Approach to anemia for Dr 128 final.pptx

Approach to anemia

1. Diagnostic Approach to Anemia Dr Prashant Patel M.B.B.S , M.D Pathology Kiran multisuperspeciality hospital and research center Surat Mobile No: 8128657259 6/11/2023 Dr Prashantkumar J Patel 2

2. Prevalence of Anemia Anemia is estimated to affect half a billion women 15–49 years of age 269 million children 6–59 months of age worldwide. In 2019, 30% (539 million) of non-pregnant women and 37% (32 million) of pregnant women aged 15–49 years were affected by anemia .   6/11/2023 Dr Prashantkumar J Patel 2

3. 6/11/2023 Dr Prashantkumar J Patel 3 Prevalence of Anemia

4. 6/11/2023 Dr Prashantkumar J Patel 4

5. Diagnostic Approach to Anemia 6/11/2023 Dr Prashantkumar J Patel 5 Blood loss Intrinsic Extrinsic Mem disorder Enzymopathy Hb Disorder Immune Infection Mechanical Defective Stem cell Defect DNA sys Defective Hb Syn Decreased EPO Displace N H P Cell

6. Diagnostic Approach to Anemia Definition Greek anemia, from an- ‘without’ + haima ‘blood’. Decrease in the oxygen-carrying capacity of the blood. Reduction in the RBC mass. A hemoglobin concentration lower than normal for the age and sex of the person. 6/11/2023 Dr Prashantkumar J Patel 6

7. Diagnostic Approach to Anemia Morphological classification Hypochromic microcytic anemia (MVC < 80 fl) Iron deficiency Anemia of chronic disease Thalassemia Sideroblastic anemia Lead poisoning Macrocytic Anemia (MCV >100 fl,MCV >110 fl) Megaloblastic anaemia (B12 or folate deficiency) Liver disease Alcohol Hypothyroidism Normochromic normocytic anemia (MCV 80 to 100 fl) Acute blood loss, Renal failure, Anemia of chronic disease 6/11/2023 Dr Prashantkumar J Patel 7

8. Diagnostic Approach to Anemia Clinical features Symptoms related to the anemia: Pallor Exercise intolerance and easy fatigue, weakness and lethargy Shortness of breath Syncope Palpitations and headaches. Older patients may have cardiac failure, intermittent claudication or confusion. (Increased cardiac output occurs when the Hb falls as low as 7g/dl) 6/11/2023 Dr Prashantkumar J Patel 8

9. Diagnostic Approach to Anemia Clinical features Sign related to the anemia: Pallor Splenomegaly (hemolysis) Jaundice (hemolysis, liver disease, megaloblastic anemia) Koilonychia (iron deficiency) Beefy red tongue (megaloblastic anemia) Painless glossitis, angular cheilosis (iron deficiency) Neuropathy (vit B12 deficiency) Purpura (accompanying thrombocytopenia) 6/11/2023 Dr Prashantkumar J Patel 9

10. Diagnostic Approach to Anemia <2.5 >2.5 Microcytic hypochromic Hemolysis, hemorrhage heamatinics Macrocytic Normocytic normochromic CBC with  RPI 6/11/2023 Dr Prashantkumar J Patel 10

11. Diagnostic Approach to Anemia <2.5 >2.5 Microcytic hypochromic Hemolysis, hemorrhage heamatinics Macrocytic Normocytic normochromic CBC with  RPI 6/11/2023 Dr Prashantkumar J Patel 11

12. Algorithm for the diagnosis of Hypochromic microcytic anemias Low N/H IDA TIBC N/H Ferritin 6/11/2023 Dr Prashantkumar J Patel 12

13. Iron deficiency anemia Laboratory evaluation 1.CBC Hb : low MCV : low(<76FLz)(note : Decreased MCV in thalassemia and ACD). MCHC : low Red cell distribution width (RDW) : high, in iron deficiency states with a greater frequency than in ACD or thalassemia trait. RPI < 2.5 6/11/2023 Dr Prashantkumar J Patel 13

14. Iron deficiency anemia 6/11/2023 Dr Prashantkumar J Patel 14

15. Iron deficiency anemia Laboratory evaluation 4. Biochemical investigation Serum ferritin :low Serum Iron :low Serum TIBC :high % Saturation :low Serum TFR level :high ZPP :high 6/11/2023 Dr Prashantkumar J Patel 15

