Anemia, Microcytic Hypochromic and Macrocytic anemia

Dr. Mehdi Ashik Chowdhury
M.B.B.S. MD. (BSMMU)
Assistant Professor &
Head of the Department of Pathology
Tairunnessa Memorial Medical College

1. Anemia , its classification,
Microcytic Hypochromic and
Macrocytic anemia
Dr. Mehdi Ashik Chowdhury
M.B.B.S. MD. (BSMMU)
Assistant Professor &
Head of the Department of Pathology
Tairunnessa Memorial Medical College

19. Deficiency anaemia
Iron deficiency anaemia

27. Cause of Iron deficiency anaemia
•A) Increased physiological demand
1) During period of growth of children.
2) During reproductive life of female-
Menstruation, Pregnancy, Parturation, lactation.
•B) Nutritional deficiency : Deficient diet.
•C) Pathological blood loss : Adult male and
Postmenopausal female
D) Impaired absorption : Coeliac disease, Tropical
sprue.

28. Total body iron content is about 3 to 5 gram. The
distribution of body iron is as follows :
Haemoglobin 2.3 gm.
Storage (available) tissue 1.0 gm.
iron (Ferritin and haemosiderin)
Essential (Non-available) tissue 0.5 gm.
Iron (myoglobin and enzyme of
Cellular respiration)
Plasma (transport) iron 3-5 mg
Total 3.8 gm.

29. •Clinical feature of Iron deficiency anaemia:
•Symptoms :
•Fatigue and weakness, Dyspnoea on exertion,
Palpitation, Headache.
In older subject Angina pectoris and
symptoms of cardiac failure.
Signs :
Pallor of mucous membrane and conjunctiva.
Tachycardia, systolic flow murmur.
Koilonychia (Brittle, spoon shaped nail)
Plummer-vinson syndrome : Glossitis, Dysphagia
due to constriction at the entrance of oesophagus and
chronic iron deficiency.

30. Diagnosis of Iron deficiency anaemia
•Hb% : Reduced
•MCV, MCH and MCHC all are reduced.
•Blood film :
•RBC : Microcytic hypochromic with
anisopoikilocytosis including a few eliptical cells and
pencil form cells with occasional target cell.
•WBC : Mature with normal count and distribution.
•Platelets are adequate in number with normal
morphology.
•Comment : Microcytic hypochromic anaemia
suggestive of iron deficiency anaemia.

31. Microcytic hypochromic anaemia

32. Biochemical test
Serum iron profile :
Serum iron : Reduced
Serum ferritin : Reduced
Total iron binding capacity : Increased
Percentage saturation of iron binding protein :Decreased
Red cell protoporphyrin level is increased.
Protoporphyrin accumulate in the free form as there is
insufficient iron to bind with it to form haem.

33. Bone marrow examination.
•Bone marrow examination is not needed in iron deficiency
anaemia unless there is unusual difficulties in the
differentiation of iron deficiency anaemia from other cause of
hypochromic anaemia. If it is done the marrow picuture will be
as follows :
•Cellularity : Hypercellular.
•Myeloid erythroid ratio : Reduced
•Erythropoiesis : Hyperplastic and micronormoblastic.
•Granulopoiesis : Active and maturing to segmented form.
•Megakaryocytes are normal in number and morphology.
•Lymphocytes and plasma cells are normal in number and
morphology.
•Perl’s prussian blue stain: No stainable iron.

34. •Causes of microcytic hypochromic anaemia:
•Iron deficiency anaemia
•Thalassaemia
•Anaemia of chronic disease.
•Sideroblastic anaemia.
•Lead poisoning.

35. Anemia of Chronic Disease
•EPO production inadequate for the degree
of anemia observed or erythroid marrow
responds inadequately to stimulation
•Causes: inflammation, infection, tissue
injury, cancer
•Low serum iron, increased red cell
porphyrin, transferrin 15-20%, normal to
increased ferritin

36. Pathophysiology

37. AICD vs. Iron Deficiency
•TIBC: elevated in cases of iron deficiency
•Ferritin: elevated in anemia of chronic
disease
•If all else fails, Bone Marrow Biopsy
–In anemia of chronic disease: macrophages
contain normal/ increased iron & erythroid
precursors show decreased/absent amounts
of iron

38. Treatment
•Treat the underlying cause
•Treat the underlying cause
•And Treat the Underlying Cause!
•Consider co-existent iron deficiency as
well
•If underlying disease state requires it,
consider EPO injection

