AnemiaAnemia

Actuality of theme:Actuality of theme:• Anemia is very often

met in 20% women of the developed countries and in 50% women of the non-developed countries;

• More than 50% patients with chronic diseases and tumors;

• Considerably worsens quality of life and capacity.

Definition of anemia

Anemiais the decreasing of hemoglobin and red blood cells level in the unit of blood volume Reduction in one or more of the major red blood cell (RBC) measurements: Hemoglobin Hematocrit RBC countFrom data of WHO:a hematocrit less than 40 in men and 37 in women, or hemoglobin less than 130 g/l in men and less than 120 g/l in women.

Signs and symptomsSigns and symptomsWeakness and fatigue are the most common

symptoms of anemia. Decreased energyShortness of breath on exertion (dyspnea)Palpitations (feeling of the heart racing or beating

irregularly) Cold hands or feet

HeadacheLightheadedness or dizzinessDizziness and passing out, especially upon standingRinging in the ears (tinnitus)Irritability and other mood disturbancesMental confusionLethargy

Signs and symptoms

Chest pain (angina or heart attack)Intermittent claudicationLoss of sexual drive

Abdominal painWeight loss

Physical ExaminationThe skin and mucous membranes are pale

(however, healthy-looking skin color does not rule out anemia if a patient has risk factors and other symptoms of anemia)

Rapid heartbeat - tachycardia, Heart murmur - systolic flow murmur, heart failuretachypneaLow blood pressure (hypotension)

Reticulocyte countReticulocyte count Retic count = % immature RBC Normal 0.5-1.5% (for non-anemic) <1% Inadequate production >=1% Increased production (? adequacy)

Classification according to mechanism Blood loss acute and chronicExcessive destruction of rbcsImpaired production of rbcs

Decreased ProductionDecreased ProductionNUTRITIONAL DEFICIENCYNUTRITIONAL DEFICIENCY

IronB12Folate

- Usually hypochromic as wellIron-deficiency anemia Anemia of chronic diseases(rare) Sideroblastosis Hereditary anemia (thalassemia) Lead poisoning Deficit of copper, poisoning by zinc

Microcytic anemia Microcytic anemia (MCV less than 80) (MCV less than 80)

Microcytic AnemiaMicrocytic AnemiaMCV <80Reduced iron

availabilityReduced heme

synthesisReduced globin

production

Microcytic AnemiaMicrocytic AnemiaREDUCED HEME SYNTHESISREDUCED HEME SYNTHESIS

Lead poisoningAcquired or

congenital sideroblastic anemia

Characteristic smear finding: Basophylic stippling

Microcytic AnemiaMicrocytic AnemiaREDUCED GLOBIN PRODUCTIONREDUCED GLOBIN PRODUCTIONThalassemiasSmear

Characteristics◦Hypochromia◦Microcytosis◦Target Cells◦Tear Drops

ThalassemiaThalassemia

Normal to inc. RPINormal RDWTarget cellsMentzer index <13 =MCV/RBCYouden’s index - using

RDW & Mentzer index - sensitivity = 82% - specificity = 80%confirm w/ Hgb

electrophoresis

koilonychiakoilonychia

Lab tests of iron deficiency of Lab tests of iron deficiency of increased severityincreased severity

NORMALNORMAL Fe Fe deficiencydeficiency

Without Without anemiaanemia

Fe Fe deficiency deficiency

With mild With mild anemiaanemia

Fe Fe deficiency deficiency

With severe With severe anemiaanemia

Serum IronSerum Iron 60-15060-150 60-15060-150 <60<60 <40<40

Iron Iron Binding Binding CapacityCapacity

300-360300-360 300-390300-390 350-400350-400 >410>410

SaturationSaturation 20-5020-50 3030 <15<15 <10<10

HemoglobinHemoglobin NormalNormal NormalNormal 9-129-12 6-76-7

Serum Serum FerritinFerritin

40-20040-200 <20<20 <10<10 0-100-10

Makrocytic anemia (MCV more than 100 fl)

- Megaloblastic anemia (vitamin В12 or folic acid deficiency )- Toxic effect of chemotherapeutic agents (methotrexate) or other medications (zidovudine (AZT), phenytoin)- Pathology of bone marrow- Chronic abuse by alcohol (toxic effect)- Liver disease

