Pimlak Charoenkwan, M.D. Division of Hematology and Oncology, Department of Pediatrics
Chiang Mai University, Chiang Mai, Thailand
APPROACH TO ANEMIA
การประชุมโลหติวทิยาสัญจร ครัง้ที ่ 15 โรงพยาบาลน่าน 20 กนัยายน 2562
Scope
• RBC production and catabolism • Criteria for diagnosis of anemia • Approach to anemia • Hemolytic anemia • Case discussion by blood smear
Erythroid differentiation
1. Pronormoblast 2. Basophilic normoblast 3. Polychromatophilic normoblast 4. Orthochromatic normoblast 5. Polychromasia 6. Mature RBC
Hoffman Hematology 5th edition
RBC catabolism
Noronha SA. Pediatr Rev 2016;37:235-46.
Hoffman Hematology 5th edition
Criteria for diagnosis of anemia
Hemoglobin level
WHO CDC
Infant 0.5-4.9 y - < 11 g/dL
Children 5.0-11.9 y - < 11.5 g/dL
Menstruating women < 12 g/dL -
Pregnant women in first or third trimester
< 11 g/dL < 11 g/dL
Pregnant women in second trimester
< 11 g/dL < 10.5 g/dL
Men < 13 g/dL -
Killip S, Bennett JM, Chambers MD. Iron deficiency anemia. Am Fam Physician 2007;75:671-8.
Approach to anemia
Hoffman Hematology 5th edition
Origin Disorder Mechanism of destruction
Acquired
Hemolytic disease of newborn Warm AIHA
Mechanical valve HA Hemolytic ureic syndrome
Cold agglutinin disease Malaria
Extravascular Extravascular Intravascular Intravascular Intravascular
Intra/Extravascular
Congenital Thalassemia
Hereditary spherocytosis G6PD deficiency
Extravascular Extravascular
Intra/extravascular
Classification of common hemolytic anemia
Adapted from: Noronha SA. Pediatr Rev 2016;37:235-46.
1. Anemia
2. Anemia
3. Neonatal jaundice
4. Anemia and jaundice
5. Neonatal anemia and jaundice
6. Anemia and jaundice
7.1 Anemia
7.2 Anemia
8. Anemia and thrombocytopenia
9. Neonatal anemia
10. Newborn with sepsis
Summary
1. Anemia Iron deficiency anemia
Iron deficiency anemia
• Microcytic, hypochromic anemia (low MCV, MCH) • Alters red cell size unevenly (high RDW) • Poikilocytic changes, seen particularly with severe iron
deficiency • Thrombocytosis with platelet counts in the range of
500,000 to 700,000 cells/fL occurs frequently
2. Anemia Hypersegmented neutrophil
Hypersegmented neutrophils
• Presence of one or more six-lobed neutrophils or • Five or more neutrophils with five well-separated
lobes
among 100 segmented neutrophils
Nathan and Oski’s Hematology of Infancy and Childhood. 9th ed. 2015.
Megaloblastic anemia
• Mostly from vitamin B12 or folate deficiency • Macrocytic anemia, usually accompanied by
leukopenia and thrombocytopenia • Maturation of the nucleus and cytoplasm is
asynchronous, with the nucleus appearing less mature than the cytoplasm.
Nathan and Oski’s Hematology of Infancy and Childhood. 9th ed. 2015.
3. Neonatal jaundice Hereditary elliptocytosis
4. Anemia and jaundice Hereditary spherocytosis
Microspherocyte
Mushroom-shaped RBC or “pincered” RBC
5. Neonatal anemia and jaundice Southeast Asian Ovalocytosis
θ
Theta cell
Red blood cell membranes
• Membrane: protein-lipid bilayer • Deformable, tolerant against mechanical stress
and various pH and salt concentrations • Cytoskeleton
• spectrin (fibrous polypeptide) • ankyrin (fix spectrin to membrane) • protein band 3 (transmembrane protein)
Nathan and Oski’s Hematology of Infancy and Childhood. 9th ed. 2015.
Southeast Asian Ovalocytosis (SAO)
SAO/G701D
SAO (27 bp deletion)
G701D
6. Anemia and jaundice G-6-PD deficiency with acute hemolysis
Enzyme metabolic activities
• Glycolytic pathway (Embden-Meyerhof): produce ATP
• Oxidative pathway (Hexose monophosphate shunt): produce NADPH
Hoffman R. Hematology: basic principles and practices 2005
Prevalence of G6PD deficiency
Region Male Female Reference
Northern 14.8-15.7 - Flatz G, et al. Lancet 1963;2:1248-50.
Northern* 16.6 13.4 (I), 1.8 (C) Charoenkwan P, et al. SEA J Trop Med Public Health 2014;45:187-93.
Siriraj hospital 12.08 - Tanphaichitr VS. SEA J Trop Med Public Health 1995;26 Suppl 1:137-41.
Chula hospital* 11.1 5.8 Nuchprayoon I, et al. Hum Mutat 2002;19:185.
*G6PD Mahidol, G6PD Kaiping, G6PD Canton, G6PD Viangchan, G6PD Union, G6PD Chinese 5 **G6PD Viangchan (class II), G6PD Canton, G6PD Mahidol (class III), G6PD Union, G6PD Kaiping
7.1 Anemia Thalassemia disease
7.2 Anemia Basophilic stippling
Basophilic stippling
• Represents aggregated ribosomes • May be observed in
• Thalassemia diseases • Iron deficiency • Ineffective erythropoiesis
• Unstable hemoglobinopathies • Lead poisoning
• Pyrimidine 5′-nucleotidase deficiency
8. Anemia and thrombocytopenia Autoimmune hemolytic anemia
9. Neonatal anemia Acid elution test: F cell
Acid elution test
• Kleihauer-Betke technique of acid elution • Resistance of fetal Hb to acid elution • Interpret with caution in
• Maternal thalassemia minor • Hereditary persistent of fetal hemoglobin • Pregnancy-induced increase in Hb F production
10. Newborn with sepsis Toxic changes in neutrophils
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