16. Iron deficiency anemia 6/11/2023 Dr Prashantkumar J Patel 16

17. Iron deficiency anemia 6/11/2023 Dr Prashantkumar J Patel 17

18. Algorithm for the diagnosis of Hypochromic microcytic anaemias Low N/H IDA TIBC Low N/H CECD Yes Ferritin ACD Dr Prashantkumar J Patel

19. Anemia of chronic diseases Laboratory evaluation 1.CBC Hb :low MCV :low or normal MCH : low or normal Red cell distribution width (RDW) : high or normal. ESR :high CRP :high RPI < 2.5 6/11/2023 Dr Prashantkumar J Patel 19

20. Anemia of chronic diseases 6/11/2023 Dr Prashantkumar J Patel 20

21. Anemia of chronic diseases Laboratory evaluation 4.Biochemical investigation Serum ferritin : normal or high Serum Iron : low Serum TIBC : low or normal % Saturation : low Serum TFR level : normal Hepcidin : high 6/11/2023 Dr Prashantkumar J Patel 21

22. Anemia of chronic diseases 6/11/2023 Dr Prashantkumar J Patel 22

23. Anemia of chronic diseases 6/11/2023 Dr Prashantkumar J Patel 23

24. Algorithm for the diagnosis of Hypochromic microcytic anemias Low N/H IDA TIBC Low N/H CECD Yes No Hb Ele Normal Abnor A Thal B Thal Minor Major Ferritin ACD 6/11/2023 Dr Prashantkumar J Patel 24

25. Thalassemia Thalassemia Alfa Thalassemia                                                     Beta Thalassemia Silent a thalassemia (–a/aa)                                                                                            b thalassemia trait a thalassemia trait (aa/– – or –a/–a)                                                                             b thalassemia intermedia Hemoglobin H disease (– –/– a)                                                                   b thalassemia major (Cooley’s anemia) Hemoglobin Bart’s hydrops fetalis (– – /– –) 6/11/2023 Dr Prashantkumar J Patel 25

26. B Thalassemia Minor Laboratory evaluation 1.CBC Hb :low MCV :low MCH :low or normal Red cell distribution width (RDW) : normal or mild high. 2.RPI < 2.5 6/11/2023 Dr Prashantkumar J Patel 26

27. B Thalassemia Minor 6/11/2023 Dr Prashantkumar J Patel 27

28. B Thalassemia Minor Laboratory evaluation 4.Biochemical investigation Serum ferritin : normal Serum Iron : normal Serum TIBC : normal % Saturation : normal Serum TFR level : normal Hepcidin : normal 6/11/2023 Dr Prashantkumar J Patel 28

29. B Thalassemia Minor 6/11/2023 Dr Prashantkumar J Patel 29

30. 6/11/2023 Dr Prashantkumar J Patel 30 B Thalassemia Minor

31. 6/11/2023 Dr Prashantkumar J Patel 31 B Thalassemia Minor

32. B Thalassemia Major Laboratory evaluation 1.CBC 2.RPI 3.Peripheral smear 4.Biochemical investigation 5.Bone Marrow 6. Hb Electrophoresis 6/11/2023 Dr Prashantkumar J Patel 32

33. B Thalassemia Major Laboratory evaluation 1.CBC Hb : very low MCV :low MCHC :low  Red cell distribution width (RDW) : mild high. RPI > 2.5 6/11/2023 Dr Prashantkumar J Patel 33

34. B Thalassemia Major 6/11/2023 Dr Prashantkumar J Patel 34

35. B Thalassemia Major Laboratory evaluation 4.Biochemical investigation Serum ferritin : normal Serum Iron : normal Serum TIBC : normal % Saturation : normal Serum TFR level : normal Hepcidin : normal 6/11/2023 Dr Prashantkumar J Patel 35

36. B Thalassemia Major 6/11/2023 Dr Prashantkumar J Patel 36

37. 6/11/2023 Dr Prashantkumar J Patel 37 B Thalassemia Major

38. Algorithm for the diagnosis of Hypochromic microcytic anemias Low N/H IDA TIBC Low N/H CECD Yes No Hb Ele Normal Abnor A Thal B Thal Minor Major Lead Po Ferritin ACD 6/11/2023 Dr Prashantkumar J Patel 38