39. Iron
deficieny
anaemia
Anaemia
of chronic
Diasease
Thalassa-
emiatrait.
Siderobl-
astic
anaemia
MCV
MCH
Reduced
in relation
with sev-
erity of
anaemia
Normal or
mild
reduction
Reduced;
very low
for degree
of
anaemia.
Usually
low but
may be
high*
Serum
iron
ReducedReducedNormalRaised
TIBC RaisedReduced**NormalNormal

40. *Normal in congenital type but MCV often raised in
acquired type. **
Iron
deficieny
anaemia
Anaemia
of chronic
Diasease
Thalassa-
emia trait.
Siderobl-
astic
anaemia
Serum
transferin
receptor
RaisedNormal/
Low
VariableNormal
Serum
ferritin
ReducedNormal
or raised
NormalRaised
Bone
marrow
iron stores
AbsentPresentPresentPresent

41. Iron
deficieny
anaemia
Anaemia
of chronic
Diasease
Thalassa-
emia trait.
Siderobl-
astic
anaemia
Erythrob-
last iron
AbsentAbsentPresentRing
form
Haemogl-
obin Elect-
rophoresis
NormalNormalHbA
2
raised in
βform.
Raised

42. •A characteristic finding of ACD (Anaemia of chronic disease) is low serum
iron with adequate reticuloendothelial iron but with reduction of iron in
marrow erythroblast. The fall in serum iron results from impaired flow of
iron from cells (Including intestinal mucosal cells, hepatocytes and
macrophages ) to plasma. The inflammatory cytokines TNF, IL-1 and IFN-γ
all have shown to cause reduced serum iron and increased serum ferritin.
Increased lactoferrin , occuring in response to inflammatory cytokines
competes with transferrin for iron and form a complex, which is taken up by
macrophages in liver and spleen. Increased intracellular apoferritin synthesis
occurs in response to inflammation and malignancy and this too also bind iron.
All of these mechanism reduce the amount of available iron for binding to
serum transferrin and thus serum iron is reduced.
•** A rise in serum ferritin and fall in serum transferrin occur as part of
acute phase response.
•*MCV and MCH are low in congenital sideroblastic anaemia but they are
higher in acquired sideroblastic anaemia.
•In iron deficiency anaemia microcytosis appear first then hypochromia
•In anaemia of chronic disorder hypochromia appear first and then microcytosis.
In anaemia of chronic disorder haemoglobin seldom become lower than
9 gm /dl, In iron deficiency anaemia haemoglobin may be much lower.

43. •Irondeficiency:Theearliestchangesinirondeficiencyareafallinbone
marrowironandaconcomitantfallinserumferritin.Thisisfollowedbya
fallinserumferritinandriseinRBCfreeerythrocyteprotoporphyrin.The
MCVthenfallsandfinallyHbfallswithhypochromiaofredcells.
•Leadpoisoning:Microcytosismaybeseeninleadpoisoningbutisnot
uniformlypresent,whileariseinfreeerythrocyteprotoporphyrinisalmost
invariablypresent.Freeerythrocyteprotoporphyrintendstobemuch
higherinleadpoisoningthaninirondeficiencyanaemia.
•ThalassemiaMinor:AlowMCVisthehallmarkofthalassemiaminor
andtheMCVmaybeusedasascreeningtestinthedetectionofbeta
thalassemiaminor.Averysimplecalculationmaybeusedtodistinguish
irondeficiencyandleadpoisoningfromthalassemiaminor.Thetestis
doneonMCVandRBCcount.IfMCVisdividedbyRBCcount,a
discriminateindexisobtained:
•MCV/RBCif<12=Thalassaemiaminor
•MCV/RBCif>14=Irondeficiencyorleadpoisoning.

44. •Pathogenesis of iron deficiency anaemia :
•Three pathogenetic factor are implicated in iron deficiency anaemia.
•The first is reduced haemoglobin synthesis.
•The second is generalized defect in cellular proliferation.
•The third is reduced RBC survival especially in severe iron deficiency.
So in severe iron deficiency fragmented RBC may be seen in peripheral
blood,
•When transferrin saturation falls below 16% , the supply of iron to the
marrow is inadequate to meet the basal requirement of haemoglobin
synthesis. The synthesis of heam is reduced and there is accumulation of
more free protoporphyrin. Each cell produced less haemoglobin, resulting
in microcytosis and hypochromia.
•Cellular proliferation is restricted in iron deficiency and red cell count
falls. Although there is relative erythroid hyperplasia in the bone marrow ,
both the degree of erythroid hyperplasia and the reticulocyte count are
low for the degree of anaemia. There is significant component of
“ineffective erythropoiesis” in iron deficiency and a proportion of
immature erythroid cells are so defective that they are rapidly destroyed.

