Anaemia evaluation

In the name of God, Most Gracious, Most Merciful

- Dr. Mohammed Sadiq Azam

PG M:1 (Dr. Siraj’s Unit)

DCMS @ PEH

EVALUATION OF A CASE OF ANAEMIA

CASE HISTORIES:

• 22/F presented with complaints of shortness of breath (NYHA GR IV),

orthopnoea+, chest discomfort and palpitations on exertion which gradually

increased over the last 6 months to attain present severity. H/s/o Pica+, H/o

passing worms in stools+. No h/o rash, photosensitivity or seizures. O/E: Pallor+,

BPPE+, JVP , s3 gallop+, b/l basal creps (fine)+, no organomegaly, no FF.

• 45/F presented with c/o shortness of breath (NYHA GR II-III), no orthopnoea, no

PND. Past h/o jaundice+. H/o blood transfusion in past +. O/E: Pallor++, Icterus++

+, Hepatomegaly~2 cm below C/m, Splenomegaly~15cm, no FF.

• 75/F presented with c/o fatigability and lethargy over last 8 month, initially mild

now increased in intensity. H/o sob on exertion (NYHA GR I-II). No H/o

orthopnoea/PND. No H/o chest discomfort. Not a known diabetic. H/s/o malena+.

H/o loss of appetitie, loss of weight+ over last 5 months. O/E: Pallor++, anicteric

no PE, CVS/RS – NAD, P/A- NAD.

EVALUATION – HISTORY:

• Age/Sex

• Rate of onset – Rapid/Slow

• Blood loss – Haematemesis / malena / bleeding piles / menorrhagia /

metorrhagia / epistaxis / hematuria / haemoptysis

• Abdomen – Appetitie / weight loss / dysphagia / regurgitation / dyspepsia / abd

pain / diarrhoea / constipation / jaundice / soreness of tongue / previous abd

surgeries

• Reproductive – Menstrual history in detail / number & interval between

pregnancies / miscarriages

• Urinary system – Nocturnal polyuria

• CNS – Parasthesiae / difficulty in walking

EVALUATION – HISTORY:

• Bleeding tendency – Easy bruising / prolonged bleeding after trivial injuries /

bleeding from more than one site

• Skeletal system – Bone pain / Arthritis / Arthralgia

• Temperature – Fever / Night sweats

• Drug ingestion – Previuos / current

• Occupation – Metal dusts / solvent fumes / lead

• Diet

• Social history – Alcoholism

• Past H/o – Previous anaemia: diag & Rx, response to Rx

• Family H/o – Anaemia / recurrent jaundice / IUD & childhood deaths

EVALUATION – EXAMINATION:

• Skin – Colour, texture, petechiae, ecchymoses, scratch marks.

• Nails – Brittleness, longitudinal ridging, koilonychia

• Conjunctiva/Sclera – Pallor, icterus, haemorrhages

• Retina – Haemorrhages, s/o HTN/renal failure, other changes

• Mouth – Mucous membrane: Pallor, petechiae

• Gums: Bleeding, hypertrophy

• Tongue: Redness, atrophy of papillae

• Abdomen – HSM, either HM or SM, tenderness, mass, ascites

• CVS – BP, valvular, vascular prosthesis

• CNS – Peripheral neuritis, s/s/o SADSC

EVALUATION – EXAMINATION:

• Supf LN – Enlargement of cervical, axillary, inguinal, epitrochlear nodes

• Bones – Tenderness (esp. of sternum), tumour

• Legs – Ulcers / scars of healed ulcers

• P/R – Haemorrhoids / CA Rectum

• Pelvic – Menorrhagia, metorrhagia, uterus, cervix

• Torniquet test

• Urine – Protein, urobilinogen, BS/BP

THE APPROACH …

Provisional Diagnosis: Anaemia for evaluation

Is anemia associated with other haematological abnormalities?

Yes No

BM Examination

LeukemiasAplastic anaemiasMDS / MFMyelophthisisMegaloblastic anaemia

Is there an appropriate reticulocyte response to anaemia?

