Anemia

Ibrahim Qaqish, MD, FACP, Raj Ravula, MD, St. Josephs Hospital & Medical Center
Anemia
RBC Mass/Hgb
R/0 Dilutional Anemia
example:- Pregnancy, CHF
volume overload

Males < 13.5 gm/dl

Females < 12.5 gm/dl
MCV

80-95 FL

<80 FL

Microcytic

>95 FL

Normocytic

RI 2

Macrocytic

RI 2

Normal, High

>110FL

Low

Hemoglobin Electrophoresis

7
B Deficiency
12
Blood Smear
Macroovalocytes
Hypersegmented
neutrophils
homocysteine

Normal, High
LDH, Peripheral Smear
Indirect bilirubin

Low

Serum Iron, TIBC, Ferritin

WBC and Platelets

Thalassemia Minor
Serum Fe

TIBC

Iron Deficiency Anemia

Ferritin

5
Anemia of chronic disease
Sideroblastic Anemia

Pappenheimer bodies
Basophilic Stippling

BM Biopsy

Ring Sideroblasts

R/O Reversible Causes

RBC Protoporphyrin
Lead Level
Copper Level
Core temperature
Medications

Auto Immune
SLE, Thymoma, congenital
Fanconis

Lead Poisoning

Congenital
Fanconi

Copper Deficiency
Hypothermia
Isoniazid, Chloramphenicol

Myelofibrosis
Myelophthesis
Fat, Malignant cells
Gauchers disease, Leukemia

Acute blood loss

BM biopsy

Pure Red
cell Aplasia

Aplastic anemia
50% Indiopathic
Infections-HIV, EBV, CMV,
HCV
Radiations, Chemicals

Normal

Peripheral Smear

Normal

Low
Pancytopenia
BM Biopsy
Peripheral Smear

Hemolysis4

Retic
Normal LDH

Parvo Virus
PCR

95-110FL

Schilling Test

Look for source

of bleeding

Renal Failure

GFR
Erythropoietin
Blood smear-Burr cells

Liver Disease

Abnormal LFT

Hypothyroidism
3
Anemia of
Chronic disease

MMA
High

Normal, Low
RBC, Folate

7
Low
Folate Deficiency
homocysteine

Congenital

Blood smear-Spur cells

TSH Target cells

1) For any type of anemia check medications

2) Reticulocyte Index, Normal >2%
If Low it means bone marrow not responding properly or BM infiltration or suppresion
If very high consider hemolysis
3) Hypothyroidism can cause microcytic, normocytic and macrocytic anemia
4) Hemolytic Anemia Absolute Retic count, LDH, unconjugated bilirubin
Sometimes conjugated if poor liver function, or absent haptoglobin if intravascular hemolysis
UA: urobilinogen, conjugated bilirubin, hemoglobin, hemosiderin
5) FE/TIBC < 18% ; RDW, MCH
Anemia of chronic Disease Fe/TIBC >18%
6) Coombs Test

Direct Test - to detect antibody on patients RBC

Indirect Test - to detect antibody on patients Serum
Both Tests ill be positive if patients RBC agglutinates

7) B12, Folate deficiency - LDH, indirect bilirubin may be elevated due to ineffective erythropoiesis

Peripheral
Smear
Elliptocytosis
Eltiptocytes

GEPD

PNH
Paroxysmal
Nocturnal
Hemoglobinuria

Hereditary
Spherocytosis
Osmotic fragility Test
Spherocytes

Ham Test
Sugar water Test
Flow cytometry
Assay CD 55

Pyruvate
Kinase
Deficiency

Reticulocytosis
-Secondary to
bleeding,
hemolysis

Non-Immunological

Hemoglobinopathies
GEPD RBC
enzyme assay

Congenital

PK RBC
enzyme assay

RI 2

Extravascular

Hgb electrophoresis

Sickle Cell
SS

Thalassemia

-Infant +
craniofacial
anatomy or
absent radius
or urogenital
anatomy
Myelodysplastic
Diamond-black fan
syndrome
syndrome
-Usually Pancytopenia
-Peripheral Smear
Pseudo-Pelger-Huet anamoly
-BM (Blast + ring sideroblasts)

Immunological

Intravascular

- IgG Cold AIHA

Monoclonal - lymphoproliferative
Polyclonal

Hypersplenism
Microangiopathic
Hemolytic Anemia
8 TTP, DIC, HUS(no neurologic deficit)
HELLP Syndrome
Schistocytes
Peripheral Smear- helmet cells
fragmented RBC
Spherocytes

- mycoplasma pneumoniae
- mononucleosis

- Paroxysmal cold
hemoglobinuria
- Alloimmune - blood transfusion
- Platelets -ITP Evans Syndrome

Mechanical (usually no thrombocytopenia)

Malignant Hypertension, Burns
Prosthetic valve
March, Joggers hemoglobinuria

Sickle / thal
Anemia
Usually B
thalassemia
trait
minor
Hb H
Hb barts

B Thalassemia
Major

Minor

Vasculitis

ESR, ANCA, CRP

Infections

Invasive
- Malaria
- Babesiosis
Toxin
- Clostridium perfringens
- Borreliosis

Intravascular

Extravascular

Schistocytes

Spherocytes

/ absent

Mild decrease

Urine hemoglobin

++

Negative

Urine hemosiderin

++

Negative

Usually ++

++++

Peripheral Smear
Haptoglobin

Direct Antiglobin Test DAT

Guyatt GM et al. Laboratory diagnosis of iron deficiency anemia. J Gen Int Med 1992;7:145-53
Griner PF.Microcytosis. In: Diagnosis Strategies for Common Medical Problems. ACP ; 1999:575-584
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Peripheral
Smear
BM Biopsy

- IgG Warm AIHA - Idiopathic, SLE, CLL

Acquired
Stomatocytosis
Hypophosphatemia

8) TTP Pentad - Fever, thrombocytopenia, MAHA, Renal failure and nuerological deficit.
Same in HUS without neuroligical deficit
9) Ferritin level <10 in females, <20 in males confirms iron deficiency anemia while level>200 excludes it.
Levels between 20-200 bone marrow aspirate and if iron levels are low, confirms iron deficiency.
Ferritin is usually high in anemia of chronic disease.

Normal, Low

Fe, TIBC
Ferritin

Extrinsic

Methemoglobinemia
2
3
Fe
Fe

TSH

High Low Normal

Enzymatic

Acquired

Normal

High
Hypothyroidism
3

Direct Coombs test 6

NOTES:

LFT

Abnormal
Anemia of Liver Disease
Alcholism

Intrinsic

Membranopathy

Normal, High

LDH