39. Lead Poisoning Laboratory evaluation 1.CBC Hb : low MCV :low MCHC :low  Red cell distribution width (RDW) : mild high. 2.RPI < 2.5 6/11/2023 Dr Prashantkumar J Patel 39

40. Lead Poisoning 6/11/2023 Dr Prashantkumar J Patel 40

41. Lead Poisoning Laboratory evaluation 4.Biochemical investigation Blood lead level < 5 µg/dL in children 6/11/2023 Dr Prashantkumar J Patel 41

42. Algorithm for the diagnosis of Hypochromic microcytic anemias CSA Low N/H IDA TIBC Low N/H CECD Yes No Hb Ele Normal Abnor A Thal B Thal BM Bx Minor Major Lead Po Ferritin ACD 6/11/2023 Dr Prashantkumar J Patel 42

43. Sideroblastic anemia Laboratory evaluation 1.CBC MCV : low (Congenital) MCH : low (Congenital) MCV : high or normal (Acquired) MCH : high or normal (Acquired) RPI < 2.5 6/11/2023 Dr Prashantkumar J Patel 43

44. Sideroblastic anemia 6/11/2023 Dr Prashantkumar J Patel 44

45. Sideroblastic anemia Laboratory evaluation 4.Biochemical investigation Serum ferritin :high Serum Iron :high  Serum TIBC : normal  % Saturation :high Serum TFR level : normal or high . Hepcidin :low 6/11/2023 Dr Prashantkumar J Patel 45

46. Sideroblastic anemia 6/11/2023 Dr Prashantkumar J Patel 46

47. 6/11/2023 Dr Prashantkumar J Patel 47 Sideroblastic anemia

48. Summary of Microcytic Anemias Test IDA ACD Thalassemia Sideroblastic a RBC count low low high low MCV low normal/low low low RDW high normal high normal Ferritin low normal/high normal high Serum iron low low normal high TIBC high low normal low Tfn Sturation low low/normal normal high 6/11/2023 Dr Prashantkumar J Patel 48

49. Case 1 3 5 years old women Decreased in energy, more marked in last few m months Complain of tiredness at the end of the day She never been pregnant She smokes 10 cigarettes a day and drinks 5 units of alcohol weekly She is well nourished and eat meat 6/11/2023 Dr Prashantkumar J Patel 49

50. Case 1 CBC with PSCM 6/11/2023 Dr Prashantkumar J Patel 50 Patient results Normal range Hb-8 gm/dl 11.5 - 16.4 gm/dl MCV-62 Fl 83 - 99 fl MCH-19 pg/cell 27 - 33 pg/cells MCHC- 30 gm/dl 33 - 35 gm/dl WBC- 5300 cells/cu.mm 4000 - 11,000 cells/cu.mm PC-5,50,000 cells/cu.mm 150000 - 450000 cell/cu.mm RDW-18% 11 – 14 %

51. Case 1 6/11/2023 Dr Prashantkumar J Patel 51

52. Case 1 Differential diagnosis Microcytic hypochromic anaemia 1. IDA 2.ACD 3.Thalassemia 4.Sideroblastic anemia 6/11/2023 Dr Prashantkumar J Patel 52

53. Case 1 What other test you asked for in this patient Serum ferritin – 9 ul/lit Normal rage: 20-300 ul/lit Diagnosis IDA Cause She had excessive menstrual blood loss 6/11/2023 Dr Prashantkumar J Patel 53

54. Diagnostic Approach to Anemia <2.5 >2.5 Microcytic hypochromic Hemolysis, hemorrhage heamatinics Macrocytic Normocytic normochromic CBC with  RPI 6/11/2023 Dr Prashantkumar J Patel 54

55. Algorithm for the diagnosis of Macrocytic anemia N/L FMA Yes FA Low Vit B12 R Tx Yes RC MA 6/11/2023 Dr Prashantkumar J Patel 55

56. Megaloblastic anemia Laboratory evaluation 1.CBC Hb :low MCV :high MCH : Normal MCHC :Normal or high RDW :high 2.RPI < 2.5 6/11/2023 Dr Prashantkumar J Patel 56

57. Megaloblastic anemia 6/11/2023 Dr Prashantkumar J Patel 57

58. Megaloblastic anemia 6/11/2023 Dr Prashantkumar J Patel 58

59. Megaloblastic anemia Laboratory evaluation 4.Biochemical investigation Serum Vitamin B12 : low Serum Folic acid : low 6/11/2023 Dr Prashantkumar J Patel 59

