ANEMIA

Anemia which is a decrease in red cell mass is

also defined as a decrease in the hemoglobin
concentration or decrease in the hematocrit
when compared with a normal group.
Anemia is functionally defined as a decrease
in the competence of blood to carry oxygen to
tissues there by causing tissue hypoxia.
 ANEMIA cntd
Total erythrocyte mass in the steady state is equal to the
number of new RBCs produced per day times the erythrocyte
life span (100-120 days):
Mass (M) = Production (p) X Survival (s)
Thus, the average 70-Kg man with 2 litres of erythrocytes
must produce 20 ml of new erythrocytes each day to replace
the 20 ml per day normally lost due to cell senescence.

2000 ml (M)/ 100 days (S) = 20 ml /day (p)

Using this formula it can be seen that if the survival time of

the erythrocyte is decreased by half, the bone marrow must
double production to maintain a constant mass.

2000 ml (M)/50 days (S) = 40 ml /day (P)

 Classification of Anemia
Morphologic classification
certain causes of anemia characteristically
produce a specific size of red cells (large, small
or normal) and a specific type of hemoglobin
content (normal or abnormal).
The general categories of a morphologic
classification include:
macrocytic hypochromic, normocytic-
normochromic, and microcytic hypochromic.
 Functional classification
Considering that the normal bone marrow
compensatory response to decreased
peripheral blood hemoglobin levels is an
increase in erythrocyte production, persistent
anemia may be expected as the result of three
pathophysiologic mechanisms:
a. Proliferation defect
b. Maturation defect
c. Survival defect
Classification of Anemia according to Severity:

1. Mild anemia Hb < 11 8 g/dl

2. Moderate Hb <8 - > 5g/dl
3. Severe anemia Hb < 5 g/dl
 Diagnosis of Anemia

History
Physical Examination
Clinical Laboratory
Laboratory Investigations
1. RBC count, Hematocrit and Hemoglobin
2. Red Cell Indices.
3. Reticulocytes count
4. Blood smear examination
5. Bone marrow examination
 The Hematological Rules of Three and Nine
The First Rule of Three
Red cell count (in million) X 1012 /L X3 = Hemoglobin/dl.
This rule expresses the normal ratio of hemoglobin to red
cells. It applies to all hemoglobinized cells regardless of
whether or not the patient is anemic.
The Second Rule of Three
Hemoglobin X 3 = Hematocrit, that is Hemoglobin =
Hematocrit/3.
 The Rule of Nine

If the normal ratio of the red cell count to the

hemoglobin and that of hemoglobin to hematocrit is
known, a rule of nine can be calculated that express the
numerical relationship of the hematocrit to the red cell
count.
Red cell count (1012/L X 9 = Hematocrit (%)
This is derived from the two rules of three as follows:
1. Red cell count X 3 = Hemoglobin
2. Hemoglobin X 3 = Hematocrit, that is Hemoglobin =
Hematocrit/3
3. Red cell count X 3 = Hemoglobin, that is, red cell
count X 9= Hematocrit
 The Peripheral Blood Smear

The peripheral blood smear is the most practical

diagnostic tool for the hematologist.
A drop of blood is applied against slide that is
subsequently stained with polychrome stains (Wright-
Giemsa) to permits identification of the various cell
types.
These stains are mixtures of basic dyes (methylene
blue) that are blue and acidic dyes (eosin) that are red.
As such, acid components of the cell (nucleus,
cytoplasmic RNA, basophilic granules) stain blue or
purple, and basic components of the cell (hemoglobin,
eosinophilic granules) stain red or orange.
 Smear.
The blood smear is used to assess red cell
size/shape; white cell appearance and
differential; abnormal cells; platelet size and
morphology; detection of parasites, e.g
malaria.
Blood Indices
 Blood indices normal range

CI = 0.67 (Normal = 0.8 to1.2)

MCV = 75 cu (Normal = 78 to 90 cu )

MCH = 20 pg (Normal = 27 to 32 pg)

MCHC = 26.67% (Normal = 30% to 38%)

