4_584165419403287358888888888888555562.ppt

Anemia

1. Approach to Anemia -
Summary

2. Approach to Anemia –Case 1
•37 year old female patient of Caucasian origin
referred to the Emergency Room because of anemia
•Medical background: generally healthy, normal
diet; during the last week treated with an antibiotic
because of suspected pharyngitis
•Complains of weakness and low-grade fever

3. Approach to Anemia –Case 1
On examination: pallor, slight jaundice; spleen
mildly enlarged, soft, tender
No lymphadenopathy, no bleeding tendency,
no glossitis
Pulse 100, regular, blood pressure and oxygen
saturation normal

4. Approach to Anemia –Case 1
Laboratory evaluation -Set I:
-Hemoglobin –7.9 gr%
-MCV –100
-RDW –17
-WBC –normal
-Platelets -normal

5. Approach to Anemia –Case 1
Interpretation: macrocyticanemia
Differential diagnosis:
-Megaloblastic anemia
-Hemolytic anemia
-Myelodysplastic syndrome/Aplastic anemia
-Other

6. Approach to Anemia –Case 1
Laboratory evaluation -Set II:
-Reticulocytes –14%
-Corrected reticulocyte count:
/%Retics X (measured to the expected Hb ratio)/
14% x 7.9/15 = 7.4%
-Reticulocyte Production Index (RPI):
/Corrected reticulocyte count/shift correction factor/
7.4 / 2 = 3.7(>2)

7. Approach to Anemia –Case 1
Interpretation: hyperproliferative anemia
Differential diagnosis:
-Megaloblastic anemia? No
-Myelodysplastic syndrome/Aplastic anemia?
No
-Hemolytic anemia? Yes

8. Approach to Anemia –Case 1
Laboratory evaluation -Set III:
-LDH –high
-Bilirubin –high (unconjugated)
-Haptoglobin –low
Diagnosis confirmed: Hemolytic anemia

9. Approach to Anemia –Case 1
Hemolytic anemia –differential diagnosis:
-Intra-corpuscular(hemoglobinopathy,
enzymopathy)
-Red cell membrane(cytoskeleton, PNH,
spur cell anemia)
-Extra-corpuscular(hypersplenism, mechanic
hemolysis, immune hemolysis, toxic/infectious
agents)

10. Approach to Anemia –Case 1
Laboratory evaluation -Set IV:
Blood smear
-Anisocytosis(high RDW)
-Polychromasia(reticulocytosis)
-Spherocytes? -Ellyptocytes?
-Bite cells? -Spur cells?
-Schistocytes?-Sickle cells?

12. Approach to Anemia –Case 1
Laboratory evaluation –Set V:
-Direct anti-globulin (Coombs) test –IgG +3

13. Approach to Anemia –Case 1
Summary:
-Mild splenomegaly, fever, jaundice
-Macrocytic anemia
-Reticulocytosis
-Spherocytosis
-Positive direct anti-globulin test
Warm-type immune hemolytic anemia, possibly
–drug related

14. An approach to anemia is based on asking 3
main questions:
1. MCV?
2.Reticulocyte count? (Bone marrow function)
3. Involvement of additional lineages?
Approach to Anemia

15. Approach to Anemia
MCV:
-Low: Iron deficiency
Thalassemia trait
Chronic disease
Sideroblastic anemia
-Normal: Iron deficiency (early)
Chronic disease
Renal failure

16. Approach to Anemia
-High: Megaloblastic anemia
Hemolytic anemia
MDS / Aplastic anemia
Drug-related
Hypothyroidism
Alcoholism
Liver disease

17. Approach to Anemia
Reticulocyte count:
-Adequte(RPI>2): Hemolytic anemias (most)
Acute blood loss
Liver disease
-Inadequate(RPI<2): Iron deficiency
Megaloblastic anemia
Anemia of chronic disease
Bone marrow failure
(malignancy, chemotherapy,
MDS/Aplastic anemia)

18. Approach to Anemia
Additional lineage(s) involvement:
-Leukopenia: Malignancy
Chemotherapy
Hypersplenism
Drug-related
Megaloblastic anemia
Aplastic anemia

19. Approach to Anemia
-Thrombocytopenia: Malignancy
Chemotherapy
Hypersplenism
Drug-related
Megaloblastic anemia
Aplastic anemia
TTP
DIC

20. Approach to Anemia
In addition, blood smearalways needs to be
carefully assessed:
Schistocytes? Spherocytes?
Target cells? Normoblasts?
Spur cells (acanthocytes)? Burr cells?
Malignant cells (leukemia, lymphoma)?
Malaria parasites? Sickle forms?

21. Anemia With Low MCV and Low
Reticulocytes
Iron deficiency
Hereditary defects in hemoglobin synthesis
(thalassemia trait)
Defects in heme synthsis (sideroblastic anemia)
Anemia of chronic disease

22. Anemia With Normal MCV and Low
Reticulocytes
Early or mild iron deficiency anemia
Chemotherapy
Anemia of chronic disease
Anemia of renal failure

23. Anemia with High MCV and Low
Reticulocytes
Megaloblastic anemia
Myelodysplastic syndrome / Aplastic anemia
Drug-related anemia
Hypothyroidism
Alcoholism

24. Anemia with High Reticulocytes
Low MCV:
-Thalassemia Major (some cases)
-Spherocytosis
High MCV:
-Sickle cell anemia
-G-6PD deficiency
-Immune hemolytic anemia
-Malaria infection

25. Anemia with Leukopenia and/or
Thrombocytopenia
Low reticulocytes:
-Aplastic anemia/Myelodysplastic syndrome
-Chemotherapy
-Alcoholism
-Megaloblastic anemia
High reticulocytes:
-TTP / DIC
-Hypersplenism

26. Approach to Anemia –Case 2
63 year old male patient presented to your clinic
with weakness and anemia; generally healthy,
no permanent medications.
On examination: afebrile, normal pulse and
blood pressure. No hepatosplenomegaly and
lymphadenopathy. Scattered purpura over
lower extremities and chest.

27. Approach to Anemia –Case 2
Laboratory evaluation -Set I:

28. Approach to Anemia –Case 2
Interpretation: macrocyticanemiawith
thrombocytopenia
Differential diagnosis:

29. Approach to Anemia –Case 2
Laboratory evaluation -Set II:

30. Interpretation: High MCV, Low RPI
Differential Diagnosis:
Megaloblastic anemia
Myelodysplastic syndrome
Aplastic anemia
Drug-related
Alcoholism

31. Approach to Anemia –Case 2
Laboratory evaluation -Set III:
-B12 and Folate levels
Thorough history taking: alcohol? medications?

32. Approach to Anemia –Case 2
Laboratory evaluation -Set IV:

34. Approach to Anemia –Case 2
Laboratory evaluation -Set V:

36. Ringed
Sideroblast
Iron

37. Approach to Anemia –Case 2
Summary:
-Macrocytic anemia
-Thrombocytopenia
-Low RPI
-Dysplastic maturation (peripheral smear,
bone marrow)
-Normal B12 and Folate levels
Myelodysplastic syndrome

38. Table 29-05
Copyright ©2005 Elsevier Inc. (USA) All rights reserved.