ANAEMIA

Year 3 MBBS 2022-2023 rotation 2

2/2/2023

Associate Professor Dr. Wint Wint Thu Nyunt

Department of Medicine
MAHSA University
• Anaemia
• Classification of anaemia based on mean corpuscular volume (MCV)
• Iron deficiency anaemia
• Megaloblastic anaemia (Vitamin B12 deficiency/ Folate deficiency)
• Approach to haemolytic anaemia
• Autoimmune haemolytic anaemia
• Microangiopathic haemolytic anaemia (MAHA) (TTP) (DIC)
• Paroxysmal nocturnal haemoglobinuria (PNH)
• Glucose-6-phosphate dehydrogenase (G6PD) deficiency
• Pyruvate kinase deficiency
• Hereditary spherocytosis
• Hereditary elliptocytosis
• Thalassaemia
• Sickle cell anaemia
 HAEMATOPOIESIS
Haematopoiesis = formation of blood cells
• Haematopoietic stem cell (HPSC)
differentiates into common myeloid
progenitor (CMP) or common lymphoid
progenitor (CLP) cells.
• Megakaryocyte-erythroid progenitors
(MEPs) produce megakaryocytic/
erythroid lineage cells.
• Granulocyte-monocyte progenitors
(GMPs) produce myeloid/monocytic
lineage cells.
• Common lymphoid progenitors (CLPs)
produce B lymphocytes, T lymphocytes
and NK cells.
• Red cell precursors formed in the bone marrow from the erythroid progenitor cells
are called erythroblasts or normoblasts. These divide and acquire haemoglobin,
which turns the cytoplasm pink; the nucleus condenses and is extruded from the cell.
• The first non-nucleated red cell is a reticulocyte, which still contains ribosomal
material in the cytoplasm, giving these large cells a faint blue tinge (‘polychromasia’).

Proliferation and differentiation of red cell precursors is stimulated by erythropoietin,

a polypeptide hormone produced by renal interstitial peritubular cells in response to
hypoxia.
Failure of erythropoietin production in patients with renal failure causes anaemia.
• Normal mature red cells circulate for about 120 days.
• They are 8 μm biconcave discs lacking a nucleus, but filled with
haemoglobin, which delivers oxygen to the tissues.

