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Approach to Anemia
How to efficiently and accurately
work up an anemic patient ?
What is Anaemia ?
Important to remember
Anemia is a clinical sign of disease
It is not a single disease by itself
Need to look for the underlying cause !
Will we ignore a fever with out investigation ?
Its diagnosis is not that simple !! Well make it
Its very common and imp. in our practice
Drug Rx. depends on the cause
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Definition of Anaemia
Decrease in the number of circulating red blood
cell mass and there by O2 carrying capacity
Most common hematological disorder by far
Almost always a secondary disorder
As such, critical for all practitioners to know
how to evaluate / determine its cause / treat
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Erythron
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Pro Erythroblast
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Early Normoblast
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Intermediate Normoblast
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Late Normoblast
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Reticulocyte
No definite nucleus
Reticulum of RNA
Deep blue staining
Light blue cytoplasm
Cell size about 10
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Hemoglobin (Hb)
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First Question
The onset of Anaemia
Acute versus chronic
Clues
Hemodynamic stability
Previous CBC
Overt blood loss
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Types of Anaemia
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India
Less than 12 g%
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PCV or Hematocrit
57% Plasma
1% Buffy coat WBC
42% Hct (PCV)
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Normal
Range
A. RBC count
5 million
4 to 6
B. Hemoglobin
15 g%
12 to 17
C. Hematocrit
45
38 to 50
Normal
Range
A. RBC count
5 million
B. Hemoglobin
15 g%
12 to 17
C. Hematocrit
45
38 to 50
MCV
MCH
MCHC
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C A x 10
B A x 10
B C x 100
4 to 6
=
=
=
90 fl
30 pg
33%
Causes of Anaemia
1. Decreased production of Red Cells
- Hypo proliferative, marrow failure
M = P x S ( L)
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Hypoproliferative Anaemias
Nuclear
breakdown
Failure of cell
maturation
Cytoplasmic
breakdown
Haem defect
Globin defect
Fe
Sickle cell A
Megaloblastic Anaemia
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Phorph
IDA, SA
Thalassemia
Reticulocytes
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Supravital
Leishmans
Anaemia
Hb% < 12, Hct < 38%
Hypoproliferative
Hemolytic
RPI < 2
RPI > 2
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Normal CBC
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MCV
Microcytic
Normocytic
Macrocytic
< 80 fl
80 -100 fl
> 100 fl
< 6.5
6.5 - 9
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>9
Microcytic
Normocytic
Macrocytic
Chronic disease
Megaloblastic anemias
Chronic Infections
Early IDA
Liver disease/alcohol
Thalassemias
Hemoglobinopathies
Hemoglobinopathies
Hemoglobinopathies
Sideroblastic Anemia
Combined deficiencies
Marrow disorders
Increased destruction
Increased destruction
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Microcytic
Normocytic
Macrocytic
Left
Mean 90
Right
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IDA -CBC
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Severe Hypochromia
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> 270pmol / l
33-270 pmol / l
TIBC
N or
HIGH
BM Fe
+
Not IDA, Other Mi A
Normal
IDA
33-270
< 33
TIBC (g/dL)
300-340
> 400
50-150
< 30
Saturation %
30-50
< 10
++
Absent
IDA Summary
MicrocyticMCV < 80 fl, RBC < 6
RDW
Hypochromic
RPI
<2
Retic. count
May be > 2 %
Serum ferritin
TIBC
Serum Iron
BM Fe Stain
Absent Fe
Response to Fe Rx.
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Excellent
Microcytic Anaemias
MCV < 80 fl
Serum Iron
TIBC
BM Perls stain
++
++++
Hemoglobinopathy
Lead poisoning
++
++
++++
Sideroblastic
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Ringed Sideroblasts in BM
Prussian Blue Stain
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Macrocytic Anaemias
A. Megaloblastic Macrocytic B12 and Folate
B. Non Megaloblastic Macrocytic Anaemias
1. Liver disease/alcohol
2. Hemoglobinopathies
3. Metabolic disorders, Hypothyroidism
4. Myelodystrophy, BM infiltration
5. Accelerated Erythropoesis - destruction
6. Drugs (cytotoxics, immunosuppressants, AZT,
anticonvulsants)
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Megaloblastic Hematopoiesis
Marrow failure due to
Disrupted DNA synth. & ineffective erythropoesis
Giant precursors (Megaloblasts)
Nuclear : Cytoplasmic dyssynchrony in marrow
Neutrophil hyper segmentation & macro ovalocytes
Anemia (and often leukopenia & thrombocytopenia)
Almost always due to B12 or folate deficiency
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MBA
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Macrocytosis -MBA
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HSN - MBA
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HSN - MBA
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Megalocyte in PS
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Normocytic Anaemias
1.
