Diagnosis of anemia.................pptx

important

1. Laboratory Diagnosis of Anemia

2. Learning Objectives At the end of this briefing, you should know Clinical presentation of anemia. Definition of anemia. Approach to diagnosis of anemia Classification of anaemia Distinct features of each type of anemia.

3. Clinical presentation of anemias Fatigue and weakness Headache Tinnitus Numbness and coldness Pallor Dyspnea and palpitations Angina pectoris Intermittent claudication Hemorrhages in the fundus of eyes Menorr h agia Anorexia Flatulence Nausea Constipation

4. Clinical presentation of anaemias

5. Initial Laboratory Work-Up Hemoglobin concentration. Packed Cell Volume. Red cell indices. Peripheral Blood Smear.

6. Definition of Anaemia Anaemia is defined as a reduction in the concentration of circulating haemoglobin below the level that is expected for healthy personsof same age and sex in the same environment. 6

7. Blood parameters (Laboratory Normal Range)

8. Blood parameters (Laboratory Normal Range) In full term infants, hemoglobin is 18.0 ± 4.0 g/dl Children - 12.5 ± 1.5 g/dl Children(6-12 years) - 13.5 ± 2.0 g/dl

9. Grading of Anaemia

10. Classification of Anaemias Morphological Classification Etiological Classification Classification based on reticulocyte response.

11. Morphological Classification of Anemias

12. Hematocrit Proportion of the volume of red cells relative to the volume of blood Rules of Three: RBC X 3 = Hemoglobin Hemoglobin X 3 = Hematocrit Packed cell volume (PCV) or Haematocrit (Hct) Men - 0.45 ± 0.05 l/l (40-50%) Women - 0.41 ± 0.05 l/l (38-45 % in non- pregnant women 36-42 % in pregnant women)

13. Mean Corpuscular Volume Dividing the total volume of red cells by the number of red cells Index for average size of red cells Normal range - 92 ± 9 fl 13

14. Mean Corpuscular Hemoglobin Average amount of haemoglobin in each red cell. It is expressed in picograms or pg. Normal range - 29.5 ± 2.5 pg

15. Mean Corpuscular Hemoglobin Concentration This represents the average concentration of haemoglobin in a given volume of packed red cells. Normal range – 330 ± 15 g/l MCHC raised in hereditary spherocytosis. Decreased in hypochromic anaemia.

16. Red cell distribution width Variation in red cell size Normal range - 12.8% ± 1.2% Low in B-thalassemia trait High in iron deficiency anaemia Normal in anaemia of chronic disease

17. 17 1 Microcytic/hypochromic 3 1 2 2 Macrocytic/Normochromic 3 Normocytic/Normochromic Morphologic Categories of Anemia N.B. The nucleus of a small lymphocyte (shown by the arrow) is used as a reference to a normal red cell size

18. Macrocytic anemia Low/normal reticulocyte count, macrocytosis(oval and round) Elevated MCV,MCHC Basophilic stippling Howell-jolly bodies Cabot rings Pancytopenia H y p e r seg m e n t ed neutrophils Bone marrow- megaloblastic maturation,sieve like chromatin,nuclear- cytoplasmic a s y n c h r o n y ,m a tu r a tion arrest

19. Normocytic Normochromic anaemia with effective erythropoiesis

20. Etiological Classification of Anaemias

21. Basic Approach to a diagnosis of anemia

22. Evaluation of microcytic hypochromic anaemia

23. Evaluation of macrocytic anaemia

24. Evaluation of normocytic anaemia

25. Evaluation of haemolytic anaemia

26. A simplified approach to diagnosis of haemolytic anaemias

27. Reticulocyte Count (In the Diagnosis of Anemia) Reticulocytes are non- nucleated RBCs that still contain RNA. Visualized by staining with supravital dyes, including new methylene blue or brilliant cresyl blue. Useful in determining response and potential of bone marrow. Normal range is 0.5-2.5% of all erythrocytes. 29

28. Fe ++ deficiency anemia Low hemoglobin and low packed cell volume Low MCV,MCH and MCHC Microcytosis & hypochromia are hallmarks RDW is increased Serum ferritin is less than 15 micro gram/dl Serum iron is low,TIBC is increased and transferrin saturation is less than 10 percent Free erythrocyte protoporphyrin is increased. Increased soluble transferrin receptor in serum Bone marrow- micronormoblastic,absence of stainable iron in bone marrow on Perls Prussian blue reaction

29. 31 Megaloblastic Anemia Mild to severe anemia, Increased MCV & MCH, normal MCHC Low RBC, HGB, WBC and PLT counts (fragile cells) due to ineffective hematopoiesis. Low reticulocyte count Macrocytic ovalocytes and teardrops; Marked anisocytosis and poikilocytosis Schistocytes/microcytes - due to RBC breakage upon leaving the BM Erythroid hyperplasia - low M:E ratio (1:1) – Iron stores increased.