• Haemoglobin is a protein specially adapted for oxygen

transport.
• It is composed of four globin chains, each surrounding an iron-
containing porphyrin pigment molecule termed haem.
• Globin chains are a combination of two alpha and two non-
alpha chains.
• Each haem molecule contains a ferrous ion (Fe2+), to which
oxygen reversibly binds.
 ANAEMIA
Anaemia refers to a state in which the level of haemoglobin in the blood is
below the reference range appropriate for age and sex.
A low Hb (at sea level) is <13.5 g/dL for men and <11.5 g/dL for women.
 CLINICAL FEATURES OF ANAEMIA
• The clinical features of anaemia reflect diminished oxygen supply to the tissues.
• A rapid onset of anaemia (e.g. due to blood loss) causes more profound symptoms than a gradually
developing anaemia.
• Individuals with cardiorespiratory disease are more susceptible to symptoms of anaemia.
 HISTORY TAKING
Identification of patient Past surgical history
• Age Previous surgery (e.g. resection of the stomach or
• Gender small bowel malabsorption of iron and/or
• Race vitamin B12)
Chief complaint Menstrual history
• Symptom x duration (chronological order) Menorrhagia (IDA)
History of Presenting illness Drug history
• Symptoms of anaemia Drugs that cause or worsen blood loss
• Cause of anaemia – bleeding, haemolytic anaemia (jaundice), (anticoagulants, anti-platelet drugs, anti-
haemolytic anaemia [features of associated disorders (SLE)] IDA inflammatory drugs), haemolysis (sulphonamides,
(pica, restless leg syndrome, hair loss, brittle nails), megaloblastic anti-malarial drugs) or aplasia (chloramphenicol,
anaemia, vitamin B12 deficiency (subacute combined degeneration mercaptopurine)
of spinal cord), haematological disorders (infection, bleeding), Social history
chronic disease (CKD) Dietary history, vegan (intake of iron, B12, folate)
• Complications (HF) (IDA, megaloblastic anaemia)
Past medical history Travel history
• Gastrointestinal disease, haemorrhoids (IDA) Family history
• Blood disease (Thalassaemia, Sickle cell anaemia, G6PD deficiency) • Haemolytic anaemia, haemoglobinopathies,
• Blood transfusion oxidative enzymopathies, membranopathies
• Rheumatoid arthritis (anaemia of inflammation), chronic kidney • Autoimmune disorder
disease, liver disease, autoimmune disease (SLE) System review: CVS, urine colour
• Gall stones
 PHYSICAL EXAMINATION
Anaemia: pallor
Haemolytic anaemia: pallor, jaundice
Vital signs *
Specific findings related to aetiology of anaemia
• Iron deficiency anaemia: glossitis, angular stomatitis,
koilonychias, brittle nails
• Right iliac fossa mass due to an underlying caecal carcinoma
• Vitamin B12 deficiency: beefy tongue, neurological signs
(peripheral neuropathy, dementia, signs of subacute combined
degeneration of the cord)
• Thalassaemia: face, pallor, jaundice, hepatomegaly,
splenomegaly
• Sickle-cell anaemia: leg ulcers, stroke, features of pulmonary
hypertension
• Associated condition: e.g. SLE, autoimmune disease
• Haematological disorder: bleeding manifestation (petechia,
purpura, bruises), infection (fever), lymphadenopathy,
hepatomegaly, splenomegaly, gum hypertrophy
Complications
• Signs of heart failure
 INVESTIGATIONS OF ANAEMIA
Full blood count (FBC) (Hb, MCV, MCH, MCHC, red cell distribution width, red cell mass)
Hb: low  anaemia
MCV: low  microcytic anaemia
Full blood picture (FBP) (peripheral blood film)
Reticulocyte count
Reticulocyte count: high  reticulocytosis
Tests for causes of anaemia
e.g. Iron studies (serum iron, TIBC, serum ferritin), vitamin B12 level, folate level, Hb electrophoresis
+/- Tests for evidence of haemolysis
Hb: low
Serum unconjugated bilirubin: high
Serum lactate dehydrogenase (LDH): high
Reticulocyte count: high or normal
Serum haptoglobulin: low
+/- Tests for causes of haemolytic anaemia
e.g. Direct Coombs test: positive for AIHA
+/- Bone marrow aspirate and trephine biopsy examination
 MANAGEMENT OF ANAEMIA
Treat the underlying cause of anaemia
e.g. IDA  Iron supplements

Role of blood transfusion

Probably not if Hb >7 g/dL

Red blood cell (RBC) transfusions are given to raise the hemoglobin level in patients with anaemia or to
replace losses after acute bleeding.

All patients should be assessed clinically when transfusion is considered. Assessment includes:
• Symptoms (and whether attributable to anemia)
• Clinical status (vital signs, signs of hemodynamic instability, cardiac and respiratory examination)
• Underlying comorbidities
• Haemoglobin level
• Rate of hemoglobin decline and cause (active bleeding versus ongoing hemolysis versus decreased
RBC production)
Copyrights apply
To obtain a full blood count (FBC), anticoagulated blood is processed through automated blood analysers that use a variety of
technologies (particle-sizing, radiofrequency and laser instrumentation) to measure the haematological parameters.
 RED CELL DISTRIBUTION WIDTH (RDW)
In health or in unifactorial anaemia, all the red cells in a sample
are about the same size, and the graph of their volume
distribution forms a narrow peak.
In mixed anaemias, this peak broadens, reflecting an abnormally
large RDW.
e.g. in coeliac disease, poor absorption of iron (low MCV) and folate
(high MCV) may occur simultaneously, resulting in a combination of
microcytes and macrocytes in the circulation.