2.
3.
4.
5.
6.
7.
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Chronic disease
Early IDA
Hemoglobinopathies
Primary marrow disorders
Combined deficiencies
Increased destruction
Anaemia of investigations -ICU
IBD
Ulcerative Colitis
Crohns Disease
Chronic Infections
HIV, Osteomyelitis
Tuberculosis
Renal Failure
Dimorphic Anaemia
Folate & Fe deficiency (pregnancy, alcoholism)
B12 & Fe deficiency (PA with atrophic gastritis)
Thalassemia minor & B12 or folate deficiency
Fe deficiency & hemolysis (prosthetic valve)
Folate deficiency & hemolysis (Hb SS disease)
Peripheral smear exam is critical to assess these
RDW is increased very much
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Poikilocytosis
Different Shapes of RBC
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Polychromasia - Spherocytosis
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Target Cells
1. Liver Disease
2. Thalassemia
3. Hb D Disease
4. Post splenectomy
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Drepanocytes - SS
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Autosplenectomy - SS
Normal spleen is 8 to 12 cm
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Hemolytic Anaemia
Anemia of increased RBC destruction
Normochromic, normocytic anemia
Shortened RBC survival
Reticulocytosis due to RBC destruction
Will not be symptomatic until the RBC life span is
reduced to 20 days BM compensates 6 times
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Reticulocyte count
Combined with serial Hb
Serum LDH
Serum bilirubin
Haptoglobin
Urine hemosiderin
Hemoglobinuria
Increased
Increased
Increased
Serum Haptoglobin
Decreased
Urine Hemoglobin
Present
Urine Hemosiderin
Present
Urine Urobilinogen
Increased
Decreased
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Tests to define
the cause of hemolysis
1.
2.
3.
4.
5.
6.
7.
8.
Hemoglobin electrophoresis
Hemoglobin A2 (eta-Thalassemia trait)
RBC enzymes (G6PD, PK, etc)
Direct & indirect antiglobulin tests (immune)
Cold agglutinins
Osmotic fragility (spherocytosis)
Acid hemolysis test (PNH)
Clotting profile (DIC)
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MAHA
Micro Angiopathic Hemolytic Anaemia
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Spherocytosis
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Spherocytosis
Hereditary Spherocytosis
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Spherocytosis
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Elliptocytes
Hereditary Elliptocytosis, B12 or Folate
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Stomatocytes
Slit like central pallor in RBC
1. Liver Disease
2. Acute Alcoholism
3. H Stomatocyosis
4. Malignancies
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Echinocytes
Evenly distributed spicules > 10
1. Uremia
2. Peptic ulcer
3. Gastric Ca
4. PK-D
Called Burr Cells
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Acanthocytes
5-8 spikes of varying length, irregular intervals
Called Spur Cells, Occur in A H A
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Shistocytes
Fragmented, Helmet or triangle shaped RBC
1. MAHA
2. Prosthetic valves
3. Uremia
4. Malignant HT
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Howell-Jolly Bodies
Absence of Splenic function; Nuclear chromatin in RBC
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Anaemia Diagnosis
-Algorithm
Anaemia Suspected
Thorough Clin, Bleed
Microcytic hypochromic
Hemolytic Anaemia
Macrocytic hypo/normo
Megaloblastic
Normoblastic
Hb electrophoresis
Ferritin, TIBC, BM Fe
Folate defici.
Osmotic fragility
Thalassemia, Hb pathy
B12 def., PA
Acid hemolysis
Sederoblastic Anaem.
Hypothyroid
Cold agglutinins
BM infiltration
Coagulopathy, DIC
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Anaemia - Summary
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