Anemias (Dept. of Pathology), Heamatology

All about anemias. Classification - morphologic, etiologic. Findings on peripheral smear. Microcytic hypochromic, macrocytic, hemolytic etc.

1. Anemi
as
- DR. URSHLLA KAUL
SR, PATHOLOGY

2. Blood
• Red Blood Cells (RBCs)
• White Blood Cells (WBCs)
• Platelets
• Plasma
• RBCs, WBCs, and Platelets Produced in Bone Marrow
• Approximately 5L of blood in adult

3. Red Blood Cells
• Carry Oxygen to Tissues
• Biconcave Disk Containing

Hemoglobin
• Life Span of 120 days
• 4.4-5.9 x 10
12
RBCs/L (M)
• 3.8-5.2 x 10
12
RBCs/L (F)

4. Hemoglobin
• Oxygen Carrying Molecule
• Tetramer of 2 alpha chains and two “beta” chains (
2 
2)
attached to Heme pocket
• Heme comprised of protoporphyrin ring and iron
• Normal range: 13-18 g/dl (M)
12-16 g/dl (F)

5. Anemia
• Definition - Reduction in Oxygen Carrying Capacity
of Blood
• Not enough production by Bone Marrow
• Too much peripheral destruction (hemolytic
anemia).

8. Reticulocyte

10. Iron deficiency anemia
• Nutritional deficiency of anemia
• The most common type of anemia
• Mostly seen in women
• 66.4% of women in India suffer from IDA

11. Clinical features in Iron
deficiency
 Easy fatigability
 Dyspnea on exertion
 Faintness/ Vertigo
 Pallor, hair loss
 Rapidly bounding pulse
 Dependent edema
 Systolic murmurs
 Special features in IDA:
◦Angular cheilitis, atrophic glossitis
◦Oesophageal atrophy/web  dysphagia
◦Koilonychia, brittle nails, gastric atrophy.

12. Etiology
Increased Need
Early childhood and adolescence (growth spurts)
Pregnancy (extra 3.8 mg/day over baseline)
Lactation
Poor Intake/Absorption
Milk baby
Achlorhydria
Inflammatory bowel disease

13. Etiology
BLOOD LOSS:
Menstruating women
GI bleeding (most common pathologic cause)
Tissue loss
Urinary Loss
Iatrogenic
 IRON DEFICIENCY IN A MALE ALWAYS NEEDS TO
BE WORKED UP!!!

14. IDA - Pathogenesis:
 Decreased Iron stores (Ferritin)
 Decreased Hb Synthesis
 Delayed maturation of erythroblasts
(cytoplasmic)
 Decreased cytoplasm, more division
(microcytes)
 Decreased Hb content (hypochromia)
 Anemia.

15. Lab investigations
CBC -  RBC Count, MCV, MCH ↓Hb
Iron studies - Low iron, high transferrin,  Serum Ferritin
Levels)
Peripheral smear - Hypochromic microcytic RBCs
Lack of stainable iron in BM

16. Microcytic Anemia (IDA)

18. Iron Deficiency Anemia

19. Prussian Blue Stain of Bone
Marrow
Iron Present No Iron Present

20. Anemia of Chronic disease
Normocytic anemia with impaired Fe utilization
Low Fe, low transferrin, High ferritin (Increased iron
stores)
High ESR
Causes:
Chronic infl: Rheumatoid arthritis, SLE
Chronic infections: TB, Chronic Osteomyelitis, HIV, CLD,
Kidney disease
Hodgkin’s and Non-Hodgkin’s lymphoma

21. Megaloblastic Anemia
Vitamin B12/Folic acid deficiency
Second most common type of anemia.
Multi System disease – All organs with increased cell division.
Macrocytic anemia, pancytopenia.
B12 binds with intrinsic factor, absorbed in terminal ileum
Schilling test
7-12 year supply
 Folate is not stored in body

22. Megaloblastic anemia - Etiology
Malnutrition
Intrinsic factor Ab - Pernicious anemia
Gastrectomy, Ileal resection
Inflammatory bowel disease
Malabsorption syndromes - Sprue
Blind loop syndrome

23. Pathogenesis
Decreased Vit B12 / Folate
Impaired DNA Synthesis
Delayed Nuclear maturation of erythroblasts
Increased cell size (Macrocytes)
Normal Hb content (Normochromia)
Decreased RBC number
Decreased WBC number (Leucopenia)
Anemia & Pancytopenia.

24. Clinical features
Fatigue, generalised weakness
Dizziness
Tingling in hands and feet (Peripheral neuropathy)
Neurologic symptoms (dorsal columns) – loss of memory,
gait abnormalities
Reduced appetite
Muscle weakness
Visual disturbances

25. Lab investigations:
CBC – low Hb, RBC count, High MCV
PS - Macrocytic anemia with hypersegmented
neutrophils
S. Vit B12, folate levels - Reduced
BMA - Nuclear/cytoplasmic asynchrony in BM
Schilling test
Ineffective erythropoiesis
High indirect bilirubin
Very high LDH

26. Macrocytic Anemia (Meg.):
CBC

28. Megaloblastic Anemia

29. Schilling Test

30. HEMOLYTIC ANEMIAS

31. Sickle Cell Anemia
Inherited disease – HbS, RBCs look sickle like
Sickle cell disease (SS) – homozygous
Sickle cell trait (AS) – heterozygous
Autosomal recessive - hemoglobinopathy
Symptomatic at 6 months
Irreversible sickling upon deoxygenation
pain crises (Sickle cell crisis)
infarcts of spleen (asplenia), kidneys, brain
Hemolytic vs. Aplastic crisis (Parvovirus B19)

32. Inheritance

35. Sickle Cell Anemia

36. Thalassemia
 Imbalance of globin chain production
 - vs. -thalassemia, Major – disease (homo), Minor – trait (hetero)
 Anemia due to both decreased production and increased
hemolysis in spleen
 - thalassemia has decreased/absent Hgb A, increased
Hgb F, and increased Hgb A
2
Treatment - Blood transfusion with chelation,
splenectomy, bone marrow transplantation

Thal major patients live max till 25-30 years of age.

38. Hereditary Spherocytosis
Defect of spectrin-Protein 4.1 interaction or in
ankyrin
decreased deformability
sluggish transversing of splenic cords
Clinical triad of anemia, splenomegaly, and jaundice
Spherocytes on smear
Osmotic fragility test

39. Hereditary Spherocytosis

40. Enzyme Deficiencies
G6PD
Pyruvate Kinase

41. Autoimmune Hemolytic
Anemia
Antibody attaching to RBCs
Direct or indirect Coombs test
May be associated with thrombocytopenia (Evan’s
syndrome)
Idiopathic, drugs, infection
Treatment
Treat underlying cause
Steroids

42. Autoimmune Hemolytic
Anemia

43. Laboratory Evidence of
Hemolysis
Increased Bilirubin
Low serum haptoglobin
Hemoglobinemia/ Hemoglobinuria
Hemosiderinuria
Increased LDH
Increased Reticulocyte count

44. Combination of History and Smear
24 year old student
with spiking fevers
every day
Recently returned
from trip to Africa