 MCV
MCV: Indices the average volume of individual red cells in
the femtoliters (fl) by the use automated cell counter is
manually calculated: MCV (FL) = Hematocrit (L/L)
RBC count (X1012/L)
Example: A patient has a hematocrit of 0.45L/L and an
RBC of 5X1012/L
MCV= 0.45/5X1012
= 90X10-15 or 90 fl
The MCV is used to classify cells as normocytic (80-
100),
microcytic cells have (< 80) and macrocytic (>100 fl).
 MCHC
Mean Corpuscular hemoglobin Concentration (MCHC):
MCHC is the average concentration of hemoglobin in
grams in a decilitre of red cells.
The MCHC is calculated from the hemoglobin and
hematocrit as follows:
MCHC g/dl = Hemoglobin (g/dl)/Hematocrit (L/L)
Example: A patient has a hemoglobin amount of 15 g/dl
and a hematocrit of 0.45 (L/L)
MCHC =15 g/dl/0.45 L/L
= 33 g/dl
Normal MCHC is 31 to 36% normochromic
< 31% Hypochromic
> 36% Hyperchromic
 MCH
Mean Corpuscular Hemoglobin (MCH) is a
measurement of the average weight of
hemoglobin in individual red cells.
The MCH may be calculated as follows:
MCH (pg) =
Hemoglobin (g/d) /RBC count (X1012/l) X 10
The normal MCH should always correlate with
the MCV and MCHC
< 27 pg microcytic > 34 pg macrocytic
 Bone Marrow Examination
Marrow examination complements clinical
and laboratory in determining the cause of
anemia, leukopenia, leukocytosis,
thrombocytopenia and thrombocytosis, as
well as contributing of lymphoproliferative
disease and various solid tumors.
 Iron Deficiency Anemia

Iron deficiency anemia is the most common

nutritional deficiency in the world. In order to
understand the symptoms, etiology and
treatment of this anemia, it is necessary to
review normal iron and heme metabolism.
 Iron Metabolism
The total body iron content of the normal
adult varies from 3 to 5 g depending on the
sex and weight of the individual.
It is great in males than in females, and it
increases roughly in proportion to body
weight.
Hemoglobin iron constitutes approximately
60-70% of the total body iron.
The absolute amount is varying from 1.5 to 3
grams.
 Contd

At the end of their life span, the aged red cells

are phagocytosed by cells of the RES.
Nearly all the iron derived from the
breakdown of hemoglobin is released into the
circulation bound to the iron binding protein,
transferrin, and is re-utilised by marrow
erythroblasts for hemoglobin synthesis.
 Absorption

