Microcytic hypochromic anemia

SEMINAR ON ANEMIA

1. MICROCYTIC HYPOCHROMIC ANEMIA -DR. NOOPUR PATIL ( JR PATHOLOGY)

2. MICROCYTIC HYPOCHROMIC ANEMIA : DEFINITION : It is a morphological type of anemia in which the circulating RBC’s are smaller than normal( with a MCV<80FL) and have increased area of central pallor due to hemoglobin deficiency. They comprise of five types: 1)Iron deficiency anemia(m/c/c of mc- hc anemia ) 2)Thalassemia 3) Sideroblastic anemia 4)Anemia of chronic disease 5)Anemia of chronic lead poisoning( Plumbism )

3. IRON DEFICIENCY ANEMIA Definition : IDA is characterised by microcytic hypochromic red cells with MCV<80fl,MCH<25pg. IRON METABOLISM AND ITS ROLE IN HOMEOSTASIS : Iron in food is in form of ferrous. Inside stomach in presence of pepsin,low ph its gets converted to ferric. At the mucosal level the ferric gets converted to ferrous in presence of enzyme ferricreductase,cytochrome B,STEAP3. The ferrous iron is transported with help of DMT-1 transporter and stored intra cellularly as FERRITIN ( preotein iron complex) The ferritin is transported across basolateral membrane to plasma with help of FERROPORTIN 1 . From here on the export of iron from enterocyte is faciliatated by ferroxidase activity of hephaestin , and ferrous gets converted to ferric iron which combines with apotransferrin to form TRANSFERRIN( carries 2 molecules of iron at any time) In IDA,there is upregulation of : 1)Duodenal DMT-1 2) Cytochrome B 3) Ferroportin 1 mRNA and preoteins 4) mobilferrin .

4. Role of hepcidin : It is master NEGATIVE regulator of iron. It inhibits Ferroportin 1,thus iron remains stuck inside the intenstinal cells and is only lost when intestinal cells are shed off. At macrophage level it inhibits release of iron from old RBCs. At hepatic level, it regulates iron release form hepatic level. Hepcidin is regulated by : 1)Iron stores. 2) Erythropoietic activity. 3)Hemoglobin 4)Oxygen carrying capacity 5)Inflammation (IL-6) Storage of Iron : 1) Hemosiderin : Brown pigment in RE cells of BM,spleen,liver . (+) for Prussian blue reaction. 2) Ferritin : Made of iron + apoferritin . (-) for Prussion blue reaction. Range M: 15-300ng/ml and F: 12-200ng/ml .

5. STAGES OF IRON DEFICIENCY ANEMIA: STAGE IRON STORES SE. FERRITIN (UG/L) TIBC HB RED CELLS SE. TF RECEPTOR NORMAL IRON BALANCE N 15-300 (N) 300-360 (N) N NC-NC N NEGATIVE IRON BALANCE <20 >360 N NC-NC N IRON DEFICIENT ERYTHROPOIESIS NIL <15 >380 NC-NC IRON DEFICIENCY ANEMIA NIL <12 >400 MC-HC

6. PATHOGENESIS OF IDA : 1)Impaired Hb synthesis 2)Impaired cellular proliferation 3) Diminshed iron containing proteins. 4)Reduced cell survival. Clinical features: Onset: fatigure,palpitations,headache,diziness,breathlessness . Pica Epithelial changes: platynychia,koilonychia,bald tongue,angular stomatitis Pharyngeal webs: Plummer winson syndrome( pharyngeaql webs,mc-hc anemia,atrophic glossitis ) CHF: hyperdynamic ciculation,tachycardia . Neuropsychiatric manifestation: Lack of concentration,low IQ,deficit cognitive function. Immune function: impaired resistance to infection. Thyroid function: production of T3 :REDUCED. Shortness of breath. Pregnancy: LBW, maternal and child mortality.

