APPROACH TO ANEMIA

ANEMIA

Defined as quantitative reduction in hemoglobin or erythrocytes or both below the level that is expected for healthy person of same age and sex in the same environment.

LEVELS

Adult male Adult female Adult female

(Pregnant) >6-12 yr 6m- 6yr 2- 6m Newborn

<13 <12 <11 <11.5 <11 <9.5 <13.6

CLASSIFICATION OF ANEMIA

APPROACH TO DX

Severity Cause

PRESENCE OF ANEMIA

HEMOGLOBIN ESTIMATION PCV ESTIMATION Colorimetric method Gasometric method Chemical method Specific gravity method

Wintrobe method Microhematocrit method

HISTORY IN A CASE OF ANEMIA

Clinical evaluation Symptoms

Fatigability Effort dyspnoea Palpitation

Signs Pallor

Chronic blood loss Pregnancy Pica Chronic alcoholism History of

malabsorption Drugs

Hypoplastic Megaloblastic IDA HA

CONT….

Primary underlying disease CVD Mlg Chronic infection AIDS ESLD ESRD Endocrine ds

Geographic Area

LABORATORY EVALUATION

Initial investigations Peripheral blood smear Reticulocyte count Red cell indices

Specialized investigations BM exam Serum iron Hemoglobin electrophoresis

PERIPHERAL BLOOD SMEAR

PERIPHERAL BLOOD SMEAR

Head Body Tail

HOW TO ASSESS THE SIZE OF RBC IN PBS By comparing the size with the

small lymphocyte

NORMOCYTIC NORMOCHROMIC

ANISOCYTOSIS

POIKILOCYTOSIS

MICROCYTIC HYPOCHROMIC

MACROCYTOSIS

Oval Round

SICKLE CELLS

SPHEROCYTES

TARGET CELLS/CODOCYTES

SCHISTOCYTES

BURR CELLS

TEAR DROP CELL

BASOPHILIC STIPPLING

HOWELL JOLLY BODY

POLYCHROMATIA

RETICULOCYTE COUNT

RETICULOCYTE COUNT

Young red cell that contain RNA element

Stains with supravital stain Brilliant cresyl blue New methylene blue

Assess erythropoietic activity of the bone marrow

RETICULOCYTE… SUPRAVITAL STAIN

RETICULOCYTE MEASURES

Reticulocyte count ( % ) 0.5 to 2.5 in adult 2 to 5 in newborn

Corrected reticulocyte count RC x PCV pt / PCV normal

Absolute reticulocyte count RC x RBC count

Reticulocyte production index

RETICULOCYTOSIS RETICULOCYTOPENIA Acute blood loss Hemolytic anaemia Response to specific

therapy in nutritional anemia

Decreased red cell production Aplastic anemia Myelopthisic anemia IDA ACD

Ineffective erythropoiesis Megaloblastic MDS

RED CELL INDICES

aka … ABSOLUTE VALUES

MCV MCH MCHC

MEASURED IN …AUTOMATED HEMATOANALYSER

MCV

in femtoliters (fl) Average volume of a single cell PCV x 10 / RBC count

RDW Mentzer index

MCH

Picogram (pg) Average amount of Hb per cell Hb x 10 / RBC count Low in microcytic High in macrocytic

MCHC

Gm/dl Average amount of HB in a given

amount of RBC Hb x 100 /PCV Low in microcytic hypochromic High in HS

RDW

Degree of variation of red cell size

RDW HELPS TO DIFFERENTIATE

IDA Β THALASSEMIA MINOR Low MCV Low MCH Low MCHC

High RDW

Low MCV Low MCH Normal MCHC

Low RDW Target cell Basophilic stippling

3 MAJOR TYPES OF ANEMIA…

CASE 1

35 yr F Strict vegetarian Weakness, paresthesias, muscle

weakness, or difficulty in walking, glossitis

She had a child with NTD

BLOOD PARAMETER

Hb 8.7gm/dl TLC 3800/cmm PLT 98000/L

ABSOLUTE VALUES

MCV 116 ___ (tell the units) MCH 33 ___ MCHC 32 ___

RETICULOCYTE COUNT

Low

?

MACROCYTIC ANEMIA

CAUSES

Oval Megaloblastic

anemia Drug therapy MDS

Round Alcoholism Liver disease Hypothyroidism

WHAT ELSE CAN BE IN PBS

Hyper segmented neutrophil Howell- jolly body Cabot’s ring

BM EXAMINATION

Ineffective erythropoiesis Megaloblastic change in all series Giant band forms Giant metamyelocytes

OTHER CAUSES OF MACROCYTOSIS…HOW TO RULE THEM OUT

Hemolytic anaemia Features of hemolysis in addition with

macrocytosis Liver disease

Target cell will be in the smear Myelodysplastic syndrome

Elderly patients Bi/ Pancytopenia BM exam- ALIP ( abnormal localization of

immature precursor)

…CONT..

Pregnancy Newborn Cytotoxic chemotherapy Aplastic anaemia

MICROCYTIC HYPOCHROMIC ANAEMIA

CAUSES

Iron deficiency anaemia Thalassemia syndrome Anaemia of chronic diseases Sideroblastic anaemia

MICROCYTIC HYPOCHROMIC EVALUATION

NORMOCYTIC NORMOCHROMIC ANAEMIA

NORMOCYTIC NORMOCHROMIC EVALUATION

EVALUATION OF HEMOLYSIS

Within circulation Blackwater fever,

mismatch blood transfusion, PNH

Spleen normal Plsama Hb%

markedly increased Hb in urine + Hemosiderin in

urine+

Within RES Hb-pathies,

Hereditary haemolytic anaemia, AIHA

Size increased Mild increased Absent Absent Negative

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