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Anaemia

Dental Students
2014

Outline
Clinical features of anaemia
Classification
Microcytic
Normocytic
Macrocytic

Data examples
Haemolytic anaemia

Definition of anaemia
Anaemia is defined as a reduction in the
haemoglobin concentration of the blood
This results in a decreased oxygen carrying
capacity

Red blood cells

Symptoms of anaemia

Shortness of breath on exercise


Weakness, fatigue
Headaches, lightheadedness, confusion
Palpitations
Angina, cardiac failure
Intermittent claudication

Signs of anaemia
Pallor
Tachcardia, bounding pulse (hyperdynamic
circulation)
Signs of congestive cardiac failure
Pulmonary oedema
Peripheral oedema

Conjunctival pallor

Classification of Anaemia
Microcytic
Normocytic
Macrocytic

Haemolytic

Classification of Anaemia:
Microcytic Hypochromic
MCV <80fl
MCH <27pg
?? Ferritin level (also check CRP/ESR)

Microcytic anaemia
Ferritin <20ug/L
Iron deficiency

Microcytic anaemia
Ferritin >20ug/L
Thalassaemia
Anaemia of chronic disease (some cases)
Lead poisoning

Iron deficiency anaemia


Assess for underlying cause:
Dietary iron deficiency
Malabsorption
Chronic blood loss
Gastrointestinal
Menorrhagia

Iron deficiency: a global perspective

Malabsorption
Coeliac disease

Autoimmune disorder
Intolerance of proteins in wheat, barley, rye
Villous atropy
Anti-tTG Ab/duodenal biopsy at OGD

Crohns disease
Inflammatory bowel disease

Tropical sprue
Villous atrophy, Carribean/Far & Middle East

Chronic blood loss


Gastrointestinal

Symptoms of GORD
Malaena/blood PR
Altered bowel habit
Family Hx bowel carcinoma

Menorrhagia
Duration of menses, flooding, clots

Management
Oral Fe replacement therapy
Galfer tablet twice daily for 3 months
Re-check FBC & ferritin
Supplement for 3 months after correction

Non-compliance
GI symptoms

Failure of Response to Oral Iron

Poor compliance
Malabsorption
Ongoing blood loss
Wrong diagnosis-thalassaemia trait
Mixed deficiency-associated vitamin B12 or folate
deficiency
Another cause for the anaemia, e.g. malignancy,
inflammation

Microcytic anaemia
Ferritin >25ug/L
Thalassaemia

Sideroblastic anaemia
Anaemia of chronic
disease (usually
normocytic)
Lead poisoning
(usually normocytic)

Consider referral to
haematologist
Refer to haematologist

Assess exposure
history: measure
urinary lead

Thalassaemia Trait
Hb is a tetramer of 2 alpha & 2 beta globin chains
Thalasseamia is a genetic disorder of unbalanced
Hb synthesis resulting in:
underproduction of one globin chain
unmatched globins precipitate causing RBC membrane
damage & premature haemolysis

Usually non-Caucasians
Microcytic anaemia
High red cell count
Normal MCHC

Microcytic Anemias
MCV < 80 fl

Serum Ferritin TIBC BM Perls stain

++

++++

Hemoglobinopathy

Lead poisoning

++
++

++++

Iron Def. Anemia


Chronic Infection
Thalassemia

Sideroblastic

Classification of Anaemia:
Normocytic Normochromic
MCV 80-100fl
MCH >26pg

Normochromic normocytic
anaemia

Often incidental finding in systemic disorders


May be first manifestation of a systemic disorder
Many haemolytic anaemias
Anaemia of chronic disease (some cases)
After acute blood loss
Bone marrow failure
post-chemotherapy
infiltration by carcinoma etc
aplastic anaemia

Classification of Anaemia:
Macrocytic
MCV >100fl
Megaloblastic
vitamin B12 or folate deficiency

Non-megaloblastic
alcohol, liver disease
myelodysplasia
aplastic anaemia

Megaloblastic Anaemia: Clinical

Insidious onset of symptoms and signs of anaemia


Lemon yellow jaundice
Glossitis, angular stomatitis
Neuropathy-subacute combined degeneration of
the cord (neuropathy affecting the peripheral
sensory nerves and posterior and lateral columns)

Vitamin B12

Normal daily intake


Main foods
Cooking
Minimal daily requirement
Body stores
Absorption
site
mechanism
limit
Usual therapeutic form

7-30mg
Animal produce only
Little effect
1-2mg
2-3mg (enough for 2-4yrs)

Ileum
Intrinsic factor

2-3mg
Hydroxocobalamin

Pernicious Anaemia
Autoimmune attack on the gastric mucosa
leading to atrophy of the stomach
Lack of gastric intrinsic factor secretion