60. Megaloblastic anemia 6/11/2023 Dr Prashantkumar J Patel 60

61. Megaloblastic anemia 6/11/2023 Dr Prashantkumar J Patel 61

62. Megaloblastic anemia 6/11/2023 Dr Prashantkumar J Patel 62

63. Megaloblastic anemia 6/11/2023 Dr Prashantkumar J Patel 63

64. Megaloblastic anemia 6/11/2023 Dr Prashantkumar J Patel 64

65. Summary megaloblastic anemia 6/11/2023 Dr Prashantkumar J Patel 65 Findings PA O Vita B12deficiencies FA Deficiencies Pancytopenia Present Present Present MCV Increased Increased Increased Hypersegmented neutrophil Present Present Present Achlorhydria Present Absent Absent Autoantibodies Present Absent Absent Chronic atrophic gastritis Present Absent Absent Gastric carcinoma risk Increased none none Neurologic disease Present Present Absent Plasma homocysteine Increased Increased Increased Serum gastrin level Increased Normal Normal Uri methylmalonic acid Increased Increased Normal

66. Algorithm for the diagnosis of Macrocytic anemia N/L FMA Yes No FA Low Vit B12 Liver D R Tx Yes RC MA 6/11/2023 Dr Prashantkumar J Patel 66

67. Liver diseases Laboratory evaluation 1.CBC Hb :low MCV :high MCH :high MCHC :Normal RDW : Normal RPI < 2.5 6/11/2023 Dr Prashantkumar J Patel 67

68. Liver diseases 6/11/2023 Dr Prashantkumar J Patel 68

69. Liver diseases Laboratory evaluation 4.Biochemical investigation Serum SGPT : Normal or high Serum SGOT :high Serum GGT :high Serum Albumin : Normal or low 6/11/2023 Dr Prashantkumar J Patel 69

70. Algorithm for the diagnosis of Macrocytic anemia High N/L H,H,H FMA Yes No FA Low Vit B12 Liver D R Tx Yes Alcoho RC MA 6/11/2023 Dr Prashantkumar J Patel 70

71. Alcohol Laboratory evaluation 1.CBC Hb :low MCV :high MCH : Normal MCHC :high RDW : Normal or mild increase RPI <2.5 6/11/2023 Dr Prashantkumar J Patel 71

72. Alcohol 6/11/2023 Dr Prashantkumar J Patel 72

73. Alcohol Laboratory evaluation 4.Biochemical investigation Serum SGPT : Normal or high Serum SGOT :high Serum GGT :high Serum Albumin : Normal or low 6/11/2023 Dr Prashantkumar J Patel 73

74. Algorithm for the diagnosis of Macrocytic anemia High N/L H,H,H FMA Yes No FA Low Vit B12 Liver D HypoTh R Tx Yes Alcoho RC MA 6/11/2023 Dr Prashantkumar J Patel 74

75. Hypothyroidism Laboratory evaluation 1.CBC HB : low MCV : high RPI < 2.5 6/11/2023 Dr Prashantkumar J Patel 75

76. Hypothyroidism 6/11/2023 Dr Prashantkumar J Patel 76

77. Hypothyroidism Laboratory evaluation 4.Biochemical investigation Seum TSH :high Serum T3 :low Serum T4 :low Serum Free T3 :low Serum Free T4 :low Serum Antithyroid antibody : 1. Anti TPO 2. Anti TG : high 6/11/2023 Dr Prashantkumar J Patel 77

78. Algorithm for the diagnosis of Macrocytic anemia AA High N/L H,H,H FMA Yes No FA Low Vit B12 Liver D HypoTh MDS Normal BM Bx R Tx Yes Alcoho RC MA No 6/11/2023 Dr Prashantkumar J Patel 78

79. Aplastic anemia Laboratory findings Reticulocytes count low Peripheral smear Varying degrees of pancytopenia Bone marrow Markedly hypocellular/aplastic with virtual absence of normal hematopoietic marrow 6/11/2023 Dr Prashantkumar J Patel 79

80. Aplastic anemia 6/11/2023 Dr Prashantkumar J Patel 80

81. Myelodysplastic syndrome Group of clonal stem cell disorder characterized by maturation defect associated with ineffective hematopoeisis and high risk of transformation to AML Bone marrow is hypercellular or normocellular but peripheral blood show pancytopenia,myeloblast are < 10 percentage of peripheral blood 6/11/2023 Dr Prashantkumar J Patel 81

