Diagnosing AnemiaDiagnosing Anemia

Dr Robert Liwski MD PhD FRCPCDr. Robert Liwski, MD, PhD, FRCPCMedical Director, HLA Typing LaboratoryDivision of HematopathologyDepartment of Pathology and Laboratory Medicinep f gy yDalhousie UniversityRobert.liwski@cdha.nshealth.ca

AnemiaAnemia• Decrease in the number of circulating redg

blood cells, resulting in decreased oxygen carrying capacity

• Most common hematologic disorder

• Most cases due to a secondary disorder

• Critical for physicians to know how to determine the causethe cause

Red cell functionRed cell function

• Function:Function:– Oxygen delivery to tissues

Removal of CO from tissues– Removal of CO2 from tissues– Mediated by hemoglobin within the red

cellscells.

Hemoglobin structureHemoglobin structure

Hemoglobin cannot be made without iron !

Normal red cell morphologyNormal red cell morphology

Central pallorNormally less than ½ diameter

Cellular blood components• Red cells • Platelets • White cells

N t hil– Neutrophils– Monocytes– LymphocytesLymphocytes– Eosinophils– Basophils

• All formed in the bone marrow through a process called hematopoiesisprocess called hematopoiesis

Erythropoiesis

Kidney

Bone MarrowBone Marrow

http://yewbiotech.com/blog/erythropoiesis/

Bone marrow examination

Bone marrow aspirate smear preparation

Drop of marrow

Slide 1Slide 2

Slide 2

On contact, slide 2 extends the drop along its 1” side

Slide 2

Pushing angled slide 2 g galong #1 smears the line of blood across slide 1

Smear

Lift away slide 2; dry #1 ; stain; coverslip

2. Basophilic erythroblastErythropoiesis

1. Proerythroblast3. Polychromatic erythroblasts

4. Orthochromatic erythroblastserythroblasts

Aspirate 100x

Erythropoiesis

5. Nuclear expulsion

4 O th h ti4. Orthochromatic erythroblasts

Aspirate 100x

PB 50x

Causes of anemiaCauses of anemia

• Blood lossBlood loss

D d d ti f d bl d ll• Decreased production of red blood cells– Nutritional deficiencies– toxic exposures– Renal failure (↓erythropoietin)– bone marrow failure/disorders

• Increased destruction (hemolysis)

Shotgun approachShotgun approach• Iron studies (Ferritin, Fe, TIBC, % sat, zinc protoporhyrin)• B12, folate, MMAB12, folate, MMA• Thyroid hormones• Hemolysis screen (LD, bili, haptoglobin, urine Hgb and

hemosiderin)hemosiderin)• Coombs/DAT test• Enzymopathy screen (G6PD, pyruvate kinase)

H l bi l t h i• Hemoglobin electrophoresis• Osmotic fragility• PNH testing• Endoscopy• Bone marrow examination• HepcidinHepcidin• Soluble transferrin receptor • HLA typing (DR15)

Targeted approachTargeted approach• History (acute vs chronic, kinetics, ethnic

backgro nd) and E ambackground) and Exam

• Complete Blood Count (CBC)Complete Blood Count (CBC)– HGB, RBC, MCV, RDW, WBC diff, PLT

• peripheral blood smear– morphology

• Absolute reticulocyte count

• Serial test selection

Case 1Case 1• 25-year-old female, G1P0 (12 weeks gestation), y ( g )

originally from China

• Asymptomatic exam unremarkable• Asymptomatic, exam unremarkable

• History of heavy menstruationHistory of heavy menstruation

• CBC: WBC 9.8 (N), Hgb 107 (L), Plt 180 (N)

• What else do you want to know?

Case 1F ll CBC P i h l bl d• Full CBC– WBC 9.8 (N)

RBC 6 35 (H)

• Peripheral blood smear

Microcytosis– RBC 6.35 (H)– HGB 107 (L)– MCV 68 (L)

– Microcytosis– Hypochromia– Target cellsMCV 68 (L)

– MCHC 240 (L)– RDW 14.7 (N)

Target cells– Elliptocytes

( )– PLT 180 (N)

Case 1F ll CBC P i h l bl d• Full CBC– WBC 9.8 (N)

RBC 6 35 (H)

• Peripheral blood smear

Microcytosis– RBC 6.35 (H)– HGB 107 (L)– MCV 68 (L)

– Microcytosis– Hypochromia– Target cellsMCV 68 (L)

– MCHC 240 (L)– RDW 14.7 (N)

Target cells– Elliptocytes

( )– PLT 180 (N)

Case 1F ll CBC P i h l bl d• Full CBC– WBC 9.8 (N)

RBC 6 35 (H)

• Peripheral blood smear

Microcytosis– RBC 6.35 (H)– HGB 107 (L)– MCV 68 (L)

– Microcytosis– Hypochromia– Target cellsMCV 68 (L)

– MCHC 240 (L)– RDW 14.7 (N)

Target cells– Elliptocytes

( )– PLT 180 (N)

Microcytic anemia (MCV < 80)Microcytic anemia (MCV < 80)

• Differential diagnosis:Differential diagnosis:– Iron deficiency

Anemia of chronic inflammation– Anemia of chronic inflammation– Thalassemia

Lead poisoning– Lead poisoning – Sideroblastic anemia

Rare

Hemoglobin structureHemoglobin structure

Hemoglobin cannot be made without iron !