Females> males
Associated autoimmune diseases
Thyroid, vitiligo, Addisons disease

Tends to occur in families


Parietal cell Ab, Intrinsic factor Ab

Folic Acid

Normal daily intake


Main foods
Cooking
Minimal daily requirement
Body stores
Absorption
site
mechanism
limit
Usual therapeutic form

200-250mg
Most liver, greens, yeast
Easily destroyed
100-150mg
10-12mg (4mths supply)

Duodenum and jejunum


Converted to methylTHF
50-80% of dietary intake
Folic acid

Causes of Folic Acid Deficiency


Nutritional -old age, poverty, diet etc
Malabsorption- coeliac disease, Crohns disease
Excess utilization
Physiological-pregnancy, lactation, prematurity
Pathological-haemolytic anaemia, myelofibrosis, malignant
disease, inflammatory disease

Drugs-anticonvulsants
Mixed-liver disease, alcoholism, intensive care

Megaloblastic Anaemia: Treatment


Vitamin B12 1mg every 2nd day x 2/52, IM
May need folic acid, iron, potassium supplements
Continue 1mg IM every 3 mths for life

Folic acid 5mg daily, oral


Ensure normal vitamin B12 levels prrio to replacement

Data Interpretation (1)

Haemoglobin (g/dl)
Haematocrit (PCV) (%)
Red cell count (x 1012/L)
Mean cell haemoglobin
(pg)
Mean cell volume (fl)
Mean cell haemoglobin
concentration (g/dl)

7.5 (11.5-16.5)
0.30 (0.37-0.47)
2.35 (3.8-5.8)
22 (27-32)
65 (76-100)
26 (32-36)

Data Interpretation (2)

Haemoglobin (g/dl)
Haematocrit (PCV) (%)
Red cell count (x 1012/L)
Mean cell haemoglobin
(pg)
Mean cell volume (fl)
Mean cell haemoglobin
concentration (g/dl)

8.2 (11.5-16.5
0.25 (0.37-0.47)
2.7 (3.8-5.8)
34 (27-32)
120 (76-100)
34 (32-36)

Haemolytic anemia
Decreased erythrocytes in circulating blood (anemia)
because of their acclerated destruction (hemolysis)
A red blood cell survives 90 to 120 days (on average) in
the circulation, therefore about 1% of human red blood
cells break down each day.
The spleen (part of the reticulo-endothelial system) is the
main organ which removes old and damaged RBCs from
the circulation.
In health the breakdown and removal of RBCs from the
circulation is matched by the production of new RBCs in
the bone marrow.

Classification of Haemolytic Anemias


Causes can be either
inherited
acquired

Inherited Haemolytic Anaemia


Abnormal RBC membrane
Hereditary spherocytosis
Hereditary elliptocytosis

Abnormal RBC metabolism


Glucose-6-phosphate dehydrogenase deficiency
Pyruvate kinase deficiency

Abnormal Haemoglobin
Sickle cell anemia
Thalassaemia

Acquired Haemolytic Anaemia


Autoimmune haemolytic anemia
Warm antibody
Idiopathic
Systemic lupus erythematosus (SLE)
Evans' syndrome (antiplatelet antibodies and hemolytic antibodies)
Cold antibody
Idiopathic cold hemagglutinin syndrome
Infectious mononucleosis and mycoplasma pneumonia
Paroxysmal cold hemoglobinuria (rare)

Physical destruction
Prosthetic heart valve
Drugs/MAHA

Haemolytic Anaemia Blood Film

MAHA
Micro Angiopathic Hemolytic Anemia

Reticulocytosis
No definite nucleus

Reticulum of RNA
Deep blue staining

Light blue cytoplasm


Cell size about 10

AIHA and the Coombs test

Laboratory diagnosis of
Haemolytic Anaemia
Reticulocyte count - increased
Blood film:
Polychromasia
Spherocytes
RBC fragments (schistocytes)

Immune-mediated haemolysis:
Direct Coombs test

Biochemical evidence of RBC lysis:

Decreased Haptoglobin
Increased unconjugated bilirubin
Increased LDH
Urinary haemosiderin

Haemolytic anemia: History

History of fatigue or jaundice


Onset/ duration (hereditary versus acquired)
Abdominal pain / cholelithiasis (chronic haemolysis)
Medications or food /ie fava bean (may exacerbate enzyme
deficiencies)
Travel (consider infection) and infection
Vascular / cardiac surgery (prosthetic valve)
Discoloured urine (intravascular haemolysis)
Family history (jaundice, gallbladder disease, splenectomy,
hereditary anaemia or other inherited diseases)

Signs of haemolytic anemia


Jaundice
Pallor
Splenomegaly / hepatosplenomegaly

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