82. Myelodysplastic syndrome 6/11/2023 Dr Prashantkumar J Patel 82

83. Case 2 65 years old women deteriorating over a period of 6 months Recently her memory detoriate She had short of breath and her eyes looks little yellow Family history- Her sister is suffering from thyroid problem 6/11/2023 Dr Prashantkumar J Patel 83

84. Case 2 Skin- Lemon yellow tinge Her walk was slightly ataxic Deep tendon reflex in her ankle and knee absent Planter reflex was extensor- Bebingki’s sign BP- 130/86 mmhg - JVP Increased Minimal pitting edema in both leg 6/11/2023 Dr Prashantkumar J Patel 84

85. Case 2 What investigation should be carries out ? CBC PSCM Liver profile Renal profile ECG Chest- Radiograph 6/11/2023 Dr Prashantkumar J Patel 85

86. Case 2 CBC with PSCM 6/11/2023 Dr Prashantkumar J Patel 86 Patient results Normal range Hb-7 gm/dl 11.5 - 16.4 gm/dl MCV-112 Fl 83 - 99 fl MCH-30 pg/cell 27 - 33 pg/cells MCHC- 32 gm/dl 33 - 35 gm/dl WBC- 2100 cells/cu.mm 4000 - 11,000 cells/cu.mm PC-98,000 cells/cu.mm 150000 - 450000 cell/cu.mm

87. Case 2 6/11/2023 Dr Prashantkumar J Patel 87

88. Case 2 6/11/2023 Dr Prashantkumar J Patel 88

89. Case 2 6/11/2023 Dr Prashantkumar J Patel 89

90. Case 2 ECG : shows sinus tachycardia Chest : Radiograph show evidence of mild heart failure Biochemical test 6/11/2023 Dr Prashantkumar J Patel 90 Patient results Normal range Bilirubin -28 umol /lit 0 - 17 umol /lit LDH - >5000 IU/L 230 - 450 IU/L Potassium – 2.8 mmol/L 3.5 - 5 mmol/L

91. Case 2 What blood test might help to clarify if the problem is related to hemolysis or ineffective erythropoiesis ? Reticulocyte count : 25000 cells/cumm normal : 50,000 to 1,00,000 cells/cumm Which vitamin deficiency is likely to be in this patient ? Vitamin B12 deficiency What should be done next ? S.Vit-B12- Low 50 ng/lit Normal range : 150 – 1000 ng/lit RBC folate level – 200 ug/lit Normal range : 150 – 1000 ug/lit Antiparietal cells Ab level - Positive Anti IF Ab level- Positive What is the diagnosis Vitamin B12 deficiency because of pernicious anemia 6/11/2023 Dr Prashantkumar J Patel 91

92. Diagnostic Approach to Anemia <2.5 >2.5 Microcytic hypochromic Hemolysis, hemorrhage heamatinics Macrocytic Normocytic normochromic CBC with  RPI 6/11/2023 Dr Prashantkumar J Patel 92

93. Algorithm for the diagnosis of Normochromic normocytic anaemia E ABL 6/11/2023 Dr Prashantkumar J Patel 93

94. Acute blood loss Laboratory evaluation 1.CBC Hb : low RBC count :low MCV :Normal MCH :Normal MCHC :Normal RDW :Normal RPI < 2.5 6/11/2023 Dr Prashantkumar J Patel 94

95. Acute blood loss 6/11/2023 Dr Prashantkumar J Patel 95

96. Algorithm for the diagnosis of Normochromic normocytic anaemia PSCM No morpho abno E ABL Renal failure,HIV,Chronic diseases 6/11/2023 Dr Prashantkumar J Patel 96

97. Renal failure Laboratory evaluation 1.CBC Hb : low MCV :Normal MCH :Normal MCHC :Normal RDW :Normal or mild increase RPI < 2.5 6/11/2023 Dr Prashantkumar J Patel 97

98. Renal failure 6/11/2023 Dr Prashantkumar J Patel 98

99. Renal failure Laboratory evaluation 4.Biochemical investigation Serum Creatinine : high 6/11/2023 Dr Prashantkumar J Patel 99

