Diagnosis of Anemia

This includes diagnosis of all types of anemia in short.

1. Diagnosis of a case of Anemia Dr. Md Shahid Iqubal Deptt Of Medicine, Nmch

2. Definition of anaemia Anaemia is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking, and pregnancy status . The WHO criteria for anemia  as hemoglobin ( Hb ) levels <12.0 g/ dL in nonpregnant women and <13.0 g/ dL in men(in adults). Anemia in pregnancy  is defined as a hemoglobin concentration of less than 11 g/ dL .

3. DATA REPORTS It is a major public health problem Estimated prevalence of anemia in india is 42 % in women 15–59 years, 30% in men 15–59 years, and  45%  in adults >60 years. According to World Health Organization, prevalence of anaemia among pregnant women in developed countries is about 14%, whereas it is still as high as 51% in the developing world The prevalence of anemia is 98% among the pregnant females in this region of rural India.

4. Grading of anaemia Grade of anemia Hb concentration Mild Hb from lower limit of normal to 10g/dl Moderate 10.0 to 7.0 g/dl Severe <7.0 g/dl

5. Classification of anemia Morphological classification Etiological classification

6. Morphological classification of anemia Microcytic anemia (MCV<80fl) Macrocytic anemia (MCV>100fl) Normocytic anemia (MCV 80-100 fl ) Iron deficiency anemia Megaloblastic anemia Reticulocyte production normal Thalassemia Nonmegaloblastic anemia Recent blood loss hemolytic anemia Sideroblastic anemia liver disease Reticulocyte production deficient Anemia of chronic disease hemolytic anemia Anemia of chronic disease alcoholism aplastic anemia myelodysplastic syndrome chronic kidney disease hypothyroidism hypothyroidism

7. Clinical presentation of anemia Symptoms Fatigue Malaise Dyspnea and palpitation Syncope Dizziness Menorrhagia Loss of appetite

8. Diagnosis of anemia History Diet history- vegeterian or nonvegeterian h/o-chronic blood loss( menorrhagia,hemorrhoids ) h/o-drugs like anticancerous agents, chloramphenicol,gold,penicillamine (aplastic anemia) Dapsone,quinine (hemolytic anemia) Family history of anemia( thalassemia,sickle cell anemia) h/o alcohol addiction h/o-renal disease,rheumatologic disease History of systemic symptoms like fever ,weight loss,night sweats. Obstetric and menstrual history

9. examination General examination- Pallor Icterus Edema Lymphadenopathy Petechiae Systemic examination CVS-flow murmur,loud S1 Chest – crepts P/A-splenomegaly

10. Investigation CBC Reticulocyte count ESR Peripheral blood smear LFT(recent viral hepatitis) RFT Iron profile LDH,uric acid Vitamin B12 and folic acid level Bone marrow examination Hg electrophoresis Flowcytometry Direct and indirect coombs test Screening test for hep A,B and C

11. Basic approach to diagnosis of anemia

12. Evaluation of microcytic hypochromic anemia (50-150ng/ml)

13. Iron deficiency anemia Cause-blood loss( menses,GI blood loss) celiac disease,h.pylori infection History of pica(consumption of substances such as ice, starch, or clay) koilonychia (“spoon nail”), and glossitis (Plummer-Vinson's syndrome) seen in severe iron deficiency anemia

14. Investigations CBC and red cell indices-↓ Hb , ↓MCV, ↓MCH, ↓MCHC Reticulocyte count-normal or decreased PBS –Microcytic and hypochromic anisocytosis and poikilocytosis Iron profile-ferritin decreased (<10ng/ml in women and <20ng/ml in men) serum iron ↓,TIBC↑ BM biopsy-absent or ↓ staining for iron. Severe iron deficiency anemia ( Normal serum iron-50-150 µ / dL Normal TIBC-300-360 µ / dL )

