approach to a patient with anemia

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Approach To A Patient With Anemia Dr. Mohammad Usman Shaikh Assistant Professor, Aga Khan University Hospital.

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Page 1: Approach To A Patient With Anemia

Approach To A Patient With Anemia

Dr. Mohammad Usman Shaikh

Assistant Professor,

Aga Khan University Hospital.

Page 2: Approach To A Patient With Anemia

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

Page 3: Approach To A Patient With Anemia

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.

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Principles of Automation

• Electrical Impedance• Light scattering

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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

Page 6: Approach To A Patient With Anemia

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

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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

Page 8: Approach To A Patient With Anemia

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

Page 9: Approach To A Patient With Anemia

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

Page 10: Approach To A Patient With Anemia
Page 11: Approach To A Patient With Anemia

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

Page 12: Approach To A Patient With Anemia

Anemia

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

Page 13: Approach To A Patient With Anemia

Anemia

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

Page 14: Approach To A Patient With Anemia

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

Page 15: Approach To A Patient With Anemia

History

• Drug history:

• History of blood loss

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

koilonychia, lymphadenophathy and

hepatoslenomegaly

Page 16: Approach To A Patient With Anemia

Koilonychia

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

Page 17: Approach To A Patient With Anemia

Glossitis

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

Page 18: Approach To A Patient With Anemia

Angular stomatitis

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

Page 19: Approach To A Patient With Anemia

Lymphadenophathy

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

Page 20: Approach To A Patient With Anemia

Splenomegaly

• Bone marrow failure/infiltration: splenomegaly

Page 21: Approach To A Patient With Anemia

Normal RBC

Page 22: Approach To A Patient With Anemia

Normal RBC

Page 23: Approach To A Patient With Anemia

WBC Morphology

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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

Page 25: Approach To A Patient With 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

Page 26: Approach To A Patient With Anemia

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

Page 27: Approach To A Patient With Anemia

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

MCH: 18 pgTLC: 22,000

Platelets: 155,000

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

Platelets: 600,000

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Page 32: Approach To A Patient With Anemia

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

Page 33: Approach To A Patient With Anemia

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

Platelets: 205,000

Page 34: Approach To A Patient With Anemia

Sickle Cell

Page 35: Approach To A Patient With Anemia

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

Page 36: Approach To A Patient With Anemia

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

Page 37: Approach To A Patient With Anemia
Page 38: Approach To A Patient With Anemia
Page 39: Approach To A Patient With Anemia

Acute Leukemia

• Presenting count• Age • Cytogenetics

Page 40: Approach To A Patient With Anemia

Hemoglobin: 5.0 gm/dl

HCT: 16%

MCV: 93 fl

MCH: 26 pg

TLC: 500

Platelets: 11,000

Pancytopenia

Cellular Vs hypocellular

Page 41: Approach To A Patient With Anemia
Page 42: Approach To A Patient With Anemia
Page 43: Approach To A Patient With Anemia
Page 44: Approach To A Patient With Anemia

Chronic Leukemias

• Cytogenetics for CML• CLL workup and staging

Page 45: Approach To A Patient With Anemia

Hemoglobin: 5.0 gm/dl

HCT: 16%

MCV: 93 fl

MCH: 26 pg

TLC: 500

Platelets: 11,000

Pancytopenia

Cellular Vs hypocellular

Page 46: Approach To A Patient With Anemia

Normal Marrow

Page 47: Approach To A Patient With Anemia

Bone Biopsy

Page 48: Approach To A Patient With Anemia

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

Platelets: 10,000

Blood culture: gram negative rods

Page 49: Approach To A Patient With Anemia

Microangiopathy /DIC

Page 50: Approach To A Patient With Anemia

Microangiopathy /DIC

Page 51: Approach To A Patient With Anemia

Macrocytic Anemia

• MCV more than 96fl– Macrocytic anemia

• Megaloblastic: B12 and folate deficiency• Non megaloblastic:

– Hemolysis– MDS– Hypothyroidism– Liver disease

Page 52: Approach To A Patient With Anemia

Hemoglobin: 6.0 gm/dl

HCT: 19%

MCV: 110 fl

MCH: 36 pg

TLC: 2,800

Platelets: 45,000

Page 53: Approach To A Patient With Anemia
Page 54: Approach To A Patient With Anemia

Hemoglobin: 7.5 gm/dl

HCT: 23%

MCV: 100 fl

MCH: 28 pg

MCHC 36%

TLC: 5000

Platelets: 100,000

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Reticulocyte

• Reticulocyte: larger than normal RBC

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

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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