blood film: anisocytosis

RDW = the standard deviation of MCV divided by the mean MCV, multiplied by 100
Reference interval: 11.5–14.6%
 RETICULOCYTES
• Normal range: 0.8–2% or <85x109/L
• Peripheral blood film: polychromasia
• Young, larger RBCs (contain RNA) signifying active erythropoiesis.
• Increased in haemolysis, haemorrhage, haematinic replacement (B12, iron, or
folate is given to marrow that lack these).
 CLASSIFICATION OF ANAEMIA
BASED ON MEAN CORPUSCULAR VOLUME (MCV)
Microcytic anaemia Normocytic anaemia
Low MCV Normal MCV
• Iron deficiency anaemia • Acute blood loss
• Thalassaemia • Haemolysis
• Sideroblastic anaemia • Anaemia of chronic disease
• Anaemia of chronic disease (anaemia of inflammation)
(anaemia of inflammation) (ACD/AI)
(ACD/AI) • Bone marrow failure
• Renal failure
• Hypothyroidism
• Pregnancy
Macrocytic anaemia
High MCV
Megaloblastic:
• Vitamin B12 deficiency
• Folate deficiency
Non-megaloblastic:
• Reticulocytosis (e.g. bleeding, haemolysis)
• Alcohol excess
• Liver disease
• Hypothyroidism
• Pregnancy
• Hyperlipidemia
• Haematological disorder: myelodysplasia,
myeloma, myeloproliferative disorders, aplastic
anaemia
• Drugs: cytotoxic drugs (e.g. Hydroxycarbamide),
antifolate drugs (e.g. Phenytoin)
• Red cells in the bone marrow must
acquire a minimum level of
haemoglobin before being released
into the blood stream.
• While in the marrow compartment,
red cell precursors undergo cell
division driven by erythropoietin.
• If red cells cannot acquire
haemoglobin at a normal rate, they
will undergo more divisions than
normal and will have a low MCV
when released into the blood.
The MCV is low because component
parts of the haemoglobin molecule are
not fully available: that is,
• iron in iron deficiency,
• globin chains in thalassaemia,
• haem ring in congenital
sideroblastic anaemia,
• occasionally, poor iron utilisation in
the anaemia of chronic
disease/anaemia of inflammation.
• Hb
• MCV, MCH
• Reticulocyte count
• Peripheral blood film

Confirmatory test
Iron studies, Ferritin (IDA)
Hb electrophoresis (Thalassaemia)
Bone marrow examination (Sideroblastic anaemia)
• In megaloblastic anaemia, the biochemical
consequence of vitamin B12 or folate deficiency
is an inability to synthesise new bases to make
DNA. A similar defect of cell division is seen in
the presence of cytotoxic drugs or
haematological disease in the marrow, such as
myelodysplasia.
• In these states, cells, haemoglobinise normally,
but undergo fewer cell divisions resulting in
circulating red cells with a raised MCV.
Macrocytic anaemia
• The red cell membrane is composed of a lipid
bilayer that will freely exchange with the plasma
pool of lipid.
• Conditions such as liver disease, hypothyroidism,
hyperlipidemia and pregnancy are associated
with raised lipids and may also cause a raised
MCV.
• Reticulocytes are larger than mature red cells, so
when the reticulocyte count is raised – e.g. in
haemolysis – this may also increase the MCV.
• Hb
• MCV
• Reticulocyte count
• Peripheral blood film

