Chronic kidney disease
Autoimmune diseases (rheumatoid arthritis, systemic lupus)
Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)
Cancer
Heart failure
Obesity

 It is the second most common type of anemia
Anemia of chronic inflammation
Having low levels of red blood cells as a result of autoimmune
diseases or other chronic illness (last longer than 3 months).
Serum iron normal or decreased
 Serum ferritin normal or elevated
TIBC normal or decreased
 Hgb electrophoresis is normal
 Reticulocyte count decreased

Although it is usually normochromic–normocytic, this
anemia can mimic that of iron deficiency in having a low
serum iron and sometimes presenting as a microcytic
anemia.

normocyticanemia

Normocytic anemia
In normocytic anemia, the
hemoglobin is low, but the
MCV is normal
Causes :
Active bleeding
pregnancy
malnutrition
renal failure
chronic disease
 hemolysis
Hypersplenism
congenital disorders
endocrine disorders
infection, and
 primary bone marrow disorders

Hemolytic anemia
Sickle Cell Disease.
Glucose-6-Phosphate
Dehydrogenase (G6PD) Deficiency.
Drug-Induced Hemolytic Anemias.
Autoimmune Hemolytic Anemias.

Sickle cell disease (AR disorder)

Sickle cell disease diagnostic tips
The peripheral smear: is normal except for an
occasional target cell and sickled cells.
Hemoglobin electrophoresis: HB S less than
50% of total HB

Sickle cell disease diagnostic tips
Intravascular occlusion: organ damage. Leg
ulcers, hepatomegaly, hematuria, mild jaundice,
stroke, MI, spleen fibrosis (auto splenectomy)
Patients report acute, severe pain in the lower
extremities, back, or abdomen.
Fever and leukocytosis
Attacks typically last from a few hours to a few
days and then resolve spontaneously.

Sickle cell trait
Asymptomatic and anemia is absent.
Manifestations occur with sever hypoxia.

G6PD, Deficiency
 The prevalence of G6PD deficiency among Egyptian
neonates is 8.9%.
 Sex-linked red cell defect (male)
Compromising the enzyme that maintains hemoglobin in an
unoxidized state.
The condition causes hemolysis after exposure to oxidant
compounds (aspirin, sulfonamides, antimalarials), infection,
fava beans.

Macrocyticanemia

Vitamin B12
Deficiency
Vitamin B12
absorption

Vitamin B12
Deficiency
RISK FACTORS

Vitamin B12
Deficiency
Clinical
presentation

Vitamin B12 Deficiency
Diagnosis
Blood smear Hyper segmented polymorphonuclear
leukocytes are an early finding, Oval macrocytes.
B12 level falls to less than 150 pg/Ml.
Serum levels of homocysteine and methylmalonic acid
increase markedly in almost all cases of B12 deficiency.

Vitamin B12 Deficiency
Diagnosis
 Anti-Intrinsic Factor Antibodies and Anti-
parietal Cell Antibodies. Assay results for these
patho-physiologically important antibodies
provide high levels of specificity and moderate
sensitivity for the diagnosis of pernicious anemia.

Hyper segmented
polymorphonuclear
leukocytes

Vitamin B12 Deficiency (ttt) AAFP
Cyanocobalamin (IM injection)
1
mg/dose
No neurologic deficit
3 doses/ week for 2
weeks
neurologic deficit
Every other day
For up to 3 weeks

Vitamin B12 Deficiency (ttt) AAFP
Intramuscular: 1 mg daily for 1 week,
weekly for 8 weeks, then 1 mg monthly
for life.

Folic acid deficiency
Causes:
Chronic alcohol abuse
Increased demand:
 pregnancy,
hemolysis,
Malignancy.
Decreased uptake ( malabsorption or drugs e.g., phenytoin,
other anticonvulsants)
folate antagonists such as methotrexate, trimethoprim, and
triamterene.

Folic acid deficiency
Diagnosis :
Elevated homocysteine, with normal methylmalonic
acid.
Treatment :
Oral folic acid 1mg/ day. And correct the cause
If vitamin B12 deficiency coexists with folate deficiency,
vitamin B12 should be replaced first to prevent
subacute combined degeneration of the spinal cord.

Diagnostic approach
to anemia

History taking
Abnormal blood loss,
Change in bowel habits,
Melena,
Heavy use of aspirin or NSAI drugs,
Family history of anemia (especially in patients of
Mediterranean descent),
Concurrent malignancy,
HIV infection,

History taking
Positive family history in inherited hemolytic anemias
such as sickle cell anemia, hereditary spherocytosis, and
(G6PD).
Symptoms of other chronic infections or chronic
inflammatory disorders,
Number of pregnancies,
 Pica,
Dysphagia,

History taking
History of lead exposure,
Dietary iron intake,
Quantity of menstrual blood loss,
 Gastric resection,
Changes in nails, and soreness of the tongue.

Physical examination
Checking for glossitis, cheilitis, koilonychia,
 Lymphadenopathy, hepatosplenomegaly,
 Rectal mass, stool positive for occult blood,
Pelvic mass, and other signs of chronic infectious,
inflammatory, and neoplastic disorders.