The small intestine is highly sensitive to repletion of

iron stores and rapidly corrects imbalance by
decreasing or increasing absorption.
The daily intake of a normal adult on a mixed type diet
contains 10-20 mg iron of which 10% or somewhat less
is absorbed.
Absorption is greater requirement due to menstrual
loss and childbearing.
The chief dietary sources are meats (liver, kidney) egg
yolk, green vegetables and fruit milk.
Heme iron present in the hemoglobin and myoglobin
of meat is well absorbed.
 Plasma (transport) Iron
Between 3 and 4 mg iron are present in the plasma,
where it is bound to a specific protein, transferrin, - a
protein that is synthesized in the liver.
Each molecule of transferrin binds one or two atoms
of ferric iron.
The function of transferrin is the transport of iron. It is
the means by which iron absorbed from the
alimentary tract is transported to the tissue stores,
from tissue stores to bone marrow erythroblasts, and
from one storage site to another.
When transferrin reaches the storage sites or the bone
marrow, it attaches to specific receptors on the cells
and liberates its ferric ions, which pass into the cell to
be stored or utilized
 Contd
Transferrin is a glycoprotein present in the serum in
concentration, which enables it to combine with 44-80
mol of iron per litre. This value is known as the total
iron binding capacity of the serum.
Serum ferritin concentration in adults range between
15-300 g/l and the
In iron deficiency, concentration is less than 12 g/l.
In iron overload, levels are very high. Serum ferritin
increased in: infections, inflammations, malignancy
(lymphomas, leukemias) and liver diseases
 Iron Storage
The amount of storage iron has been estimated
to be about 1000-2000 mg in the healthy adult
male, and less in the female.
Storage irons occur in two forms- ferritin and
hemosiderin. Ferritin is normally predominant.
In the normal person, storage iron is divided
about equally between the reticuloendothelial
cells (mainly in spleen, liver and bone marrow),
hepatic parenchyma cells and skeletal muscle.
Hemosiderin, the main storage form in
reticuloendothelial cells, is more stable and less
readily mobilized for hemoglobin formation than
ferritin, which predominates in hepatocytes.
 Contd
Non-heme iron is released from food as ferric or ferrous
ions by the action of acid in the stomach.
Absorption of iron is most efficient in the duodenum and
proximal jejunum, following entry into the cell, depending
on the body requirement for iron; a proportion is rapidly
transferred across the cell and on to the portal circulation
for distribution to tissue iron stores
Excretion
The amount of iron lost from the body per day is between
0.5 and 1.0 mg under physiological conditions.
The rate of loss is relatively constant and independent of
intake.
 Iron Imbalance
The daily iron requirement for hemoglobin
synthesis is 20-25 mg.
In normal individual red cell destruction and
formation take place at almost identical rates.
Normal males are a state of positive iron balance.
Female of childbearing age, the positive balance
is only very slender, because of the additional
loss by menstruation.
Thus, a moderate increase in menstrual loss,
especially if associated with impaired intake, can
easily induce negative iron balance
 Causes
1. Increased physiological requirements;
a. Growth: IDA is more common in children between age of 6 month and 2
years, and froom11 to 16 years due to spurts of growth during these
periods.
b. Menstruation: Anemia common in adult menstruating females.
c. Pregnancy: During pregnancy anemia is almost universal.
2. Pathological blood loss:
a. Menorrhagia- Antepartum and postpartum bleeding.
b. Gastrointestinal tract:
Bleeding piles
Drugs: Aspirin, Indomethacin, Butazolidin and Corticosteroids
Peptic ulcer
c. Malabsorption: Coeliac disease, postgastrectomy and atrophic gastritis
3. Nutritional defect
Low iron intake
Inhibitors in diet
4. Excess iron loss
Exfoliative dermatitis, PNH, gastritis, GI infection and intravascular
hemolysis
 Pathophysiology

Iron deficiency develops in sequential stages over

a period of negative balance (loss exceeds
absorption).
Since Fe is absorbed with difficulty, most people
barely meet their daily requirements added
losses due to menstruation (mean 0.5 mg/day),
pregnancy (0.5 to 0.8 mg/day), lactation (0.4
mg/day) and blood loss due to disease or
accident readily lead to Fe deficiency.
Fe depletion results in sequential changes or
stages.
Stage I (Depletion of iron stores):
Fe loss exceeds intake: with this negative Fe balance, storage of
Fe (represented by bone marrow Fe content) is progressively
depleted. Although the Hb and serum Fe remain normal, the
serum ferritin concentration falls to <20 ng/ml.
As storage Fe decreases, there is a compensatory increase in
absorption of dietary Fe and in the concentration of transferrin
(represented by a rise in Fe-binding capacity.
Stage II (Impaired erythropoiesis):
Exhausted Fe stores cannot meet the needs of the erythroid
marrow, while the plasma-transferrin level increases, the
serum-Fe concentration declines, leading to a progressive
decrease in Fe available for RBC formation. When serum falls
to < 50 g/dl, and transferrin saturation to <16%,
erythropoisis is impaired.
Stage III (Anemic stage):
The anemia with normal appearing RBCs and
indices is defined.
Stage IV:
Microcytosis and then hypochromia are present.
The most significant finding is the classic
microcytic hypochromic anemia.
Stage V:
Fe deficiency affects tissue, resulting in symptoms
and signs
 Clinical and laboratory features
The onset is insidious. In early stage, there is no
clinical manifestation. But with complete
depletion of iron stores, anemia develops and
clinical symptoms appear.
Symptoms such as weakness and lethargy are
considered to be related to hypoxia cause by the
decrease in hemoglobin.
A variety of other abnormalities may occur from
an absence of tissue iron in iron-containing
enzymes.
 Contd
Peripheral blood Picture: The blood picture is
well-developed iron deficiency is microcytic (MCV
55 to 74 fl), hypochromic (MCHC 22 to 31g/dl,
MCH 14 to 26 pg).
When the anemia is mild, the morphologic
aspects of the red blood cells are little affected.
Microcytosis and anisocytosis are usually the first
morphologic signs to develop even before anemia
develops.
 Treatment of Iron Deficiency Anemia