Confirmatory test
Serum Vitamin B12 level
(Vitamin B12 deficiency)
Serum Folate level
(Folate deficiency)
20-year-old lady
C/O fatigue, lethargy x 1 month
P/E Pallor
FBC
• Hb 7.5 g/dL (N 11.5-16 g/dL)
• MCV 60 fL (N 76-96 fL)
• WCC 6x109/L (N 4-11x109/L)
• Plt 160x109/L (N 150-400x109/L)
20-year-old lady
C/O fatigue, lethargy x 1 month
P/E Pallor
FBC
• Hb 7.5 g/dL (N 11.5-16 g/dL)
• MCV 60 fL (N 76-96 fL)
• WCC 6x109/L (N 4-11x109/L)
• Plt 160x109/L (N 150-400x109/L)
 IRON DEFICIENCY ANAEMIA
Iron deficiency anaemia is the most common type of anaemia worldwide.
Causes
• Blood loss, e.g. menorrhagia or GI bleeding (e.g. bleeding haemorrhoid)
• Poor diet or poverty may cause IDA in babies or children (but rarely in
adults).
• Malabsorption (e.g. coeliac disease) is a cause of refractory IDA.
• In the tropics, hookworm (GI blood loss) is the most common cause.
Symptoms *History taking slide
Symptoms of anaemia
Pica, restless leg syndrome, hair loss, brittle nails, lack of concentration,
decrease in libido
Signs *Physical examination slide
Pallor
Atrophic glossitis, angular cheilosis
Chronic IDA (signs: now rare): koilonychia
Rarely, post-cricoid webs (Plummer–Vinson syndrome)
(chronic iron-deficiency anemia, postcricoid web, dysphagia)
 IRON DEFICIENCY ANAEMIA
INVESTIGATIONS
FBC: microcytic anaemia
low Hb (anaemia); low MCV (microcytosis), low MCH, low MCHC
Iron deficiency anaemia
• Peripheral blood film: microcytic, hypochromic anaemia with anisocytosis and poikilocytosis, pencil-shaped red cells
• Confirmed by low ferritin
(low serum iron with low TIBC, but these are less reliable).
(Ferritin is an acute phase protein and increased with inflammation, e.g. infection, malignancy.)
Transferrin is also low in IDA but is less affected by inflammation.
Cause of iron deficiency anaemia
This will depend on the age and sex of the patient, as well as the history and clinical findings.
• IDA with no obvious source of bleeding mandates careful GI workup.
• Check coeliac serology: if negative then refer all males and females who are not menstruating for urgent gastroscopy and
colonoscopy.
• Consider stool microscopy for ova if relevant travel history.
• Faecal occult blood is not recommended as sensitivity is poor.
 IRON DEFICIENCY ANAEMIA
MANAGMENT
• Iron
• Oral iron, e.g. ferrous sulfate 200mg/8h PO
• SE: nausea, abdominal discomfort, diarrhoea or constipation, black stools
• Hb should rise by 1 g/dL/week, with a modest reticulocytosis (young RBC).
• Continue for at least 3 months after Hb normalizes to replenish stores.
• IV iron is indicated if the oral route is impossible or ineffective, e.g. functional
iron deficiency in chronic renal failure, where there is inadequate mobilization
of iron stores in response to erythropoietin therapy.
• Role of blood transfusion *Slide
• Treat the cause of iron deficiency
• Prevention of iron deficiency
 MACROCYTIC ANAEMIA
INVESTIGATIONS
FBC
Hb  low
MCV  high
Reticulocyte count If high  reticulocytosis (bleeding, haemolysis)
Peirpheral blood film
• Oval macrocytes, hypersegmented neutrophils in B12 deficiency and/or folate deficiency
• Target cells (liver disease)
Other tests
Serum vitamin B12 level (vitamin B12 deficiency)
Serum folate (or red cell folate—a more reliable indicator of folate status, as serum folate only
reflects recent intake) (folate deficiency)
Liver function test (include gamma-GT) (Liver disease)
Thyroid function test (hypothyroidism)
Fasting lipid profile (hyperlipidemia)
Bone marrow biopsy is indicated if the cause is not revealed by the above tests.
It is likely to show one of the following four states:
1 Megaloblastic marrow
2 Normoblastic marrow (e.g. in liver disease, hypothyroidism)
3 Abnormal erythropoiesis (e.g. sideroblastic anaemia, leukaemia, aplasia)
4 Increased erythropoiesis (e.g. haemolysis).

B12 and folate deficiency result in similar blood film and bone marrow biopsy appearances.
 Oval macrocytes seen here in myelodysplastic
Megaloblastic anaemia: peripheral blood film showing many syndrome.
macrocytes and one hypersegmented neutrophil (normally there Note aniso- and poikilocytosis with small fragmented
should be ≤5 segments). cells (schistocytes).
Note:
B12 and folate deficiencies also cause oval
Macrocytes.
Macrocytes caused by alcohol and liver disease are
usually round.