Megaloblastic AnemiaMegaloblastic Anemia

FolateInadequate intakeSynthesized by plants

and micro-organismGreen leafy vege’sFruitsAbsorbed in jejunum

B12Inadequate absorptionSynthesized by bacteria Meat, fish, dairy (strict

vegans)Absorbed as B12-IF

complex in ileum (gastrectomy)

Ca++ and pH dependant (PPI)

Megaloblastic Megaloblastic AnemiaAnemia

SmearMacro-ovalocyticPolychromasiaHypersegmented

neutrophil

Normocytic Anemia (MCV 80-100 Normocytic Anemia (MCV 80-100 fl)fl)

Type of anemia

Blood film Ferritin Fe TIBC Marrow Fe stores

Chronic disease*

Normochromic, normocytic

Nl or ↑ ↓ ↓ Nl or ↑, clumped

Early Fe deficien

cy

Mild anisocytosis

hypochromia

Nl or ↓ ↓ ↑ absent

*including anemia due to renal disease and AIDS

Aplastic AnemiaAplastic Anemia

Fanconi anemia – congenitalDirect stem cell destruction – external radiationDrugs - chloramphenicol, gold, sulfonamides,

felbamateOther Toxins - Solvents, degreasing agents,

pesticides Viral infection - parvovirus B19, HIV, otherIdiopathic

Hemolytic AnemiaHemolytic Anemia

Coombs’ (DAT)

Positive Negative

Immune HemolysisDrug related HemolysisTransfusion, Infection, Cancer

Hemoglobinopathy, G6PD, PK, Spherocytosis, Eliptocytosis, PNH, TTP, DIC

Hemolytic AnemiaHemolytic Anemia

Coombs’ (DAT)

Positive Negative

Immune HemolysisDrug related HemolysisTransfusion, Infection, Cancer

Hemoglobinopathy, G6PD, PK, Spherocytosis, Eliptocytosis, PNH, TTP, DIC

TTP-HUS TTP-HUS // DIC DIC

Spherocytes. One arrow points to a Spherocytes. One arrow points to a spherocyte; the other, to a normal RBC spherocyte; the other, to a normal RBC with a central pallor.with a central pallor.

Schistocytes (thrombotic Schistocytes (thrombotic thrombocytopenic purpura).thrombocytopenic purpura).

Peripheral blood smear with sickled cells

Clinical Presentation: Signs and Clinical Presentation: Signs and SymptomsSymptoms

General anemia pallor, fatigue, SOB on exertion

Acute chest syndrome cough, dyspnea, chest pain, fever

Infection malaise, cough and chest pain, diarrhea and/or vomiting

Painful crises persistent pain in skeleton, chest, and/or abdomen

Hand-foot syndrome swollen and painful hands and feet (by 2 years of age: 50% of Jamaican and 25% of American children with sickle cell anemia have experienced at least one episode of dactylitis)

Stroke (affects 10% of patients; 6-17% of children and young adults), sudden neurologic deficits including motor, difficulty with language, writing, and/or reading; seizures; sensory deficits; altered consciousness

Priapism penile erection not related to arousal

Delayed growth and puberty

Patient more slender or small in size.

Jaundice Yellowing of skin and eyes

Other Some people remain asymptomatic into late childhood and are only incidentally diagnosed

http://www.ornl.gov/sci/techresources/Human_Genome/posters/chromosome/sca.shtml

A prolonged environment of low oxygen leads to aggregation and polymerization of hemoglobins into long chains of rod-like fibers, causing the RBC to form the shape of a crescent or sickle.

http://www.humanillnesses.com/original/images/hdc_0001_0003_0_img0235.jpg

• Donut-shaped• Soft and malleable• Able to pass through

small spaces• Lifespan ~120 days

• Sickle-shaped• Hard and rod-like• Gets stuck in narrow

spaces• Lifespan ~20 days

Sickling of red blood cells Sickling of red blood cells leads to:leads to:

1. Vaso-occlusive complications

2. Severe anemia

3. Chronic hyperbilirubinemia

Vaso-occlusive complicationsVaso-occlusive complications

Occur in areas with:

• Prolonged, low oxygen tension

• Decreased pH

• Inflammation

• Low blood flow

Source: Robbins

Severe Anemia and Chronic Severe Anemia and Chronic HyperbilirubinemiaHyperbilirubinemia

• Irreversibly sickled cells end up in the spleen.

• Hemolysis occurs at the splenic cords.

• Decreased RBCs and increased bilirubin

• Infarction and fibrosis causes autosplenectomy.

Source: Robbins

Thank you for attention!