approach to anemia - summary

Approach to Anemia - Approach to Anemia - SummarySummary

Approach to Anemia – Case 1Approach to Anemia – Case 1

• 37 year old female patient of Caucasian origin 37 year old female patient of Caucasian origin

referred to the Emergency Room because of anemiareferred to the Emergency Room because of anemia

• Medical background: generally healthy, normal Medical background: generally healthy, normal

diet; during the last week treated with an antibiotic diet; during the last week treated with an antibiotic

because of suspected pharyngitisbecause of suspected pharyngitis

• Complains of weakness and low-grade feverComplains of weakness and low-grade fever


On examination: pallor, slight jaundice; spleen On examination: pallor, slight jaundice; spleen mildly enlarged, soft, tendermildly enlarged, soft, tender

No lymphadenopathy, no bleeding tendency, No lymphadenopathy, no bleeding tendency, no glossitisno glossitis

Pulse 100, regular, blood pressure and oxygen Pulse 100, regular, blood pressure and oxygen saturation normalsaturation normal


Laboratory evaluation - Set I:Laboratory evaluation - Set I:

- Hemoglobin – 7.9 gr%- Hemoglobin – 7.9 gr%

- MCV – 100- MCV – 100

- RDW – 17- RDW – 17

- WBC – normal- WBC – normal

- Platelets - normal- Platelets - normal


Interpretation: Interpretation: macrocyticmacrocytic anemia anemia Differential diagnosis:Differential diagnosis:

- Megaloblastic anemia- Megaloblastic anemia

- Hemolytic anemia- Hemolytic anemia

- Myelodysplastic syndrome/Aplastic anemia- Myelodysplastic syndrome/Aplastic anemia

- Other- Other


Laboratory evaluation - Set IILaboratory evaluation - Set II::

- Reticulocytes – - Reticulocytes – 14%14%

- - Corrected reticulocyte countCorrected reticulocyte count: :

/%/% Retics X (Retics X (measured to the expected Hb ratio)/measured to the expected Hb ratio)/

14% x 7.9/15 = 14% x 7.9/15 = 7.4%7.4%

- - Reticulocyte Production Index (RPI):Reticulocyte Production Index (RPI):

/Corrected reticulocyte count/shift correction factor//Corrected reticulocyte count/shift correction factor/

7.4 / 2 = 7.4 / 2 = 3.73.7 (>2) (>2)


Interpretation: Interpretation: hyperproliferative hyperproliferative anemiaanemia Differential diagnosis:Differential diagnosis:

-- Megaloblastic anemia? Megaloblastic anemia? NoNo

- Myelodysplastic syndrome/Aplastic anemia?- Myelodysplastic syndrome/Aplastic anemia?

NoNo

- Hemolytic anemia? - Hemolytic anemia? YesYes


Laboratory evaluation - Set IIILaboratory evaluation - Set III: :

- LDH – high- LDH – high

- Bilirubin – high (unconjugated)- Bilirubin – high (unconjugated)

- Haptoglobin – low- Haptoglobin – low

Diagnosis confirmed: Diagnosis confirmed: Hemolytic anemiaHemolytic anemia


Hemolytic anemia – differential diagnosis:Hemolytic anemia – differential diagnosis:

- - Intra-corpuscularIntra-corpuscular (hemoglobinopathy, (hemoglobinopathy, enzymopathy)enzymopathy)

- - Red cell membraneRed cell membrane (cytoskeleton, PNH, (cytoskeleton, PNH, spur cell anemia)spur cell anemia)

- - Extra-corpuscularExtra-corpuscular (hypersplenism, (hypersplenism, mechanic hemolysis, immune hemolysis, mechanic hemolysis, immune hemolysis, toxic/infectious agents)toxic/infectious agents)


Laboratory evaluation - Set IVLaboratory evaluation - Set IV::

Blood smearBlood smear

- - AnisocytosisAnisocytosis (high RDW) (high RDW)

- - PolychromasiaPolychromasia (reticulocytosis) (reticulocytosis)

-- Spherocytes? - Ellyptocytes?Spherocytes? - Ellyptocytes?