15. Thalassemia The thalassemia syndromes are inherited disorders of α- or β-globin biosynthesis. Alpha and beta thalassemia Alpha beta thalassemia Silent carrier Minor trait intermedia Hemoglobin H Major( cooley’s anemia) hydrops fetalis

16. Diagnosis of Thalassemia The diagnosis of β Thalassemia major made during childhood. Minor and intermedia remains asymptomatic On examination – jaundice, hepatosplenomegaly , Investigation – CBC- ↓MCV, ↓MCH Reticulocytosis Peripheral smear-microcytic hypochromic RBCs with poikilocytosis , target cells

17. Peripheral blood smear of thalassemia Microcytic and hypochromic resembling severe iron-deficiency anemia. Many elliptical and teardrop -shaped red blood cells are noted. Target cells have a bull’s-eye appearance

18. Diagnosis of Thalassemia contd …. Hb electrophoresis is diagnostic for β –thalassemia HbF ( α 2 γ 2 ) , HbA2  (α 2 δ 2 ) or both increased. In α thalassemia trait HbA2 and HbF levels are normal . (Normal HbF <1%,HbA2-2.5-3.5%) Hb H disease have increased β tetramers.

19. Differential diagnosis of Microcytic anemia Tests Iron Deficiency Inflammation Thalassemia Sideroblastic Anemia smear Micro/hypo Normal Micro/hypo Micro/hypo with targeting variable Serum iron (μ g/ dL ) <30 <50 Normal to high Normal to high TIBC (μ g/ dL ) >360 <300 normal normal Percent saturation <10 10-20 30-80 30-80 Ferritin (μ g/L) <15 30-200 50-300 50-300 Hemoglobin pattern on electrophoresis Normal Normal Abnormal with β thalassemia; Normal

20. Evaluation of macrocytic anemia

21. Megaloblastic anemia Megaloblastic anemia is a term used to describe disorders of impaired DNA synthesis in hematopoietic cells but affects all proliferating cells . Due to folic acid or vitamin B12 deficiency Diagnosis- In addition to sx of anemia peripheral neuropathy, paresthesias , Seizures and dementia may found due to vit b12 deficiency On examination- Jaundice or splenomegaly Decreased vibratory and positional sense, ataxia,

22. Investigations of megaloblastic anemia Increased MCV & MCH,normal MCHC Low RBC , WBC,and platelets Peripheral smear-oval macrocytes,anisocytosis,poikilocytosis , Hypersegmented neutrophils LDH and indirect bilirubin are elevated Raised urine urobilinogen Serum vitamin B12 ,or folate or both decresed (Normal serum vit B12levels 160–200 ng /L and normal serum folate 2 -15 μ g/L) Serum methylmalonic acid (MMA) and homocysteine (HC ) are elevated in vitamin B12 deficiency; and only HC is elevated in folate deficiency . Detecting antibodies to intrinsic factor is specific for the diagnosis of PA.

23. Peripheral smear of megaloblatic anemia Severe megaloblastic anemia Macro- ovalocytes

24. Evaluation of normocytic anemia

25. Aplastic anemia Aplastic anemia is pancytopenia with bone marrow hypocellularity . Inherited- fanconi anemia,dyskeratosis congenita Acquired- radiation,drugs like cytotoxic drugs,benzene,chloramphenicol,NSAIDS,sulfonamides,gold,mercury,hydantoin,parvo virus,hepatitis,EB virus,HIV-1

26. Diagnosis of aplastic anemia History-of bleeding,easy bruising,nose bleeds,heavy menstrual flow Family history of hematologic ds Examination- petechiae and ecchymoses Lymphadenopathy and splenomegaly are highly atypical of aplastic anemia . Cafe au lait spots and short stature suggest Fanconi anemia MCV- increased,reticulocytes are absent or few Peripheral smear- shows large erythrocytes and a paucity of platelets and granulocytes. Bone Marrow-only red cells,residual lymphocytes,mainly fat Chromosome studies of bone marrow cells for MDS Flow cytometry to rule out PNH .

