approach to a patient with anemia

Approach To A Patient With Anemia

Dr. Mohammad Usman Shaikh

Assistant Professor,

Aga Khan University Hospital.

Hematology

• Study of blood forming tissue and circulating blood component

• Clotting factors • Blood groups• CBC and smear examination regardless of specialty• Accessible, close proximity to tissues, often provide

some information• Important for accurate diagnosis and therapeutics

choices

Manual Versus AutomationFeasibility:Workload:• Depend on number of samples per day

• Less than 20 samples, prefer manual method

• Tertiary care hospital setting in western hospitals, CBC is mandatory for consultation.

• Rapid analysis

• Require only an appropriate blood sample.

• Measure 8-25 variables, no equivalent manually.

Principles of Automation

• Electrical Impedance• Light scattering

Electrical Impedance

Detection & measurement of changes in

electrical resistance produced by cells as

they passes via a small aperture

Electrical resistance between two electrodes,

or impedance in current leads to the formation of

pulses

A stream of cells passes through aperture across which electrical current is applied. Each cell that passes alters

electrical impedance and can thus be counted and sized.

Good Pulse

Diluent stream

Sensing Zone

Red Blood Cells

Electrical Impedance

OscilloscopeOscilloscope

Each time a cell passes a pulse is produced.The pulse height is proportional to Cell

volume

Animation by M.A.Ghauri

Light Scattering

O-3 deg(relative size)

Light Scatter estimates relative cell size based on forward scatter - that is a measurement of cross-sectional diameter

LaserLaser

Hemogram/ Histogram

• Visual representation of what was counted at the aperture.

• Verify a count that has a typical pattern according to the reference ranges

• Alert for possible interfering particles and abnormalities

Hematological Variables on Automation

RBCHb, HCT, MCV, MCH, MCHC, RBC count, RDW

WBC

Total count, differential and absolute count

Platelet

Total count

Others: Nucleated RBC, reticulocyte count

flags

Anemia

– Definition: low Hemoglobin and hematocrit– Results from a wide variety of disorders

Anemia

• Laboratory data is more informative when considered in the context of history and physical examination

Approach to Anemia

• History:– Family history– inherited causes such as

thalassemia, sickle cell anemia, G6PD deficiency and hereditary spherocytosis.

– In most of these cases morphological findings of smear are diagnostic

• B symptoms• Systemic or other chronic disorders

History

• Drug history:

• History of blood loss

• Clinically: Degree of pallor, with or without icterus, angular stomatitis and glossitis,

koilonychia, lymphadenophathy and

hepatoslenomegaly

Koilonychia

Physical Examination: helps to direct the clinician to the cause of anemiaIron deficiency: koilonychia, glossitis, angular stomatitis.

Glossitis

B12 deficiency: decrease vibration and postural senseFolate deficiency: glossitis, sign of malabsorption, alcohol abuse and pregnancy

Angular stomatitis

Angular stomatitis: non specific, can be seen in iron deficiency, B12 and folate deficiency

Lymphadenophathy

• Bone marrow failure/infiltration: fever, Petechiae, lymphadenophathy, splenomegaly and sternal tenderness

Splenomegaly

• Bone marrow failure/infiltration: splenomegaly

Normal RBC

Normal RBC

WBC Morphology

Classification of Anemia on the Basis of MCV

Less than 76fl --- microcyticIron deficiencyThalassemia Anemia of chronic diseaseSideroblastic anemia and lead poisoning

MCV between 76 to 96 flAnemia of chronic diseaseAcute blood loss Chronic renal failureAnemia due to infiltrationAplastic anemia

Classification of Anemia on the Basis of MCV

• MCV more than 96fl– Macrocytic anemia

• Megaloblastic: B12 and folate deficiency• Non megaloblastic:

– Hemolysis– MDS– Hypothyroidism– Liver disease

Etiological Classification of Anemia:

• Increase destruction

1-Hemolytic anemia

inherited and acquired• Impaired Production

2-Anemia due to bone marrow failure states

3-Nutritional deficiencies

4-Anemia due to infiltrative disorders

5-Anemia of chronic disorders

Hemoglobin: 3.5 gm/dlHCT: 12%MCV: 57 fl

MCH: 18 pgTLC: 22,000

Platelets: 155,000

Hemoglobin: 4.5 gm/dlHCT: 14%MCV: 56 flMCH: 20 pgTLC: 6,000

Platelets: 600,000

NORMOCYTIC NORMOCHROMIC ANEMIA

MCV between 76 to 96 fl• Anemia of chronic disease• Acute blood loss • Chronic renal failure• Anemia due to infiltration• Aplastic anemia

Hemoglobin: 8 gm/dlHCT: 25%MCV: 84 flMCH: 27 pgTLC: 5000

Platelets: 205,000

Sickle Cell

Sickle Cell Disease

• Rare in Pakistan (Balochistan), common in Middle East, and up to 40% trait in Central Africa

• Qualitative globin chain defect; Homozygous inheritance• Deoxy Hb S--- tendency to aggregate--- sickle cell• Increase blood viscosity --- vascular stasis---tissue

damage + RBC membrane damage• Sickling depend on Hb S concentration• Hb S <50%, usually no symptoms• Hb F---confer protection• Hb: 5-11 g/dl, Normocytic normochromic, Target cells,

reticulocytosis, Increase WBC & Platelets

Hemoglobin: 7.0 gm/dlHCT: 22%MCV: 89 flMCH: 28 pgTLC: 22,000Platelets: 20,000

Acute Leukemia

• Presenting count• Age • Cytogenetics

Hemoglobin: 5.0 gm/dl

HCT: 16%

MCV: 93 fl

MCH: 26 pg

TLC: 500

Platelets: 11,000

Pancytopenia

Cellular Vs hypocellular

Chronic Leukemias

• Cytogenetics for CML• CLL workup and staging

Hemoglobin: 5.0 gm/dl

HCT: 16%

MCV: 93 fl

MCH: 26 pg

TLC: 500

Platelets: 11,000

Pancytopenia

Cellular Vs hypocellular

Normal Marrow

Bone Biopsy

• Hemoglobin: 9.5 gm/dlHCT: 30%MCV: 99 flTLC: 2200

Platelets: 10,000

Blood culture: gram negative rods

Microangiopathy /DIC

Microangiopathy /DIC

Macrocytic Anemia

• MCV more than 96fl– Macrocytic anemia

• Megaloblastic: B12 and folate deficiency• Non megaloblastic:

– Hemolysis– MDS– Hypothyroidism– Liver disease

Hemoglobin: 6.0 gm/dl

HCT: 19%

MCV: 110 fl

MCH: 36 pg

TLC: 2,800

Platelets: 45,000

Hemoglobin: 7.5 gm/dl

HCT: 23%

MCV: 100 fl

MCH: 28 pg

MCHC 36%

TLC: 5000

Platelets: 100,000

Reticulocyte

• Reticulocyte: larger than normal RBC

• RNA and Golgi remnants, Ribosome, maturation take another 24 to 48 hours in the blood circulation

Conclusions

• Peripheral blood smear examination and reporting is one of the most important aspect of hematology.

• It is diagnostic in many hematological and non hematological disorders.

• It is cost effective and non invasive and helps the clinicians in further diagnostic workup