100. Algorithm for the diagnosis of Normochromic normocytic anaemia PSCM No morpho abno E ABL Renal failure,HIV,Chronic diseases BM Bx BM Infil,Aplastic anemia,RCA 6/11/2023 Dr Prashantkumar J Patel 100

101. Algorithm for the diagnosis of Normochromic normocytic anaemia Featu of hemolysis PSCM No morpho abno E ABL Approach to hemolytic anemia Renal failure,HIV,Chronic diseases BM Bx BM Infil,Aplstic anemia,RCA 6/11/2023 Dr Prashantkumar J Patel 101

102. Algorithm for the diagnosis of Normochromic normocytic anaemia Featu of hemolysis PSCM LEB reaction No morpho abno E ABL Approach to hemolytic anemia Hemolysis, severe infection Renal failure,HIV,Chronic diseases BM Bx Bone marrow infiltration BM Infil,Aplstic anemia,RCA 6/11/2023 Dr Prashantkumar J Patel 102

103. Algorithm for the diagnosis of Normochromic normocytic anaemia Featu of hemolysis PSCM LEB reaction No morpho abno E ABL Approach to hemolytic anemia Hemolysis, severe infection Measure level Renal failure,HIV,Chronic diseases Com Megalo,IDA BM Bx Bone marrow infiltration BM Infil,Aplstic anemia,RCA 6/11/2023 Dr Prashantkumar J Patel 103

104. Diagnostic Approach to Anemia <2.5 >2.5 Microcytic hypochromic Hemolysis, hemorrhage heamatinics Macrocytic Normocytic normochromic CBC with  RPI 6/11/2023 Dr Prashantkumar J Patel 104

105. Hemolytic anemia Laboratory evaluation (common features of hemolytic anemia) Hb : low Serum LDH : high Serum Bilirubin total : high Serum bilirubin unconjugated : high Serum haptoglobin : low 6/11/2023 Dr Prashantkumar J Patel 105

106. 6/11/2023 Dr Prashantkumar J Patel 106

107. Algorithm for the diagnosis of Hemolytic anemia +ve -Ve C T(MS) Warm AIHA PSCM Sickle cell Cold AIHA Normal morpholo Freg MAHA Bite cell PCH Spherocytes Coom Test SLE,Drugs,Lymphoproliferative disorder,Delayed transfusion reaction DIC,TTP,Vasculitis, Malignant Hypertension Other enzymopathies,PNH G6PD deficiency,Unstable haemoglobins Hereditary spherocytosis,Clostridium infections Sickle cell anemia Infectious mono,Mycoplasma,Lymphoproliferative Paroxymal cold hemoglobinuria 6/11/2023 Dr Prashantkumar J Patel 107

108. Algorithm for the diagnosis of Hemolytic anemia +ve -Ve C T(MS) Warm AIHA PSCM Sickle cell Cold AIHA Normal morpholo Freg MAHA Bite cell PCH Spherocytes Coom Test SLE,Drugs,Lymphoproliferative disorder,Delayed transfusion reaction DIC,TTP,Vasculitis, Malignant Hypertension Other enzymopathies,PNH G6PD deficiency,Unstable haemoglobins Hereditary spherocytosis,Clostridium infections Sickle cell anemia Infectious mono,Mycoplasma,Lymphoproliferative Paroxymal cold hemoglobinuria 6/11/2023 Dr Prashantkumar J Patel 108

109. Diagnostic Approach to Anemia Warm AIHA IgG antibody that react with RBC membrane Causes SLE Drugs Lymphoproliferative disorder Delayed transfusion reaction 6/11/2023 Dr Prashantkumar J Patel 109

110. Warm AIHA 6/11/2023 Dr Prashantkumar J Patel 110

111. Algorithm for the diagnosis of Hemolytic anemia +ve -Ve C T(MS) Warm AIHA PSCM Sickle cell Cold AIHA Normal morpholo Freg MAHA Bite cell PCH Spherocytes Coom Test SLE,Drugs,Lymphoproliferative disorder,Delayed transfusion reaction DIC,TTP,Vasculitis, Malignant Hypertension Other enzymopathies,PNH G6PD deficiency,Unstable haemoglobins Hereditary spherocytosis,Clostridium infections Sickle cell anemia Infectious mono,Mycoplasma,Lymphoproliferative Paroxymal cold hemoglobinuria 6/11/2023 Dr Prashantkumar J Patel 111