45. •Inirondeficiency,survivalofcirculatingerythrocyteisnormalor
somewhatreduced.Thereisstrongcorrelationbetweenthedegreeto
whichredcellsurvivalisshortenedandtheproportionofmorphologically
abnormalcells.
•Withhaemorrhagicanaemia,incontrasttohaemolyticanaemia,therate
ofredcellproductionmayberestrictedbytheavailabilityofiron,evenin
theabsenceofirondeficiency.Ironmustbedrawnfromferritinand
haemosiderinstoredinmacrophages,aslowprocesscomparedto
mobilizationofironfromdestroyedredcells.Marrowproductionafter
hemorrhagemaybelimitedtoapproximatelythreetimesthenormal
level,comparedwithfiveoreventimesthenormallevelinchronic
haemolyticstates.Ifthereisconcurrentinflammation,ironsupplymay
alsofurtherrestricted.

46. Pathogenesis of anaemia of chronic
disease.
•A mild decrease of red cell lifespan occurs in ACD, but it is at a level that
could be compensated by a normal marrow. The major cause of ACD is
disturbance of erythropoiesis due to reduced sensitivity to physiological
erythropoietic activity, relative lack of erythropoietin and reduced iron
utilization.
•Relative lack of erythropoietin : Normally with reduction of
haemoglobin there is increase of erythropoietin. In ACD there is also
increase in erythropoietin but the increase is relatively low compared
with other type of anaemia.
•Inhibition of erythropoiesis :TNF and IL-1 may cause inhibition of
erythropoiesis.

47. •Reduced Iron Utilisation :
•A characteristic finding of ACD (Anaemia of chronic disease) is low
serum iron with adequate reticuloendothelial iron but with reduction of
iron in marrow erythroblast. The fall in serum iron results from
impaired flow of iron from cells (Including intestinal mucosal cells,
hepatocytes and macrophages ) to plasma. The inflammatory cytokines
TNF, IL-1 and IFN-γall have shown to cause reduced serum iron and
increased serum ferritin. Increased lactoferrin , occuring in response to
inflammatory cytokines competes with transferrin for iron and form a
complex, which is taken up by macrophages in liver and spleen. Increased
intracellular apoferritin synthesis occurs in response to inflammation and
malignancy and this too also bind iron. All of these mechanism reduce the
amount of available iron for binding to serum transferrin and thus serum
iron is reduced.

48. Deficiency Anaemia
Megaloblastic anaemia

49. •Megaloblastic anemiais an anemiathat results
from inhibition of DNA synthesisin red blood cell
production. When DNA synthesis is impaired, the
cell cyclecannot progress from the G2 growth stage
to the mitosis (M) stage. The cells have a prolonged
intermitotic resting phase and a block early in mitosis.
This leads to continuing cell growth without division,
which presents as macrocytosis. Cytoplasmic
maturation and growth continue accounting for
enlargement of cytoplasm as well as nucleus of cells.
Due to block early in mitosis there is also increased
number of mitotic figure. Nuclear chromatin is open,
delicate and stippled ( Granular chromatin or salt and
pepper chromatin). Stippled nuclei can be observed
even in the orthochromatic stage. There is increased
number of promegaloblast and basophilic megaloblast
in the bone marrow than in normal erythropoiesis.
This has termed as maturation arrest.

50. •Megaloblastic anaemia are anaemia resulting from
impaired DNA synthesis characterized by presence
of megaloblast in the bone marrow and macrocyte
(macro-ovalocyte) in the peripheral blood. They
usually result from deficiency of Vitamin B
12and
folic acid.

51. Causes of megaloblastic anaemia due to vitamin B12
deficiency :
1)Decreased intake : Nutritional deficiency
2)Impaired absorption
Gastric cause : Pernicious anaemia
Gastrectomy
3)Intestinal cause : Coeliac disease
Tropical sprue
Fish tapeworm infestation

52. Clinical manifestation of megaloblastic anaemia due
to vitamin B12 deficiency :
1)Sign symptoms of anaemia
2)Glossitis.
3)Peripheral neuropathy and subacute combined
degeneration of spinal cord.
Neurological manifestation occur more frequently in
pernicious anaemia than other cause of vitamin B12
deficiency.