30. 32 Macrocytic Ovalocytes Blo o d NR B C Blo o d Howell-Jolly body Teardrop Schistocyte Stippled RBC & Cabot Ring Giant Platelet Pap bodies H y persegmented Neutrophil >5 lobes Megaloblastic anemia

31. T e s ts Folate and B12 levels Schilling test may be useful to establish etiology of B12 deficiency Assesses radioactive B12 absorption with and without exogenous IF Other tests if pernicious anemia is suspected Anti- parietal cell antibodies, anti-IF antibodies Secondary causes of poor absorption should be sought (gastritis, ileal problems, etc.)

32. Anemia of chronic disease Normocytic anemia with ineffective erythropoiesis (reduced reticulocyte count) Normochromic Results from Chronic inflammation (e.g. rheumatologic disease): Cytokines released by inflammatory cells cause macrophages to accumulate iron and not transfer it to plasma or developing red cells (iron block anemia) Inflammation malignancy Bone marrow suppression (EPO is elevated)

33. Anemia of chronic disease Decreased serum iron,decreased total iron binding capacity and normal or raised ferritin Increased marrow storage iron ESR is high

34. Normochromic, normocytic anemia with effective erythropoiesis INCREASED reticulocyte count Acute blood loss Very acutely, with hypovolemia, may have normal blood counts, will become anemic with volume replenishment Hemolytic anemia Increased reticulocyte production cannot keep pace with loss of RBCs peripherally. Response to specific therapy in nutritional anemias

35. Aplastic anemia Pancytopenia caused by bone marrow failure…decreased production of all cell lines and replacement of marrow with fat. Inherited- Fanconis anaemia, Dyskeratosis congenita Acquired - Idiopathic,drugs like NSAIDs,chloramphenicol,benzene,parvo virus,hepatitis and EB virus.

36. Hemolytic anemia Abnormality intrinsic to red cells- Hereditary spherocytosis Thalassamia Sickle cell anaemia Glucose -6-phosphate dehydrogenase deficiency Abnormality extrinsic to red cells- Immune Mechanical etc

37. Evaluation of haemolytic anaemia

38. Hereditary spherocytosis Inherited defect in the red cell membrane cytoskeleton (spectrin, ankyrin or band 3) leading to the formation of spherocytic red cells. Autosomal dominant Mild to moderate anaemia Intermittent jaundice Splenomegaly Pigment gall stones Peripheral smear-microspherocytes Screening test-osmotic fragility

39. Thalassemia Decreased or absent globin chains Alpha and beta thalassemias Microcytic hypochromic,target cells,basophilic stippling Reticulocytosis Hb F elevated in electrophoresis

40. Sickle cell anaemia Presence of Hb S Point mutation in 6th place of beta chain Substitution of valine for glutamic acid On deoxygenation,sickle cells are formed Chronic hemolytic anaemia,vaso- occlusive crisis Aplastic crisis Hemolytic crisis Infections

41. Sickle cell anaemia Sickling test is positive. Solubility test is positive. Electrophoresis shows HbS. In sickle cell trait, electrophoresis shows 60 percent of Hb A and 40 percent Hb S

42. 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 Heinz bodies Red cells with heinz bodies destroyed in spleen(extravascular hemolysis)

43. Glucose-6-phosphate dehydrogenase deficiency Asymptomatic Neonatal jaundice Acute hemolytic anaemia Chronic hemolytic anaemia On peripheral smear- polychromasia,fragmented red cells,spherocytes,bite cells,half ghost cells Biochemical-increased bilirubin,hemoglobinemia and hemoglobinuria

44. Glucose-6-phosphate dehydrogenase deficiency Screening tests-fluorescent spot test,methemoglobin reduction test and dye decolorisation test

45. Immune hemolytic anaemia Warm antibody-persons over 50 years,mild jaundice and splenomegaly,red cells coated with IgG,spherocytes.Seen in autoimmune disorders,lymphoma Col d a n tibod y -ac r oc y anosi s ,IgM.Seen in c old agglutinin disease, Paroxysmal cold hemoglobinuria (PCH)

46. Coomb’s test Detects presence of either antibody on RBC or of antibody in serum Helpful in determining if a hemolytic anemia is immune-mediated

47. SUMMARY Microcytic hypochromic anaemia-iron deficiency Macrocytic hyperchromic-megaloblastic anaemia Normochromic normocytic-hemolytic anaemia Pancytopenia-megaloblastic and aplastic anemias