27. Anemia of chronic kidney disease Primarily due to decreased endogenous EPO production Other causes are-Diminished red blood cell survival, Bleeding diathesis Iron deficiency Hyperparathyroidism/bone marrow fibrosis Chronic inflammation Folate or vitamin B12 deficiency Comorbid conditions: hypo-/hyperthyroidism, pregnancy,

28. Diagnosis Anemia of chronic kidney disease cbc -normal MCV Reticulocyte count-normal PBS- normocytic,normochromic,echinocytes (burr cell)

29. Hemolytic anemia Abnormality intrinsic to red cells- Hereditary spherocytosis Sickle cell disease Thalassemia G-6PD deficiency Abnormality extrinsic to red cells Immune Mechanical

30. Evaluation of hemolytic anemia

31. Diagnosis of hemolytic anemia General examination- Jaundice, pallor Other physical findings Splenomegaly; bossing of skull Hemoglobin level From normal to severely reduced MCV, MCH Usually increased Reticulocytes Increased Bilirubin Increased (mostly unconjugated) LDH Increased Haptoglobin Reduced to absent direct Coombs test [ DAT ] is an indicator of the presence of antibodies attached to RBC. The indirect Coombs test indicates the presence of free antibody in the plasma. A peripheral blood smear-in Intravascular hemolysis may show red cell fragmentation (i.e., schistocytes,helmet cells)

32. Hereditary Spherocytosis Autosomal dominant Jaundice,splenomegaly,gall stones MCHC increased Peripheral smear- normocytic,spherocytes Screening test-osmotic fragility test Definitive dx by molecular studies of gene

33. Sickle cell anemia Due to point mutation in 6 th place of beta chain ,glutamic acid→valine On deoxygenation sickle cells are formed Clinical presentation Vaso -occlusive crisis-acute chest syndrome,pain crisis Aplastic crisis-by parvovirus B19 Hemolytic crisis-gall stones infections

34. Diagnostic testing of sickle cell anemia Reticulocytosis,bilirubin (indirect↑,LDH↑, leukocytosis,thrombocytosis Peripheral smear shows sickle shaped RBCs,target cells and howell -jolly bodies

35. Diagnostic testing of sickle cell anemia Sickling test Sickling and solubility test –screening test of sickle cell anemia

36. Diagnostic testing of sickle cell anemia HPLC- Hb analysis by high performance liquid chromatography homozygote heterozygote

37. Glucose-6-phosphate dehydrogenase deficiency X-linked disorder Reduced activity of G6PD Inability to remove H2O2 Accumulated H2O2 leads to oxidation of hemoglobin with precipitation of globin chains May Present as neonatal jaundice Incresed bilirubin and Hemoglobinuria .

38. Peripheral smear of G6PD On Peripheral smear- bite cells and heinz bodies (precipitated Hb within RBCs).

39. Autoimmune Hemolytic Anemia Warm antibody AIHA-by an IgG autoantibody Lymphoma,CLL,collagen vascular ds Cold antibody AIHA-by an IgM autoantibody Seen in cold agglutinin ds,mycoplasma EB virus Diagnosis- reticulocytosis,elevated LDH, and indirect hyperbilirubinemia . Peripheral blood smear may show spherocytes , occasional fragmented RBCs , Positive DAT(direct coombs test) Warm AIHA: IgG +and/or C3+ Cold AIHA: IgG - and C3+

40. Take home message Anemia is one of the important cause of morbidity and mortality in women. Iron deficiency anemia is the most common type of anemia Iron deficiency in adult male means GI blood loss until proven otherwise. Hb electrophoresis is diagnostic for thalassemia Megaloblastic anemia may present as pancytopenia Reticulocytosis present in hemolytic anemia Microcytic hypochromic –iron deficiency anemia Macrocytic- megaloblastic anemia Normocytic normochromic-hemolytic anemia

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