Iron deficiency vs thalassemiaRBC Hgb MCV RDW

Iron deficiency vs thalassemia

Thalassemia N or high 100 120 <70 NThalassemia N or high 100-120 <70 N

Iron deficiency

Low or N <100 <80Proportionate

High

to Hgb

Confirm with hemoglobin electrophoresis and serum iron studies

Serum Iron StudiesIron deficiency vs ACI

Serum Iron Ferritin TIBC % Iron Saturation

ACI Low or N High Low Low

I L N Low Hi h LIron deficiency

Low or N Low High Low

Case 1Case 1

• Full CBC • Peripheral bloodFull CBC– WBC 9.8 (N)– RBC 6.35 (H)

Peripheral blood smear– Microcytosis( )

– HGB 107 (L)– MCV 68 (L)

– Hypochromia– Target cells

– MCHC 240 (L)– RDW 14.7 (N)

PLT 180 (N)

– Elliptocytes

– PLT 180 (N)

Case 1Case 1

• Full CBC • Peripheral bloodFull CBC– WBC 9.8 (N)– RBC 6.35 (H)

Peripheral blood smear– Microcytosis( )

– HGB 107 (L)– MCV 68 (L)

– Hypochromia– Target cells

– MCHC 240 (L)– RDW 14.7 (N)

PLT 180 (N)

– Elliptocytes

– PLT 180 (N)

Ferritin 50 (N)Hgb electro shows increased Hgb A2

DiagnosisDiagnosis

• Beta Thalassemia TraitBeta Thalassemia Trait

Case 2Case 2

• 40-year-old female diagnosed with lupus40 year old female, diagnosed with lupus 1 year ago

• Presents with week of progressive fatigue d SOB 3 d f “ ll ki ”and SOB, 3 days of “yellow skin”.

• On exam: BP=110/70, HR=110/min, pallor, jaundice, swollen MCP jointsp , j , j

Case 2Case 2

• Full CBC • Peripheral bloodFull CBC– WBC 4.8 (N)– RBC 2.1 (L)

Peripheral blood smear– Spherocytes( )

– HGB 70 (L)– MCV 96 (N)

– Marked polychromasia

– MCHC 355 (N)– RDW 16.1 (H)

PLT 140 (L)– PLT 140 (L)

Normocytic anemia (MCV 80-100)Normocytic anemia (MCV 80 100)

• Low/N reticulocyte count: • High reticulocyte county– Anemia of chronic

inflammation

g y– Acute blood loss– Hemolysis

– Early iron deficiency– Renal failure

Endocrinopathies

• Congenital (enzymopathies, membrane defects,

– Endocrinopathies– Bone marrow disorder

(MDS, marrow failure,

hemoglobinopathy)• Acquired (Immune vs

Non-immune)( , ,leukemia, lymphoma, infiltration)

Case 2Case 2

• Full CBC • Peripheral bloodFull CBC– WBC 4.8 (N)– RBC 2.1 (L)

Peripheral blood smear– Spherocytosis( )

– HGB 70 (L)– MCV 96 (N)

– Marked polychromasia

– MCHC 355 (N)– RDW 16.1 (H)

PLT 140 (L)– PLT 140 (L)

Case 2Case 2

• Full CBC • Peripheral bloodFull CBC– WBC 4.8 (N)– RBC 2.1 (L)

Peripheral blood smear– Spherocytosis( )

– HGB 70 (L)– MCV 96 (N)

– Marked polychromasia

– MCHC 355 (N)– RDW 16.1 (H)

PLT 140 (L)– PLT 140 (L)

What would you order now?

Case 2Case 2

• Reticulocyte countReticulocyte count

• Hemolysis screen (LDH indirect bili• Hemolysis screen (LDH, indirect bili, haptoglobin)

• DAT

• Type and screen***

Case 2Case 2• Reticulocyte count 450 y

• LDH 710

• Indirect bili 80

• Haptoglobin 0

• DAT: IgG 3+, C3b 2+

• Type and screen: A+ screen pan-reactiveType and screen: A+, screen pan reactive

DiagnosisDiagnosis

• Autoimmune hemolytic anemiaAutoimmune hemolytic anemia

Case 3Case 3

• 70-year-old female history of gastritis70 year old female, history of gastritis

6 k f f ti 3 k i 1• 6 weeks of fatigue, 3 weeks angina, 1 week shortness of breath

• On exam: BP=140/90, HR=110/min, , ,pallor, ataxia, weakness

Case 3Case 3

• Full CBC • Peripheral bloodFull CBC– WBC 2.0 (L)– RBC 1.5 (L)

Peripheral blood smear– Macrocytosis( )

– HGB 55 (L)– MCV 124 (H)

– Hypersegmented neutrophils

– MCHC 355 (N)– RDW 17.1 (H)

PLT 140 (L)– PLT 140 (L)

Macrocytic anemia (MCV > 100)Macrocytic anemia (MCV > 100)

• Differential diagnosis:Differential diagnosis:– Megaloblastic anemia:

• Vitamin B12/folate deficiency• Anti-metabolite chemotherapeutic drugs

– Increased reticulocyte countDrug induced (anti retroviral therapy)– Drug induced (anti-retroviral therapy)

– Alcohol abuse– Liver diseaseLiver disease– Hypothyroidism– Myelodysplastic syndrome– Aplastic anemia

Case 3Case 3

• Full CBC • Peripheral bloodFull CBC– WBC 2.0 (L)– RBC 1.5 (L)

Peripheral blood smear– Macrocytosis( )

– HGB 55 (L)– MCV 124 (H)

– Tear drop cells– Hypersegmented

t hil– MCHC 355 (N)– RDW 17.1 (H)

PLT 140 (L)

neutrophils

– PLT 140 (L)

What would you order next?What would you order next?

Case 3Case 3

• Reticulocyte count 25 (L)Reticulocyte count 25 (L)

Vit i B12 100 /L (L )• Vitamin B12 100 ng/L (Low)• Folate normal

DiagnosisDiagnosis

• Vitamin B12 deficiencyVitamin B12 deficiency

Questions?

Thank you