53. Megaloblastic anaemia due to folate deficiency :
1)Decreased intake : Nutritional deficiency
2)Impaired absorption : Coeliac disease
Tropical sprue
3) Increased demand : Pregnancy
Haemolytic anaemia
Myeloproliferative disorder.
Leukaemia and lymphoma
Inflammatory disorder.
Hyperthyroidism.
4) Drugs : Anticonvulsant drugs
Oral contraceptive
Methotrexate, Trimethoprim.

54. Clinical manifestation of megaloblastic anaemia due
to folate deficiency :
•1) Symptoms and signs of anaemia.
•2) Glossitis.

55. Diagnosis of megaloblastic anaemia
•Blood picture :
•Hb : Reduced.
•MCV : Increased. Commonly 110 to 140 fl.
•MCHC : Normal
•MCH : Increased.
•Blood film : Macrocytic RBC many of which are
macro-ovalocyte. WBC count may be reduced with
increased number of hypersegmented neutrophil
(Five or more lobes). Platelets are normal or reduced.

57. •Bone marrow examination :
•Cellularity :Hypercellular.
•Myeloiderythroidratio:Reduced.
•Erythropoiesis:Hyperactiveand megaloblastic.
Megaloblasticchangesareseenatallstagesofdevelopment.
Megaloblastsarelargerthanerythroblastwithanincreasein
cytoplasmandnuclearsize.Thechromatinismoreopen
beingarrangedinfinereticularfashiontogiveastippled
appearance.Thepredominantcellsarepromegaloblastand
basophilicmegaloblastindicatingmaturationarrest.
•Granulopoiesis:Granulopoiesisisactiveandshowgiant
metamyelocyte.
•Megakaryocytesareusuallynormal.
•Lymphocytesandplasmacellsarenormal.

58. •Biochemical test : Serum Vitamin B12 and
serum and red cell folate assay.
•Pernicious Anaemia : Pernicious anaemia are
vitamin-B12 deficiency anaemia caused by
lack of intrinsic factor resulting from atrophic
gastritis.
•Blood and bone marrow picture are similar to
above.
•The schilling test is done to diagnose
pernicious anaemia.

59. •Causes of Macrocytosis :
•Macrocytosis with megaloblastic bone
marrow:
•Vitamin B12 deficiency
•Folic acid deficiency.
•Macrocytosis with normoblastic or
macronormoblastic bone marrow:
•Macrocytosis common :
•Haemolytic anaemia
•Posthaemorrhagic anaemia.

60. •Macrocytosis Occasional :
•Alcoholism
•Liver disease
•Aplastic anaemia
•Sideroblastic anaemia.
•Myelodysplastic syndrome.
•Scurvy
•Hypothyroidism.

61. •Macronormoblastarelargenormoblasti.ecellsthatarelarger
thantheirnormalcounterpartofasimilarstageofdevelopment,
whichtheyresembleinallotherrespect,includingtheirnuclear
structure.Megaloblasthavemorecytoplasmwithrespectto
macronormoblastandtheirnucleushavefinereticular
chromatinthantheirnormalcounterpartmacronormoblast.In
megaloblastnuclearmaturationlagbehindthancytoplasmic
maturation.Thereisdelayinintermitoticphasein
megaloblasticerythropoiesisbutinmacronormoblastic
erythropoiesisthereissuchrapidmitosisthattheremaybeskip
mitosisinanystageofmacronormoblasticdevelopmentwhich
maygiverisetogianterythrocyte.
•Megaloblasticanaemiaalsoseeninconditionwherethereis
retardedDNAsynthesis.Suchconditionareseeninneoplastic
disorderofhaematopoieticstemcellwherethereisDNA
mutationinstemcellwhichgiverisetobothmyeloidand
erythroidseries.Suchdisorderincludeerythroleukaemiaand
myelodysplasticsyndrome.

62. •So macrocytic anaemia can be seen in following condition :
•1) Condition associated with megaloblatic erythropoiesis :
Such as : Vitamin B12 or folate deficiency.
Erythroleukaemia.
Myelodysplastic syndrome.
2) Condition associated with macronormoblastic erythropoiesis without
increase of reticuloyte count :
Liver disease, Aplastic anaemia.
Due to direct toxic effect Alchohol.
Sometimes in Hypothyroidism
3) Condition associated with macronormoblastic erythropoiesis with increase
reticulocyte count:
Posthaemorrhagic anaemia
Haemolytic anaemia.
This condition also known as stress erythropoiesis. In this condition high
level of erythropoietin are released. High level of erythropoietin may cause
macronormoblastic erythropoisis with increase production of reticulocyte
and other young red cell. There may be skip mitosis which may cause
formation of giant RBC.