CBC
Low HB
MCV <80 = microcytic
1.Testing for Iron Deficiency and Differentiating It
from Anemia of chronic disease

Therapeutic Trial of Iron
A therapeutic trial of oral iron therapy can
also be used in uncomplicated cases as a
simple alternative to the determination of the
ferritin level or an examination of the marrow.
The reticulocyte count is monitored during a
7-to 10-day period. A significant increase in the
reticulocyte count is a strong evidence for the
diagnosis of iron deficiency.

Iron deficiency has been
ruled out
2. Differentiating among anemia
of chronic disease, thalassemia, and sideroblastic
anemia.
Testing for thalassemia

3.Differentiating Anemia of Chronic
Disease from Sideroblastic Anemia
ANEMIA OF CHRONIC
DISEASE
Serum iron and transferrin
saturation (low normal or )
Ferritin normal or
SIDEROBLASTIC
ANEMIA
Serum iron and transferrin
saturation (high normal or )
Ferritin
Absence of other cause of iron
overload
Bone marrow aspirate for
ringed sideroblasts

MCV >100 = macrocytic
1. distinguish megaloblastic from non-
megaloblastic
The blood smear is the most helpful test.

2.Folate versus Vitamin
B12 Deficiency

MCV 80-100 = normocytic
Reticulocyte Count
Elevated Reticulocyte Count: Workup for Hemolysis
Reticulocyte Count Reduced or Not Appropriately Elevated:
Workup for Metabolic Disease and Anemia of Chronic Disease

Reticulocyte Count Nil:
Workup for Aplastic Anemia
A very low or absent reticulocyte count
pancytopenia on the peripheral smear
A history of:
 drug use (e.g., chloramphenicol, phenylbutazone)
toxin exposure (benzene, insecticides),
or a recent viral illness may provide a clue to the
cause.
Fatty bone marrow on biopsy strongly suggests
marrow aplasia

Prevention
Primary Supplementation
Secondary Screening

Supplementation
Iron supplementation is recommended to high-risk
groups (pregnant, children)
Patients older than 50 years and strict vegetarians
should be counseled to consume fortified cereals or
supplements of vitamin B12.
The American Society for Metabolic and Bariatric
Surgery recommends that patients who have had
bariatric surgery take vitamin B12 supplementation
indefinitely.

Screening
Screening of iron deficiency anemia
Target groups:
 Men and postmenopausal women
Pregnant women
Children

Men and postmenopausal women
 Asymptomatic men and postmenopausal women
should not be screened for iron deficiency anemia.
 Testing should be performed in patients with signs and
symptoms of anemia, and a complete evaluation should
be performed if iron deficiency is confirmed.

Pregnant women:
The American Academy of Family Physicians,
USPSTF, and CDC recommend routine screening of
asymptomatic pregnant women for iron deficiency
anemia.

The defined values consistent with anemia in pregnancy are
hemoglobin levels < 11 g per dL in the first or third
trimester, or < 10.5 g per dL in the second trimester.
 Maternal hemoglobin level of less than 6 g per dL has been
associated with poor fetal outcomes, including death.

Children:
The American Academy of Pediatrics recommends
universal hemoglobin screening and evaluation of risk
factors for iron deficiency anemia in all children at one
year of age.
Risk factors include low birth weight, history of
prematurity, exposure to lead, and weaning and
complementary foods without iron-fortified foods.

The USPSTF found insufficient evidence for
screening in asymptomatic children six to 12 months
of age and does not make recommendations for other
ages.

Screening
Iron deficiency anemia
Persons at risk of having a child with thalassemia
should be offered preconception genetic counseling.
 Neonates should be screened for G6PD deficiency if
there is positive family history.

Patient education
Patients and any accompanying family members
should be educated about:
 the signs and symptoms of anemia,
the diagnostic testing
 treatment regimens specific to their anemia,
 medication compliance issues.

Patient education
Educate the patient on the importance of alcohol
cessation, in B12 and folate deficiency.
Patients with iron deficiency anemia should be
advised about the importance of good nutrition and
compliance with iron supplementation.

Referral criteria for a case of anemia
Sever anemia (HB < 8 gm/dl)
Anemia associated with suspected malignancy (eg.
Weight loss, fever/night sweats, bone pain)
Children with severe malnutrition
Pregnant women in the last month of pregnancy
Patients with respiratory distress or cardiac abnormalities

Patients started the oral iron and folate therapy but have
their conditions worsening at the first follow-up visit
Patients having oral iron and folate therapy but show no
improvement at 4-week follow-up visit
Requiring bone marrow biopsy
Hemolytic anemia after initial labs and work up

Elderly patients whose anemia remains unexplained after a
basic but systematic initial assessment by the primary care
physician should be considered for hematologic specialty
consultation, especially if
hemoglobin <10 mg/dL,
worsening,
macrocytic with a low reticulocyte count,
 or accompanied by other blood cytopenias (neutropenia or
thrombocytopenia).

Thank you

Anemia, dr yasmin husseiny

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Anemia, dr yasmin husseiny

Similar to Anemia, dr yasmin husseiny (20)

Recently uploaded

Recently uploaded (20)

Anemia, dr yasmin husseiny