A. Prophylactic
1. Adequate iron intake for pregnant mothers, a
supplement of 30 mg/day should be adequate.
2. Breast-feeding: Has a preventive effect during at
least the first 6 months.
3. Prophylactic iron supplementation after the 3rd
Month, and earlier in premature by fortified
formulas or cereals during infancy.
4. Prophylactic needed after partial gastrectomy.
B. Curative
1. Specific treatment of the causes e.g. as Ancylostoma,
or cow- milk protein allergy etc.
2. Oral iron therapy: The best is ferrous sulphate in a dose
of 6 mg/kg/day of elemental iron (=30 mg/kg/day
ferrous sulphate), in 3 divided doses.
Better absorption occurs if given between meals (on
empty stomach).
It is given for 4-6 weeks after correction of
hematological values.
3. Parenteral iron therapy: Iron dextran complex
(Imferon). It is not superior to oral iron administration
(50 mg iron/ml).
 OTHER CAUSES OF HYPOCHROMIC ANEMIA
CHRONIC LEAD POISONING

It is a hypochromic microcytic anemia, with coarse

basophilic stippling of RBCs.
Diagnosed by increased of free erythrocyte
protoporphyrin (FEP) more than 150mg/dl of blood and
urinary excretion of large amounts of corporphirin in
urine.
Other manifestations of chronic lead poisoning are
usually present as:
Acute abdominal colic associated with constipation,
acute lead encephalopathy; with vomiting, ataxia
impaired consciousness, convulsions and coma.
Peripheral neuropathy (motor) is less common in
children than adults
 SIDEROBLASTIC ANEMIAS

These are hypochromic microcytic anemia,

caused by defects in iron or heme metabolism.
There is elevated serum iron.
The bone marrow contains sideroblasts, which
are nucleated red blood cells with a perinuclear
collar of coarse hemosiderin granules that
represent iron-laden mitochondria.
A. X-linked type usually presents in late childhood
(splenomegaly is usually present).
B. Vitamin B responsive anemia. Responds to large
doses of vitamin B6 (200-500 mg/day)
 ANEMIA OF CHRONIC DISEASE
It is seen in patients with infection, cancer, liver
disease, inflammatory and rheumatoid disease,
renal disease and endocrine disorders (thyroid).
Pathophysiology
A mild hemolytic component is often present.
Red blood cell survival modestly decreased.
Erythropoietin levels are normal or slightly
elevated but are inappropriately low for the
degree of anemia.
Iron cannot be removed from its storage pool in
hepatocytes and reticuloendothelial cells.
 Anemia of chronic . contd

Laboratory Features
Usually anemia is mild normocytic and
normochromic.
It may be microcytic and normochromic if the
anemia is moderate.
May be microcytic and hypochromic if the
anemia is severe but rarely <90 g/L.
Bone marrow shows normal or increased iron
stores but decreases
normal sideroblasts
 Anemia of chroniccontd.