112. Diagnostic Approach to Anemia Cold  AIHA IgM antibody that react with the I antigen on RBC leading to hemolysis Causes  Infectious mono Mycoplasma Lymphoproliferative 6/11/2023 Dr Prashantkumar J Patel 112

113. Cold  AIHA Laboratory evaluation Cold agglutination test : positive Peripheral smear : spherocytes Hb : low MCV : high MCHC : high 6/11/2023 Dr Prashantkumar J Patel 113

114. Algorithm for the diagnosis of Hemolytic anemia +ve -Ve C T(MS) Warm AIHA PSCM Sickle cell Cold AIHA Normal morpholo Freg MAHA Bite cell PCH Spherocytes Coom Test SLE,Drugs,Lymphoproliferative disorder,Delayed transfusion reaction DIC,TTP,Vasculitis, Malignant Hypertension Other enzymopathies,PNH G6PD deficiency,Unstable haemoglobins Hereditary spherocytosis,Clostridium infections Sickle cell anemia Infectious mono,Mycoplasma,Lymphoproliferative Paroxymal cold hemoglobinuria 6/11/2023 Dr Prashantkumar J Patel 114

115. PCH Causes follow upper respiratory and gatrointestinal infection 6/11/2023 Dr Prashantkumar J Patel 115

116. PCH 6/11/2023 Dr Prashantkumar J Patel 116

117. PCH 6/11/2023 Dr Prashantkumar J Patel 117

118. Algorithm for the diagnosis of Hemolytic anemia +ve -Ve C T(MS) Warm AIHA PSCM Sickle cell Cold AIHA Normal morpholo Freg MAHA Bite cell PCH Spherocytes Coom Test SLE,Drugs,Lymphoproliferative disorder,Delayed transfusion reaction DIC,TTP,Vasculitis, Malignant Hypertension Other enzymopathies,PNH G6PD deficiency,Unstable haemoglobins Hereditary spherocytosis,Clostridium infections Sickle cell anemia Infectious mono,Mycoplasma,Lymphoproliferative Paroxymal cold hemoglobinuria 6/11/2023 Dr Prashantkumar J Patel 118

119. MAHA Causes DIC TTP/HUS Vasculitis Malignant Hypertension 6/11/2023 Dr Prashantkumar J Patel 119

120. Algorithm for the diagnosis of Hemolytic anemia +ve -Ve C T(MS) Warm AIHA PSCM Sickle cell Cold AIHA Normal morpholo Freg MAHA Bite cell PCH Spherocytes Coom Test SLE,Drugs,Lymphoproliferative disorder,Delayed transfusion reaction DIC,TTP,Vasculitis, Malignant Hypertension Other enzymopathies,PNH G6PD deficiency,Unstable haemoglobins Hereditary spherocytosis,Clostridium infections Sickle cell anemia Infectious mono,Mycoplasma,Lymphoproliferative Paroxymal cold hemoglobinuria 6/11/2023 Dr Prashantkumar J Patel 120

121. Hereditary spherocytosis 6/11/2023 Dr Prashantkumar J Patel 121

122. Hereditary spherocytosis 6/11/2023 Dr Prashantkumar J Patel 122

123. Hereditary spherocytosis 6/11/2023 Dr Prashantkumar J Patel 123

124. Algorithm for the diagnosis of Hemolytic anemia +ve -Ve C T(MS) Warm AIHA PSCM Sickle cell Cold AIHA Normal morpholo Freg MAHA Bite cell PCH Spherocytes Coom Test SLE,Drugs,Lymphoproliferative disorder,Delayed transfusion reaction DIC,TTP,Vasculitis, Malignant Hypertension Other enzymopathies,PNH G6PD deficiency,Unstable haemoglobins Hereditary spherocytosis,Clostridium infections Sickle cell anemia Infectious mono,Mycoplasma,Lymphoproliferative Paroxymal cold hemoglobinuria 6/11/2023 Dr Prashantkumar J Patel 124

125. G6PD deficiency 6/11/2023 Dr Prashantkumar J Patel 125

126. G6PD deficiency 6/11/2023 Dr Prashantkumar J Patel 126

127. G6PD deficiency 6/11/2023 Dr Prashantkumar J Patel 127

128. G6PD deficiency Laboratory evaluation G6PD test Qualitative : Dye decolorization method Quantitative : Enzymatic method 6/11/2023 Dr Prashantkumar J Patel 128