Yes No

Evidence of haemolysis?

Yes No

Evaluate causeof haemolysis

Evaluate:haemorrhagic causes

RBC Indices

MCV >100 MCV 80-100 MCV <80

Evaluate:Macrocytic anemia

Evaluate:Normocytic anemia

Evaluate:Microcytic anemia

(Ref: Bertil Glader: Anaemia: General Considerations, Wintrobe’s Clinical Haematology 11/e, 2004: 951-978)

• Retic count = % reticulocytes in RBC population

• Retic count corrected for anaemia = % retculocytes x pt Hb/15 or pt Hct/45

• BUT, Retics released under intense EPO stimulation remain in circulation for approx 2x the usual 1 day survival of non stress retics, so:

• Corrected Retic index = Retic count corrected for anaemia x 0.5

• < 2.5 = inadequate response – hypoprolifertive / maturation disorder (marrow prod impaired)

• ≥ 2.5 = adequate response – haemolytic / haemorrahgic

• Absolute retic count = %retics x RBC count/l3

• Low retic count + active marrow erythropoiesis = ineffective erythropoiesis

• IDA

• Sideroblastic anaemia

• Thalassemias

• (Also associated with LDH)

RETICULOCYTOSIS: A WORD


Macrocytic anaemia

Does the P/S reveal hypersegmented neutrophils / macroovalocytes?

Yes No

Megaloblastic anaemia – BM to confirmTest for B12/Folate levels

B12 def No def Folate def

Schilling’s test:Corrects with IF

Yes No

Pernicious anaemia:Gastric resection

Ileal diseasePrevious ileal SxSmall bowel bac overgrowthFish tapewormDrug induced malabsorption

Inherited disorders of DNA synDrugs tht interfere with DNA syn

Poor dietDrug induced malabsJejuneal resectionTropical sprueGluten sensitivity Needs - Pregnancy - Chronic hemolysis

Nonmegaloblastic anaemia

Reticulocytosis

Haemolytic N /

Consider: - Alcohol - Hypothyroidism - Liver disease

If NO: BM exam

- MDS- Red cell aplasia- Acq siderobl anaemia- Herid dyserythropoietic anaemia (I& III)


Microcytic anaemia Appropriate age: Rule out malignancy

Reticulocytes

Low / N Increased

P/S: Abnorm morphologyLabs for RBC destrucHb studies

- Homozygous β thal- Haemolytic elliptocyt- Herid pyropoikilocytosis

Iron Profile

Fe TIBC Ferritin

FeN/ TIBCN/ Ferritin

N. FeN. TIBCN. Ferritin

FeN. TIBC Ferritin

Iron deficiency

ESR, CRP+or other studies s/o underlying Inflammatory disorder

AOCD

Hb electrophoresis

- α Thal trait- β Thal trait- Hb E syn- Hb C disorder

BM examination with Fe stains

Sideroblastic anaemia


Normocytic anaemia

Reticulocytes

RBC prod N./ RBC prod

H/o jaundice, splenomegalyPresence of P/S abnormalities Bilirubin / LDH

Yes

No

Haemolysis

Haemolytic anaemia

S.Fe

LowN. / High

AOCDEarly IDA

- S. Chemistries to screen for renal, hepatic, endocrine disease- Consider EPO levels, thyroid studies

Positive Negative

- Anaemia of renal disease- Anaemia of liver disease- Anaemia due to endocrine failure

BM aspirate & Bx

- Infiltrative disorder (Leuk, myeloma, MF, Mets)

- Red cell aplasia- MDS- Dyserythropoietic anaemia (Type II)

• Retic index ≥ 2.5. Polychromatophilic macrocytes ++ in P/S

• Marrow examination is rarely required if retic index is increased appropriately.