-- Bite cells? - Spur cells?Bite cells? - Spur cells?

-- Schistocytes?Schistocytes? - Sickle cells? - Sickle cells?


Laboratory evaluation – Set VLaboratory evaluation – Set V::

- Direct anti-globulin (Coombs) test – IgG +3- Direct anti-globulin (Coombs) test – IgG +3


SummarySummary::- Mild splenomegaly, fever, jaundice- Mild splenomegaly, fever, jaundice- Macrocytic anemia- Macrocytic anemia- Reticulocytosis- Reticulocytosis- Spherocytosis- Spherocytosis- Positive direct anti-globulin test- Positive direct anti-globulin testWarm-type immune hemolytic anemia, possibly Warm-type immune hemolytic anemia, possibly

– drug related– drug related

An approach to anemia is based on asking 3 An approach to anemia is based on asking 3

main questions:main questions:

1. 1. MCV?MCV?

2.2. Reticulocyte count? (Bone marrow function) Reticulocyte count? (Bone marrow function)

3. 3. Involvement of additional lineages?Involvement of additional lineages?

Approach to AnemiaApproach to Anemia


MCVMCV::

- - LowLow: Iron deficiency: Iron deficiency

Thalassemia traitThalassemia trait

Chronic diseaseChronic disease

Sideroblastic anemiaSideroblastic anemia

- - NormalNormal: Iron deficiency (early): Iron deficiency (early)

Chronic diseaseChronic disease

Renal failureRenal failure


- - HighHigh: Megaloblastic anemia: Megaloblastic anemia

Hemolytic anemiaHemolytic anemia

MDS / Aplastic anemiaMDS / Aplastic anemia

Drug-relatedDrug-related

HypothyroidismHypothyroidism

AlcoholismAlcoholism

Liver diseaseLiver disease

Approach to AnemiaApproach to Anemia Reticulocyte countReticulocyte count::

- - AdequteAdequte (RPI>2): Hemolytic anemias (most) (RPI>2): Hemolytic anemias (most) Acute blood lossAcute blood loss Liver diseaseLiver disease - - InadequateInadequate (RPI<2): Iron deficiency (RPI<2): Iron deficiency Megaloblastic anemiaMegaloblastic anemia Anemia of chronic diseaseAnemia of chronic disease Bone marrow failure Bone marrow failure (malignancy, chemotherapy, (malignancy, chemotherapy, MDS/Aplastic anemia)MDS/Aplastic anemia)


Additional lineage(s) involvementAdditional lineage(s) involvement::

- - LeukopeniaLeukopenia: Malignancy: Malignancy

ChemotherapyChemotherapy

HypersplenismHypersplenism

Drug-relatedDrug-related

Megaloblastic anemiaMegaloblastic anemia

Aplastic anemiaAplastic anemia


- - ThrombocytopeniaThrombocytopenia: Malignancy: Malignancy ChemotherapyChemotherapy HypersplenismHypersplenism Drug-relatedDrug-related Megaloblastic anemiaMegaloblastic anemia Aplastic anemiaAplastic anemia TTPTTP DICDIC


In addition, In addition, blood smearblood smear always needs to be always needs to be carefully assessed:carefully assessed:

Schistocytes? Spherocytes?Schistocytes? Spherocytes?

Target cells? Normoblasts?Target cells? Normoblasts?

Spur cells (acanthocytes)? Burr cells? Spur cells (acanthocytes)? Burr cells?

Malignant cells (leukemia, lymphoma)?Malignant cells (leukemia, lymphoma)?

Malaria parasites? Sickle forms?Malaria parasites? Sickle forms?