Treatment
Treat the underlying disease. Erythropoietin
may normalize the hemoglobin value
Dose of erythropoietin required is lower for
patients with renal disease
Only treat patients who can benefit from a
higher hemoglobin level.
 Hemolytic anemia
Hemolytic anemia results from an increase in
the rate of red cell destruction.
The life span of the normal red cell is 100-120
days; in the hemolytic anemia varying degrees
shortens it.
 A. Extrinsic hemolytic anemia:
It is the type of anemia caused by destruction of RBCs by
external factors.
Healthy RBCs are hemolized by factors outside the blood cells
such as antibodies, chemicals and drugs.
Extrinsic hemolytic anemia is also called autoimmune hemolytic
anemia.
Common causes of external hemolytic anemia:
i. Liver failure
ii. Renal disorder Hypersplenism
iv. Burns
v. Infections like hepatitis, malaria and septicemia
vi. Drugs such as penicillin, antimalarial drugs and sulfa drugs
vii. Poisoning by chemical substances like lead, coal and tar
viii. Presence of iso-agglutinins like antiRh
 B. Intrinsic hemolytic anemia:
It is the type of anemia caused by destruction of
RBCs because of the defective RBCs.
There is production of unhealthy RBCs, which are
short lived and are destroyed soon.
Intrinsic hemolytic anemia is often inherited and it
includes sickle cell anemia and thalassemia .
Because of the abnormal shape in sickle cell anemia
and thalassemia, the RBCs become more fragile and
susceptible for hemolysis.
 Hemolytic anemia contd..
Most hemolysis occurs extravascularly; i.e. in
phagocyte cells of the spleen,liver and bone
marrow (monocytic-macrophage system).
Hemolysis usually stems
(1) from intrinsic abnormalities of RBC contents
(Hb or enzymes or membrane (permeability
structure of lipid content
 Cont
(2) problems extrinsic to RBCs (serum
antibodies (AB), trauma in the circulation or
infectious agents).
The spleen is usually involved and if
splenomegaly results it reduces RBC survival
by destroying mildly abnormal RBC or warm
AB-coated cells
 RBC destruction
Destruction of senescent cells is largely limited to
extravascular pathway.
Red blood cells are phagocytized by the
reticuloendothelial cells, the membrane is disrupted,
and hemoglobin is broken down by lysozymal enzymes.
The iron recovered from heme is then stored or
transported back to the marrow for new red blood cell
production. Amino acids are also recovered. At the
same time, the protoporphyrin ring is metabolised to
the tetrapyrrol (bilirubin) with the release of carbon
monoxide.
The bilirubin is subsequently transported to liver
where it is conjugated and excreted into bile.
 Intra-vascular lysis
Intravascular hemolysis is uncommon; it results in
hemoglobinuria when the Hb released into
plasma exceeds the Hb-binding capacity of
plasma haptoglobin.
Hb is reabsorbed into renal tubular cells when Fe
is converted to hemosiderin, part of which is
assimilated for reutilization and part of which
reaches the urine when the tubular cells sloughs.
Identification of hemosiderinuria in a fresh urine
specimen provides clear evidence of an
intravascular hemolytic process
Diagnostic criteria of hemolysis
 Hyperbilirubinemia
If liver and biliary functions are normal an
unconjugated hyperbilirubinemia occurs in
hemolysis
The standard teaching that a conjugated
hyperbilirubinemia excludes hemolysis is
incorrect.
There are several clinical situations in which
there may be a combination of hemolysis in
conjugation with impaired hepatobiliary
handling of conjugated bilirubin.
 Reticulocytosis

Reticulocytes are usually expressed as a

percentage of the red cells. In normal subjects
the reticulocyte count varies from 0.2-2%.
In hemolytic anemia it usually ranges from 5-20%
but occasionally raises too much higher values
e.g. 50-70% or even more.
In acute hemolysis there may not have been time
for the bone marrow to respond, as some days
are usually necessary for erythropoiesis to
increase to a point where the reticulocytosis is
manifest in the peripheral blood.
 As long as the hematocrit and level of
erythropoietin stimulation are normal, the
observed reticulocyte percentage may also be
considered of (normal reticulocyte production
index=1).
 Elevated Lactic Dehydrogenase (LDH)