7. DIAGNOSIS : 1)PERIPHERAL SMEAR : MCV<80FL, MCH< 25PG, MCHC< 27G/DL, RDW> 15% RDW>17.1 is diagnostic of IDA. Mild-moderate Anisopoikilocytosis is an important sign. Microcytic hypochromic RBC. Poikilocytosis showing PENCIL CELLS/CIGAR CELLS. Hypochromia with central pallor >1/3 rd . If hypochromia is 2/3- 3/4 th then the cells are known as RING CELLS/PESSARY CELLS. Microcytic RBC is when size of RBC is smaller than nucleus of small lymphocyte. Reticulocyte : 1-2% Platelets : INCREASED. RING CELLS PENCIL CELLS.

8. 2)BONE MARROW: BM is hypercellular with micronormoblastic reaction( normoblast are smaller and late micronormoblast demonstrate persistant Basophilia ME ratio- 2/1- 1/2 Mild degree of dyserythropoesis in form of nuclear budding and karyorrhexis .. 3)ASSESSMENT OF IRON STORES: A)Serum ferritin : <15 (Adults) <12(children) B)Serum iron: It is the measure of iron bound to transferrin . Decreased(10-15ug) C)TIBC: Increased(360-450) D) Transferrin saturation: <16% C and D are diagnostic of IDA . E)Serum transferrin receptors assay: Increased F)Free zinc protoporphyrin : Increased(200ug/dl) Early and sensitive sign of iron deficiency anemia . G)Serum ferrtin index: >2 s/o IDA

9. TREATMENT: 1)ORAL IRON : Ferrous sulphate 200mg containing 60mg iron Response to therapy is assesed by retic count on 7-10 th day. Hb restored in 6-8weeks. Continue for 3-6months to replenish stores. 2)PARENTERAL IRON: INDICATION : Late stage of pregnancy Post opwerative cases Rapid blood loss GI disturbances, IBD. Patient intolerant to oral iron IRON SORBITOL (IM) single dose/week IRON SUCROSE( well tolerated) (iv) Dose- 100-125mg/dl FERRIC GLUCONATE FERUMOXYTOL Dose- 500mg in 3-5mins. 3)BLOOD TRANSFUSION : INDICATION : Patient actively bleeding Severe symptoms like chest pain or shortness of breath.

10. THALASSEMIA: DEFINITION: group of hemolytic anemia which results from an inherited abnormality of globin production(quantitative hemoglobinopathy ). CLASSIFICATION : 1)B THALAESSEMIA : Commonest type. Decreased sybthesis of B chains of globin 2)A THALAESSEMIA : Decreased synthesis of a chain of globin 3)MISC THALESSEMIA : Due to multiple combinations of b and a gene with structurally abnormal HB like HbD,HbS.HbE .

11. 1)B THALAESSEMIA : They are AR disorders. Various mutations that bring suppression of B chains synthesis are single nucleotide subsitutions which are subdivided into: (a)Promoter region,chain terminator mutants. (b)Mutation affecting m-RNA procesing . (c)splicing mutations(m/c/c). B0/B+: some chains are formed . B0/B0: complete absence of B CHAINS . B+/B+: decreased amount of HbF,uncommon type .

12. (A)THALAESSEMIA MAJOR/COOLEYS ANEMIA : It is a homozygous state. Most severe form is characterised by severe anemia,increased HbF,transfusion dependant . PATHOPHYSIOLOGY OF THALAESSEMIA MAJOR : D efect in gene chromosome 11 This b chains are not produced. There is accumulation of free a chains inside the normoblasts . 1)Free a chains accumulate, and precipitate forming inclusions, this results in membrane damage and normoblastic maturation fails, this results in INEFFECTIVE ERYTHROPOEISIS. 2)Few red cells are formed from this ineffective erythropoeisis having membrane abnormalities, once such cells pass through the spleen they are sequestred and broken down and a HEMOLYTIC ANEMIc picture presents. 3)Development of anemia: leads to production of EPO which causes erythroid hyperplasia and expansion of medullary cavities. 4) Hepatosplenomegaly due to extramedullary hematopoeitic foci. 5)A chain combines with gamma chains to form HbF (20-95%) 6)Iron overload develops and starts getting deposited in myocardium(cardiac failure),pituitary(growth failure,delayed puberty),islets(DM). 7)Increased level of hepcidin .