Anemia With Low MCV and Low Anemia With Low MCV and Low ReticulocytesReticulocytes

Iron deficiencyIron deficiency

Hereditary defects in hemoglobin synthesis Hereditary defects in hemoglobin synthesis

(thalassemia trait)(thalassemia trait)

Defects in heme synthsis (sideroblastic anemia)Defects in heme synthsis (sideroblastic anemia)

Anemia of chronic diseaseAnemia of chronic disease

Anemia With Normal MCV and Low Anemia With Normal MCV and Low ReticulocytesReticulocytes

Early or mild iron deficiency anemiaEarly or mild iron deficiency anemia

ChemotherapyChemotherapy

Anemia of chronic diseaseAnemia of chronic disease

Anemia of renal failureAnemia of renal failure

Anemia with High MCV and Low Anemia with High MCV and Low ReticulocytesReticulocytes

Megaloblastic anemiaMegaloblastic anemia Myelodysplastic syndrome / Aplastic anemiaMyelodysplastic syndrome / Aplastic anemia Drug-related anemiaDrug-related anemia HypothyroidismHypothyroidism AlcoholismAlcoholism

Anemia with High ReticulocytesAnemia with High Reticulocytes

Low MCVLow MCV:: - Thalassemia Major (some cases)- Thalassemia Major (some cases) - Spherocytosis- Spherocytosis High MCVHigh MCV:: - Sickle cell anemia- Sickle cell anemia - G-6PD deficiency- G-6PD deficiency - Immune hemolytic anemia- Immune hemolytic anemia - Malaria infection- Malaria infection

Anemia with Leukopenia and/or Anemia with Leukopenia and/or ThrombocytopeniaThrombocytopenia

Low reticulocytesLow reticulocytes:: - Aplastic anemia/Myelodysplastic syndrome- Aplastic anemia/Myelodysplastic syndrome - Chemotherapy- Chemotherapy - Alcoholism- Alcoholism - Megaloblastic anemia- Megaloblastic anemia High reticulocytesHigh reticulocytes:: - TTP / DIC- TTP / DIC - Hypersplenism- Hypersplenism


63 year old male patient presented to your clinic 63 year old male patient presented to your clinic with weakness and anemia; generally healthy, with weakness and anemia; generally healthy, no permanent medications. no permanent medications.

On examination: afebrile, normal pulse and On examination: afebrile, normal pulse and blood pressure. No hepatosplenomegaly and blood pressure. No hepatosplenomegaly and lymphadenopathy. Scattered purpura over lymphadenopathy. Scattered purpura over lower extremities and chest.lower extremities and chest.


Laboratory evaluation - Set I:Laboratory evaluation - Set I:


Interpretation: Interpretation: macrocyticmacrocytic anemiaanemia with with thrombocytopeniathrombocytopenia

Differential diagnosis:Differential diagnosis:


Laboratory evaluation - Set II:Laboratory evaluation - Set II:

Interpretation: High MCV, Low RPIInterpretation: High MCV, Low RPIDifferential DiagnosisDifferential Diagnosis::

Megaloblastic anemiaMegaloblastic anemia Myelodysplastic syndrome Myelodysplastic syndrome Aplastic anemiaAplastic anemia Drug-related Drug-related AlcoholismAlcoholism


Laboratory evaluation - Set III:Laboratory evaluation - Set III:

- B12 and Folate levels- B12 and Folate levels

Thorough history taking: alcohol? medications?Thorough history taking: alcohol? medications?


Laboratory evaluation - Set IV: Laboratory evaluation - Set IV:


Laboratory evaluation - Set V:Laboratory evaluation - Set V:

Ringed Sideroblast Iron


SummarySummary:: - Macrocytic anemia- Macrocytic anemia - Thrombocytopenia- Thrombocytopenia - Low RPI- Low RPI - Dysplastic maturation (peripheral smear, - Dysplastic maturation (peripheral smear, bone marrow)bone marrow) - Normal B12 and Folate levels- Normal B12 and Folate levels

Myelodysplastic syndromeMyelodysplastic syndrome

approach to anemia - summary

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