• RBC indices are typically normocytic or slightly macrocytic (reflects retics)

HAEMORRHAGIC ANAEMIA:

Blood loss

AcuteSubacute Chronic

Missed

No reticulocytosis

Modest reticulocytosis

Presents ///ar to IDAObserve for 2-3 weeksSigns of recovery - Hb - Retic count

HAEMORRHAGIC ANAEMIA:

Volume of blood loss (ml)

Blood volume (%)

Symptoms

500-1000 10-20 Few if any symptoms

1000-1500 20-30 Asymptomatic while at rest in a recumbent position; light headedness and hypotension when upright; tachycardia

1500-2000 30-40 Symptoms present when recumbent; thirst, SOB, clouding or LOC; BP, CO, venous pressure decrease, pulse usually rapid; extremities become cold, clammy & pale

2000-2500 40-50 Lactic acidosis, shock; irreversible shock, death

• Least common form of anaemia

• High retic count: Reflects the ability of the erythroid marrow to compensate for haemolysis, and, in the case of extravascular haemolysis, the efficient recycling of iron from the destroyed RBC to support RBC production.

• Intravascular haemolysis – PNH – loss of Fe – limits marrow response

• Hence, the level of marrow response depends on:

• The severity of anaemia

• The nature of the underlying disease process

• Hemoglobinopathies – mixed picture. (Retic count is but with respect to degree of marrow erythroid hyperplasia).

HAEMOLYTIC ANAEMIA:

• Presentation varies:

• Acute self limiting illness (autoimmune/EM pathway/GR defects)

• Chronic process (Hb defects/ RBC defects) with a typical history

• HS: chronic course – present with complications such as bilirubin gallstones or splenomegaly and not anaemia per se.

• Chronic haemolysis also prone to aplastic anaemia if infections occur.

HAEMOLYTIC ANAEMIA:

• PNH

• Erythrocyte fragmentation disorders

• Transfusion reactions resulting from ABO incompatability

• Paroxysmal cold haemoglobinuria

• AIHA (occasionally)

• Infections:

• Blackwater fever in falciparum malaria

• Clostridial sps

• Chemical mediated:

• Arsine poisoning

• Snake & Spider venoms

• Acute drug reactions with G6PD def

• I.V. admin of distilled water

• Thermal injury

HAEMOLYTIC ANAEMIA: INTRAVASCULAR LYSIS

• Morphological abnormalities: Spherocytes, Elliptocytes, Stomatocytes, Acanthocytes, Echinocytes, Sickle cells, Target cells, Schistocytes

• Direct Antiglobulin test (Coomb’s test): +ve in IHA (2-5% false neg)

• Osmotic fragility test : HS (Osmotic gradient ektacytometry is more sensitve & specific, but not widely available)

• Tests for Heinz bodies (supravital staining): G6PD def, unstable Hb disease, thalassemias, chemicals. (Not seen when spleen is intact)

HAEMOLYTIC ANAEMIA: LABS

• Asso with anaemia & retculocytosis:

• Hemorrhage

• Recovery from iron, folate or vitamin B12 deficiency

• Recovery from marrow failure

• Asso with jaundice & anaemia:

• Ineffective erythropoiesis (intramedullary erythropoiesis)

• Bleeding into a body cavity or tissue

• Asso with jaundice without anaemia

• Defective bilirubin conjugation

• Crigler-Najjar syndrome

• Gilbert syndrome

• Marrow invasion

• Myoglobinuria

HAEMOLYTIC ANAEMIA: D/D

• Any case of anaemia requires a detailed work up starting with history.

• Stepwise approach is the golden rule.

• IDA in elderly – avoid being ‘Penny wise, Pound foolish’

• In tropical countries, tropical malabsorption syndromes are more rampant than we realize – LOOK OUT, it may be missed unless you look for it.

• Better not to start any IFA or B12 supplements until we diagnose the cause of anaemia.

• Bone marrow is not the answer to every anaemia – AVOID indiscriminate use.

• No cost is greater than the patient’s life. Investigate what’s mandatory.

• Delayed diagnosis is better than a wrong diagnosis – DO NOT hurry to treat.

CONCLUSION:

Health & Medicine

Anaemia evaluation