A diagnostic approach to anemia

Dr Nighat majeed

Assistant professor

Medical unit 11

SIMS/SHL Lahore

Definition

Anemia refers to a state in which level of hemoglobin in blood is below the normal range appropriate for age and sex.

Anemia is present in adults if the hematocrit is less than 41% (hemoglobin < 13.5 g/dL) in males or less than 37% (hemoglobin < 12 g/dL) in females.

Anemia

• For adult men, a hemoglobin level less than 13.0 g/dl (grams per deciliter) is diagnostic of anemia, and for adult women, the diagnostic threshold is below 12.0 g/dl.

• Normal red cell count is 6.9 million/mm6in women and 6.3 million/mm6in men.

• Normal red cell volume in men is 32+ 6.5 ml/kg in men and 25 + 6.5 ml/kg in women.

Peripheral blood smear microscopy of a patient with iron-deficiency anemia

Classification

Decreased production • Hemoglobin synthesis: iron deficiency,

thalassemia, anemia of chronic disease. • DNA synthesis: megaloblastic anemia.• Stem cell: aplastic anemia, myeloproliferative

leukemia.• Bone marrow infiltration: carcinoma,

lymphoma.• Pure red cell aplasia.

Classification

Increased destruction   1-Blood loss  2-Hemolysis (intrinsic)•     Membrane: hereditary spherocytosis, elliptocytosis.•     Hemoglobin: sickle cell, unstable hemoglobin.•     Glycolysis: pyruvate kinase deficiency, etc•     Oxidation: glucose-6-phosphate dehydrogenase

deficiency.  

Classification

Hemolysis

(extrinsic)•     Immune: warm antibody, cold antibody.•     Microangiopathic: thrombotic.

thrombocytopenic purpura, hemolytic-uremic syndrome, mechanical cardiac valve, paravalvular leak.

•     Infection: clostridial.•     Hypersplenism.

Classification

Classification of anemias by mean cell volume.

1-Microcytic(MCV<80)

• Iron deficiency.• Thalassemia.• Anemia of chronic disease.

Classification 2-Macrocytic(MCV>100) Megaloblastic•  Vitamin B12 deficiency.• Folate deficiency.   Nonmegaloblastic•   Myelodysplasia, chemotherapy.•   Liver disease.•   Increased reticulocytosis.•   Myxedema.

Classification

3- Normocytic(80<MCV<100)

•   Many causes.

History

Iron deficiency anemia Blood loss

•   Gastrointestinal•   Menstrual•   Blood donation

History

Iron deficiency anemia• Deficient diet.• Decreased absorption.• Increased requirements. (Pregnancy, Lactation)• Hemoglobinuria.• Iron sequestration. • Pulmonary hemosiderosis.

History

B12 deficiency anemia• Abdominal or intestinal surgery that affects

intrinsic factor production or absorption. • A diet low in vitamin B12 (for example, a strict

vegetarian diet that excludes all meat, fish, dairy products, and eggs).

• Chronic alcoholism.

History

B12 deficiency anemia • Crohn's disease. • Infection with the fish tape worm. • Intestinal malabsorption disorders. • Pernicious anemia, which is caused by the

destruction of intrinsic factor by the immune system.

History

Folate deficiency anemia

•Alcoholism.• (which interferes with the• Absorption of folate).•Eating overcooked food. • Malabsorption diseases. •Poor diet.•Pregnancy.

History

Past medical history

• May reveal a disease which is known to be associated with anemia, such as rheumatoid arthritis, or previous intestinal surgery causing malabsorption.

History

Family history• Haemolytic anemias such as the

haemoglobinopathies and heriditary spherocytosis may be suspected from family history.Ask about anemia, jaundice, gallbladder disease, splenectomy in blood relatives.

• Pernicious anemia may also be familial.

History

• Dug history• Aspirin and anti-inflammatory drugs, may cause

the blood loss. • Drugs like chloramphenicol can cause aplastic

anemia.• Radiation, chemotherapy, or infection can cause

bone marrow aplasia.

History

Dietary history• Alcohol intake, causes folic acid deficiency.• Vegetables are deficient in B12.• Assess the dietary intake of iron and folate.• Lead exposure is toxic to the bone marrow,

leading to fewer red blood cells. Lead poisoning occurs in adults from work-related exposure and in children who eat paint chips. Improperly glazed pottery can also taint food and liquids with lead.

History

• A feeling of weakness or fatigue in general or during exercise, general malaise and poor concentration.

• Dyspnoea.• Heart failure.• Sweating.• Palpitation.

Physical examination

• Pallor (pale skin, mucosal linings and nail beds).• Cheilosis. • koilonychia.• Pica, the consumption of non-food based items

such as dirt, paper, wax, grass, ice, and hair, may be a symptom of iron deficiency, although it occurs often in those who have normal levels of hemoglobin.

Physical examination

• Jaundice.• Periphral neuropathy.(B12 deficiency)• Dementia.(B12 deficiency)• Signs of subacute combined degeneration of cord.

(B12 deficiency)

Diagnosis

• complete blood counts is the first blood tests in the diagnosis of an anemia.

• Examination of a stained blood smear

Diagnosis

In modern counters, four parameters • (RBC count). • Hemoglobin concentration. • MCV and RDW are measured.• Allowing others (hematocrit, MCH and MCHC)

to be calculated, and compared to values adjusted for age and sex.

Diagnosis

Reticulocyte counts.• A reticulocyte count is a quantitative measure of

the bone marrow's production of new red blood cells.

• The reticulocyte production index is a calculation of the ratio between the level of anemia and the extent to which the reticulocyte count has risen in response.

Diagnosis

• Other tests: ESR, ferritin, serum iron, transferrin, RBC folate level, serum vitamin B12, hemoglobin electrophoresis, renal function tests.

• When the diagnosis remains difficult, a bone marrow examination allows direct examination

Investigation of anem ia w ith norm al or low Mcv

In vestig a te

F e de ficient

F erritin (lo w )

B eta T h alassem ia tr iat

In c reased H B A2

A lp ha tha lassem ia tr iat

N o rm al H B A2

H B electro ph o res is

T arge t ce ll b asop hilic stip pling

L o w M CV

H yp och ro m ia

S id ero b las tic

B o ne m arrow

D im o rph ic

o r ch eck iro n s tores

If H B < 8g/l co n s id er b o ne m arrow

if ferr itin is n orm al o r h ighan em ia o f ch ron ic d isease

C o ns ider fe rritin )

N o nsp ec ific

N o rm a l or low reticulo cyte co u nt

M C V n o rm al(76-98 fl) o r lo w (<76 fl)

Investigation of anem ia w ith h igh MCV

In ves tig ate ca u se D ru gs c yto tox ic ag e nt

F o la te B 12

H ype rse g m e n te d n e utro ph ils

L iver fun c tio n te st

T a rge t c e lls to m a to cytes

S id ero b la s ticA n em ia

B o ne m arrow

D im o rph ic

M ye lo dys p la s ia

M a rrow

D ys p las ia c yto p e n ia

h a e m o lys isb le ed ing

p o lyc h ro m a s iah ig h retics

N o rm a l or low retic u lo c yte co u nt

B lo od film a nd retic u lo c yte co u nt

M C V H igh (> 9 8 fl) C lin ic al c lu es

THANKU