13. CLINICAL FEATURES : Baby <1year of age is affected. At birth child is asymptomatic due to high level of HbF,once this hbf starts falling after 3 months the symptoms start developing. Baby has failure to thrive,infection,poor feeding,increased pallor. Protuberant abdomen due to hepatosplenomegaly . Frontal bossing(mongoloid facies / thalassemic facies ) Mild jaundice of hemolytic type. Cholelithiasis . Bone changes: expansion of diploe with thinner outer and inner table. Hair on end appearance of skull on X RAY. X RAY of metatarsals,metacarpals,phalanges demonstrates: MOSAIC PATTERN due to trabeculations . Growth development:short stature,large head,delayed puberty,increased risk of infections. Myocardial hemosiderosis : arrythmias and ccf . MRI with cardiac T2<10cm: MOST IMPORTANT PREDICTOR OF HEART FAILURE. Used to assess cardiac iron overload Early detection of cardiomyopathy

14. HEMATOLOGIC FINDINGS : A nemia- mod to severe. Hb : 3-8gm% RBC: MC-HC. PS:marked degree of anisopoikilocytosis . Target cells,central pallor of Hb maybe eccentric. Basophilic stippling. Nucleated RBCs: 5-40/100WBC. Tear drop cells,elliptical,fragmented RBC, RBC with howell jolly bodies. Aggregates of A chain inside RBC can be visualised by SUPRAVITAL STAINING WITH METHYL VIOLET. Retic <2% Iron status: Se ferrtin >1000ug/dl Tf saturation 55-90% TIBC: decreased (250-300ug%) Se iron: increased Se LDH: HIGH Se haptoglobin : low. NUCLEATED RBCs.

15. LAB TESTS FOR DIAGNOSIS: 1)ACID ELUTION TEST: KLEIHAUER BETKE METHOD FOR HbF . MOA: HbF are resistant to hb elution,thus they get stained. But HbA are not resistant to elution,thus they appear as Ghost cells. 2) Hb electophoresis : On starch agarose celluose acetate Demonstrates HbA,HbF in B+ thal . Demopnstrates HbF >90% IN B0 thal . Reverse phase HPLC: important tool for detection of various hemoglobinopathies . 3)Globin chain synthesis: A:B globin chain ration- 2-30: 1 4)ARMS(amplification refractory mutation system ) 5)PCR and multiplex PCR 6) Minisequencing . 7)Reverse Dot blot assay.

16. THALASSEMIA SCREENING : All mothers with Hb <11gm% Check MCV,MCH,MCHC,MESTROF. If MCV <70, MCH< 23, + NESTROF. Check HbA2 Evaluation. 1)HbA2 : 3.6-9% DIAGNOSIS: THAL TRAIT. 2)HbA2: 3.3-3.7% Do Se. ferritin Then rule out fe deficiency anemia. 3)HbA2: >9% DIAGNOSIS: HbE / Hb lepore .

17. (B)THALAESSEMIA INTERMEDIA : Double hetereozygous state. Moderately severe hemolysis. NOT TRANSFUSION DEPENDENT. Clinical features: Pallor: mild-moderate Growth development: normal or retarded. Adult develop: iron overload. Endocrine function: normla . Hematological functions : Hb : 7-10gm/dl Moderate degree of anisopoikilocytosis . with MC-HC anemia. HbF : 10-30% Marrow iron stores: Increased. TYPE HB MCV MCH MAJOR <7 50-70 12-20 INTERMEDIA 7-10 60-80 15-25 MINOR 9-11 65-70 25-30

18. (C)THALASSEMIA MINOR/B THAL TRAIT-BTT: Heterozygous state Asymptomatic. Little/no anemia. HEMATOLOGICAL FINDINGS : Hb : 10-12gm/dl. RBC: increased. MCV,MCH: decreased. MCHC: normal. Mentzer index : <13 s/o trait >13 s/o Fe def anemia. HbA 90-93% HbA2 3.9-8%(DIAGNOSTIC) Borderline HbA2 3.3-3.7%: creen for nutritional anemia. PS: mild anisopoikilocytosis with MC-HC anemia, Target cells,stippled RBCs. Low RDW <17%. NESTROF CELLS : In Thal trait,the RBC are more resistant to lysis than Normal RBC. Thus black line behind the test tube are not seen.

