Approach To A Patient With Anemia

1. Approach To A Patient With Anemia Dr. Mohammad Usman Shaikh Assistant Professor, Aga Khan University Hospital.

2. Hematology Study of blood forming tissue and circulating blood component Clotting factors Blood groups CBC and smear examination regardless of specialty Accessible, close proximity to tissues, often provide some information Important for accurate diagnosis and therapeutics choices

3. Manual Versus Automation Feasibility: Workload: Depend on number of samples per day Less than 20 samples, prefer manual method Tertiary care hospital setting in western hospitals, CBC is mandatory for consultation. Rapid analysis Require only an appropriate blood sample. Measure 8-25 variables, no equivalent manually.

4. Principles of Automation Electrical Impedance Light scattering

5. Electrical Impedance Detection & measurement of changes in electrical resistance produced by cells as they passes via a small aperture Electrical resistance between two electrodes, or impedance in current leads to the formation of pulses

6. A stream of cells passes through aperture across which electrical current is applied. Each cell that passes alters electrical impedance and can thus be counted and sized. Good Pulse Diluent stream

7. Sensing Zone Red Blood Cells Electrical Impedance Oscilloscope Oscilloscope Each time a cell passes a pulse is produced. The pulse height is proportional to Cell volume Animation by M.A.Ghauri

8. Light Scattering O-3 deg (relative size) Light Scatter estimates relative cell size based on forward scatter - that is a measurement of cross-sectional diameter Laser

9. Hemogram/ Histogram Visual representation of what was counted at the aperture. Verify a count that has a typical pattern according to the reference ranges Alert for possible interfering particles and abnormalities

10. Hematological Variables on Automation RBC Hb, HCT, MCV, MCH, MCHC, RBC count, RDW WBC Total count, differential and absolute count Platelet Total count Others: Nucleated RBC, reticulocyte count flags

11. Anemia Definition: low Hemoglobin and hematocrit Results from a wide variety of disorders

12. Anemia Laboratory data is more informative when considered in the context of history and physical examination

13. Approach to Anemia History: Family history – inherited causes such as thalassemia, sickle cell anemia, G6PD deficiency and hereditary spherocytosis. In most of these cases morphological findings of smear are diagnostic B symptoms Systemic or other chronic disorders

14. History Drug history: History of blood loss Clinically: Degree of pallor, with or without icterus, angular stomatitis and glossitis, koilonychia, lymphadenophathy and hepatoslenomegaly

15. Koilonychia Physical Examination: helps to direct the clinician to the cause of anemia Iron deficiency : koilonychia, glossitis, angular stomatitis.

16. Glossitis B12 deficiency : decrease vibration and postural sense Folate deficiency : glossitis, sign of malabsorption, alcohol abuse and pregnancy

17. Angular stomatitis Angular stomatitis: non specific, can be seen in iron deficiency, B12 and folate deficiency

18. Lymphadenophathy Bone marrow failure /i nfiltration : fever, Petechiae, lymphadenophathy, splenomegaly and sternal tenderness

19. Splenomegaly Bone marrow failure /i nfiltration : splenomegaly

20. Normal RBC

21. Normal RBC

22. WBC Morphology

23. Classification of Anemia on the Basis of MCV Less than 76fl --- microcytic Iron deficiency Thalassemia Anemia of chronic disease Sideroblastic anemia and lead poisoning MCV between 76 to 96 fl Anemia of chronic disease Acute blood loss Chronic renal failure Anemia due to infiltration Aplastic anemia

24. Classification of Anemia on the Basis of MCV MCV more than 96fl Macrocytic anemia Megaloblastic : B12 and folate deficiency Non megaloblastic : Hemolysis MDS Hypothyroidism Liver disease

25. Etiological Classification of Anemia: Increase destruction 1-Hemolytic anemia inherited and acquired Impaired Production 2-Anemia due to bone marrow failure states 3-Nutritional deficiencies 4-Anemia due to infiltrative disorders 5-Anemia of chronic disorders

26. Hemoglobin: 3.5 gm/dl HCT: 12% MCV: 57 fl MCH: 18 pg TLC: 22,000 Platelets: 155,000

27. Hemoglobin: 4.5 gm/dl HCT: 14% MCV: 56 fl MCH: 20 pg TLC: 6,000 Platelets: 600,000

28. NORMOCYTIC NORMOCHROMIC ANEMIA MCV between 76 to 96 fl Anemia of chronic disease Acute blood loss Chronic renal failure Anemia due to infiltration Aplastic anemia

29. Hemoglobin: 8 gm/dl HCT: 25% MCV: 84 fl MCH: 27 pg TLC: 5000 Platelets: 205,000

30. Sickle Cell

31. Sickle Cell Disease Rare in Pakistan (Balochistan), common in Middle East, and up to 40% trait in Central Africa Qualitative globin chain defect; Homozygous inheritance Deoxy Hb S--- tendency to aggregate--- sickle cell Increase blood viscosity --- vascular stasis---tissue damage + RBC membrane damage Sickling depend on Hb S concentration Hb S <50%, usually no symptoms Hb F---confer protection Hb: 5-11 g/dl, Normocytic normochromic, Target cells, reticulocytosis, Increase WBC & Platelets

32. Hemoglobin: 7.0 gm/dl HCT: 22% MCV: 89 fl MCH: 28 pg TLC: 22,000 Platelets: 20,000

33. Acute Leukemia Presenting count Age Cytogenetics

34. Hemoglobin: 5.0 gm/dl HCT: 16% MCV: 93 fl MCH: 26 pg TLC: 500 Platelets: 11,000 Pancytopenia Cellular Vs hypocellular

35. Chronic Leukemias Cytogenetics for CML CLL workup and staging

36. Hemoglobin: 5.0 gm/dl HCT: 16% MCV: 93 fl MCH: 26 pg TLC: 500 Platelets: 11,000 Pancytopenia Cellular Vs hypocellular

37. Normal Marrow

38. Bone Biopsy

39. Hemoglobin: 9.5 gm/dl HCT: 30% MCV: 99 fl TLC: 2200 Platelets: 10,000 Blood culture: gram negative rods

40. Microangiopathy /DIC

41. Microangiopathy /DIC

42. Macrocytic Anemia MCV more than 96fl Macrocytic anemia Megaloblastic : B12 and folate deficiency Non megaloblastic : Hemolysis MDS Hypothyroidism Liver disease

43. Hemoglobin: 6.0 gm/dl HCT: 19% MCV: 110 fl MCH: 36 pg TLC: 2,800 Platelets: 45,000

44. Hemoglobin: 7.5 gm/dl HCT: 23% MCV: 100 fl MCH: 28 pg MCHC 36% TLC: 5000 Platelets: 100,000

45. Reticulocyte Reticulocyte: larger than normal RBC RNA and Golgi remnants, Ribosome, maturation take another 24 to 48 hours in the blood circulation

46. Conclusions Peripheral blood smear examination and reporting is one of the most important aspect of hematology. It is diagnostic in many hematological and non hematological disorders. It is cost effective and non invasive and helps the clinicians in further diagnostic workup