129. Pyruvate kinase deficiency 6/11/2023 Dr Prashantkumar J Patel 129

130. Pyruvate kinase deficiency 6/11/2023 Dr Prashantkumar J Patel 130

131. Pyruvate kinase deficiency 6/11/2023 Dr Prashantkumar J Patel 131 Laboratory evaluation Serum methhemoglobin level : increased RBC : 2,3 DPG level increased Genetic test

132. Algorithm for the diagnosis of Hemolytic anemia +ve -Ve C T(MS) Warm AIHA PSCM Sickle cell Cold AIHA Normal morpholo Freg MAHA Bite cell PCH Spherocytes Coom Test SLE,Drugs,Lymphoproliferative disorder,Delayed transfusion reaction DIC,TTP,Vasculitis, Malignant Hypertension Other enzymopathies,PNH G6PD deficiency,Unstable haemoglobins Hereditary spherocytosis,Clostridium infections Sickle cell anemia Infectious mono,Mycoplasma,Lymphoproliferative Paroxymal cold hemoglobinuria 6/11/2023 Dr Prashantkumar J Patel 132

133. Sickle cell anemia Causes Autosomal recessive disorder lead to production of HbS. 6/11/2023 Dr Prashantkumar J Patel 133

134. Sickle cell anemia 6/11/2023 Dr Prashantkumar J Patel 134

135. 6/11/2023 Dr Prashantkumar J Patel 135 Sickle cell anemia

136. Sickle cell anemia 6/11/2023 Dr Prashantkumar J Patel 136

137. 6/11/2023 Dr Prashantkumar J Patel 137 Sickle cell anemia

138. 6/11/2023 Dr Prashantkumar J Patel 138 Sickle cell anemia

139. Diagnostic Approach to Anemia 6/11/2023 Dr Prashantkumar J Patel 139 Anemia IDA ACD Thalassemia SDA Hemolytic Non hemolytic ACD Renal diseases Aplastic anemia Intrinsic Extrinsic RBC membrane RBC Enzyme Abnormal Hb PNH MAHA Infection AIHA Microcytic MCV < 80 Normocytic MCV 80 to 100 Macrocytic MCV >100 Megaloblastic Nonmegaloblastic Vit B12 Defi Liver diseases Folic acid defi Hypothyroidism Alcohol Drugs

140. Case 3 30 years old male school teacher Tired for Last 2 week His wife noticed yellow color eye Pain in stomach on & off for last week Eye examination confirm the jaundice Spleen palpable - 2 cm below left costal margin 6/11/2023 Dr Prashantkumar J Patel 140

141. Case 3 What investigation should be carries out ? CBC PSCM Chest - Radiograph Urine - RM USG Abdomen 6/11/2023 Dr Prashantkumar J Patel 141

142. Case 3 CBC with PSCM 6/11/2023 Dr Prashantkumar J Patel 142 Patient results Normal range Hb- 12.5 gm/dl 13.5 - 18 gm/dl MCV-103 Fl 83 - 99 fl MCH-30 pg/cell 27 - 33 pg/cells MCHC- 36 gm/dl 33 - 35 gm/dl WBC- 10500 cells/cu.mm 4000 - 11,000 cells/cu.mm PC-98,000 cells/cu.mm 150000 - 450000 cell/cu.mm RBC- 6 mili cells/cu.mm 4.5 to 6.5 mili cells/cu.mm Reticulocytes – 1,30,000 cells/cumm 50,000 to 1,00,000 cells/cumm

143. Case 3 6/11/2023 Dr Prashantkumar J Patel 143

144. Case 3 6/11/2023 Dr Prashantkumar J Patel 144

145. Case 3 6/11/2023 Dr Prashantkumar J Patel 145

146. Case 3 6/11/2023 Dr Prashantkumar J Patel 146

147. Case 3 DCT : negative Osmotic fragility test : positive Biochemical test Diagnosis : hereditary spherocytosis 6/11/2023 Dr Prashantkumar J Patel 147 Patient results Normal range Bilirubin -25 umol /lit 0 - 17 umol /lit LDH - > 650 IU/L 230 - 450 IU/L

148. Case 3 6/11/2023 Dr Prashantkumar J Patel 148

149. Case 3 6/11/2023 Dr Prashantkumar J Patel 149

150. Thank you for your attention….. 6/11/2023 Dr Prashantkumar J Patel 150