19. SIDEROBLASTIC ANEMIA: DEFINITON: They are heterogenous group of disorders characterised by amorphous iron deposition in the erythroblast mitochondria giving rise to ring sideroblasts -PATHOGNOMIC OF DIEASES. Ring sideroblasts are seen in a lot of conitions but their presence in BM is diagnostic of sideroblastic anemia.

20. 1)HEREDITARY SA : (A)X LINKED SA : X linked inheritence m/c occurs in males,3 rd decade Defect in : ALA SYNTHASE. MUTATION: are missense mutations affecting exons 5,7,8,9. Anemia is mild- mod,with decreased MCV. BM: erythroid hyperplasia with normoblasts showing inadequate hemoglobinization with cytoplasmia vacuoles. (B)X LINKED SA WITH ATAXIA : MUTATION: in ABC7 gene. There is disrupted mitochondrial iron hemostasis in neural cells- which causes neural dysfunction. Patients have cerebellar ataxia and incordination ( C)PEARSON SYNDROME : DEFECT: mitochondiral DNA affecting the respiratory chain generating ATP. Infantila SA with leucopenia,thrombocytopenia and dysfuntion of pancreas and liver. There is pancreatic insufficiency,malabsorption , cataract,weakness,ataxia and lactic acidosis. Anemia is moderately severe.

21. (D)THIAMINE RESPONSIVE ANEMIA(ROGERS SYNDROME ): Patient presentd with anemia. MUTATION: SLC19A2 gene. Dyserthropoesis aw DM and SHNL. (E)AUTOSOMAL RECESSIVE SA : MUTATION: SLC25A38. Severe disease not responding to pyridoxine. ( F)CONGENITAL SA WITH BCELL IMMUNODEFICIENCY: MUTATION: loss of function of TRNT1 GENE. 2)ACQUIRED SIDEROBLASTIC ANEMIA : ( A)IDIOPATHIC : Stem cell disorder resulting in abnormal hematopoesis . Occur due to : heteroplasmic point mutations of mitochondrial DNA,which impair mitochondrial iron metabloism and heme synthesis. Reduction in ALA ysynthase activity is more pronounced. HEMATOLOGICAL FINDINGS: Dimporhic anemia,ith basophilic stippling which stains + for iron granules. RBC: formed from ring sideroblasts are- MC-HC, but macrocytic BRC: Represent progeny of normal erythroid residual precursors.. Marrow reveals ring siderblasts : 25-90%. 3 criterias must be met: Iron granules must be large,granules >5,should be perinuclear .

22. PERINUCLEAR SIDEROTIC GRANULES. (B)CLONAL SA (MDS) 1)MDS WITH RING SIDEROBLAST 2)MDS WITH RING SIDEROBLAST AND DYSPLASIA 3)MDS WITH RING SIDEROBLAST AND THROMBOCYTOSIS.

23. ANEMIA OF CHRONIC LEAD POISONING: Exposure to lead results from large array of sources like fumes,ingestion of lead based paints, workers involved in battery charging industries. Lead inhibits enzymes: ALA dehyradatase,ferrochelatase . Hemolysis of RBC is increased as Lead inhibits ATPase and pyrimidine 5 nucleotidase activity. CF appear when lead level >75ug/dl. And urine concentration >0.1mg in 24hour urine sample. CF: abdominal pain,lead colic,motor neuropathy along with neuropsychiatric symptoms. Mild-mod degree of MC-HC anemia with basophilic stippling of red cells. Retic count- 10-15% Treatment: EDTA(chelating agent), and remove lead source.

24. ANEMIA OF CHRONIC DISEASES(ACD)/ANEMIA OF CHRONIC INFLAMMATION: DEFINITION : It is anemia associated with chronic infection and inflammations and malignances. Mild to mod anemia,variable hypochromia , hypoferremia,lower serum Iron,abundanct iron stores. Its is a hypoproliferative anemia.

25. PATHOGENESIS OF ACD:

26. LAB DIAGNOSIS: Evidence of chronic disease Raised ESR,CRP Mild to moderate anemia. It is a type of anemia in which microcytosis preceds the hypochromia . Lower serum iron, low TIBC,low transferrin saturation. Serum ferritin: normal or raised Serum transferrin receptor/log ferritin ratio <1 Serum hepcidin : high. Serum EPO: ELEVATED.