Lactic dehydrogenase is a cytoplasmic enzyme and can

be helpful in determining the presence of hemolysis.
An isolated marked elevation of LDH with other
"profile" enzymes remaining normal (AST, ALT, CPK,
ALP) is highly suggestive of red cell destruction
(hemolysis or ineffective erythropoiesis).
Red cells do not contain mitochondria so the levels of
other "standard" enzymes for tissue damage (e.g., ALT
and AST) which are mitochondrial in origin are normal
or only marginally elevated.
 Haptoglobins
This family of hemoglobin binding plasma proteins will
be reduced if significant hemolysis is occurring.
Haptoglobins are acute phase reactants and may be
elevated in infection and inflammation.
In contrast they may be rapidly reduced by blood
transfusion as a result of nonsurviving-stored red cells.
If they are present or increased significant hemolysis
can be interpreted with caution.
The normal range is 30-200 mg/100 ml. It is estimated
either chemically or by electrophoresis.
 haemosiderin
haemosiderin is an iron-storage complex.
It is only found within cells (as opposed to
circulating in blood) and appears to be a
complex of ferritin, denatured ferritin and
other material.
The iron within deposits ofhemosiderin is very
poorly available to supply iron when needed
 Hemosiderinuria
A Week after an episode of intravascular
hemolysis, or in-patients with chronic
intravascular hemolysis, examination of the urine
with a Prussian blue stain for iron may confirm
the presence of hemosiderinuria.
After the kidney filters the dimers of hemoglobin
they are resorbed by the proximal tubules and
metabolised.
The resultant iron can be found in the tubular
cells shed into the urine.
 Blood Film
Whatever it was the cause of hemolysis.
The end result is rupture and destruction of
the red cell.
This rupture involves membrane damage,
which need not be complete from the outset,
so degrees of development of red cell damage
may be observed in the circulating red cells.
 Methods Used For Diagnosis of Hemolytic
Anemia
1. High peripheral reticulocytes more than 2% (usually
>10%) + nucleated RBCs in the peripheral.
2. Bone marrow aspiration: Increased erythroid tissue;
with low Myeloid/Erythroid ratio. Normally it is 2:1
to 4:1
3. Hyperbilirubinemia (indirect).
4. High serum irons and low iron-binding capacity.
5. Low red blood cell life span (Normal is 120 days).
6. High urobilinogen in urine (Normal level is 2-5 mg/d
and in stool is 30- 300 mg/d)
7. Hemoglobinuria in acute hemolysis
 Hemolytic Disease of the Newborn

Hemolytic disease of the newborn, or erythroblastosis

fetalis is example of a cytotoxic reaction
In addition to the ABO blood group, red blood cells can
have Rh antigens, so named because the antigens were
discovered first in Rhesus monkeys.
Blood with Rh antigens on red blood cells is designated
Rh-positive; red blood cells lacking Rh antigens are
designated Rh-negative.
Anti-Rh antibodies normally are not present in the
serum of either Rh-positive or Rh-negative blood.
Consequently, sensitization is necessary for an Rh
antigen-antibody reaction.
 Sensitization typically occurs when an Rh-
negative woman carries an Rh-positive fetus,
which inherited this blood type from its father.
The fetal Rh antigen rarely enters the mothers
circulation during pregnancy but can leak across
the placenta during delivery, miscarriage, or
Abortion.
The Rh-negative mothers immune system then
becomes sensitized to the Rh antigen and can
produce anti-Rh antibodies if it again encounters
the Rh antigen.
 Contd
Because sensitization usually occurs at
delivery, the first Rh-positive child of an Rh-
negative mother rarely suffers from hemolytic
disease.
But when a sensitized Rh-negative mother
carries a second or subsequent Rh positive
fetus, the mothers anti-Rh antibodies cross
the placenta and cause a Type II
hypersensitivity reaction in the fetus.
 Contd
If this occurs, fetal red blood cells agglutinate,
and the red blood cells are destroyed.
The result is hemolytic disease of the
newborn. The baby is born with an enlarged
liver and spleen caused by efforts of these
organs to eliminate damaged red blood cells
 Ultimately due to excessive hemolysis severe
complica tions develop, viz.
1. Severe anemia
2. Hydrops fetalis
3. Kernicterus
 Treatment.
Hemolytic disease of the newborn can be
prevented by giving Rh-negative mothers
intramuscular injections of anti-Rh IgG antibodies
(Rhogam) within 72 hours after delivery.
The antibodies presumably bind to Rh antigens
on the fetal red blood cells that have leaked into
the mothers blood.
These anti-Rh antibodies destroy the fetal red
blood cells before they can act to sensitize her
immune system