A normal blood film, with a neutrophil, red cells, and platelets (arrows)
 MEGALOBLASTIC ANAEMIA
• A megaloblast is a cell in which nuclear maturation is delayed compared with the cytoplasm.
• This occurs with B12 and folate deficiency: both are required for DNA synthesis.
 VITAMIN B12 DEFICIENCY
CLINICAL FEATURES
General:
• Symptoms of anaemia
• ‘Lemon tinge’ to skin due to combination of pallor (anaemia) and mild
jaundice (due to haemolysis)
• Glossitis (beefy-red sore tongue)
• Angular cheilosis
Neuropsychiatric: Irritability, depression, psychosis, dementia
Subacute combined degeneration of the spinal cord
• Combination of peripheral sensory neuropathy with both upper and lower
motor neuron signs due to LOW B12
• Classical triad: extensor plantars (UMN), absent knee jerks (LMN), absent
ankle jerks (LMN)
• Onset is insidious (subacute) and signs are symmetrical.
• There is a combination of posterior (dorsal) column loss, causing the
sensory and LMN signs, and corticospinal tract loss, causing the motor and
UMN signs.
• The spinothalamic tracts are preserved so pain and temperature sensation
may remain intact even in severe cases.
• Joint-position and vibration sense are often affected first leading to ataxia,
followed by stiffness and weakness if untreated.
• The neurological signs of B12 deficiency can occur without anaemia.
 VITAMIN B12 DEFICIENCY
CAUSES
• Body stores of B12 are sufficient for 4 years.
• Vitamin B12 deficiency is common, occurring in up to 15% of older people.
• B12 helps synthesize thymidine, and hence DNA, so in deficiency, RBC production is slow.
• Untreated, it can lead to megaloblastic anaemia and irreversible CNS complications.

Causes of deficiency
• Dietary (e.g. vegans)
B12 is found in meat, fish, and dairy products, but not in plants.
• Malabsorption:
During digestion, intrinsic factor (IF) in the stomach binds B12, enabling it to be absorbed in terminal ileum.
Malabsorption can arise in the stomach due to lack of IF (pernicious anaemia, post gastrectomy) or the
terminal ileum (ileal resection, Crohn’s disease, bacterial overgrowth, tropical sprue, tapeworms).
• Congenital metabolic errors
 PERNICIOUS ANAEMIA (PA)
This is an autoimmune condition in which atrophic gastritis leads to a lack of IF
secretion from the parietal cells of the stomach. Dietary B12 therefore remains
unbound and conseqeuently cannot be absorbed by the terminal ileum.
Incidence: 1:1000; female:male≈1.6:1; usually >40yrs; higher incidence if blood
group A.
Associations:
• Other autoimmune diseases: thyroid disease (~25%), vitiligo, Addison’s disease,
hypoparathyroidism.
• Carcinoma of stomach is ~3-fold more common in pernicious anaemia, so have a
low threshold for upper GI endoscopy.
FOLATE DEFICIENCY
CAUSES

(poverty, alcoholic, elderly)

MEGALOBLASTIC ANAEMIA
INVESTIGATIONS
VITAMIN B12 DEFICIENCY ANAEMIA
• Hb: low
• MCV: high
• WCC: low or normal
• Platelets: low or normal
• Peripheral blood film: Oval macrocytes, hypersegmented
neutrophils
• Serum B12 level: low
• Bone marrow biopsy examination is not necessary to diagnose
Vit B12 deficiency. (Megaloblasts in bone marrow)
Specific tests for PA:
1 Parietal cell antibodies: found in 90% with PA
2 IF antibodies: specific for PA, but lower sensitivity
 VITAMIN B12 DEFICIENCY ANAEMIA
MANAGMENT
• Vitamin B12
• If due to malabsorption, give hydroxocobalamin (B12) 1mg IM alternate days
for 2wks (or, if CNS signs, until improvement stops), then 1mg IM every 3
months for life.
• If the cause is dietary, then oral B12 can be given after the initial IM course
(50–150mcg/daily, between meals).
• Folic acid (oral)
• Role of blood transfusion*slide
• Treat the cause if possible.
• Management of neurological condition (if present)
 FOLATE DEFICIECY ANAEMIA
MANAGMENT
• Treat with folic acid 5mg/day PO for 4 months
*** never without B12 unless the patient is known to have a
normal B12 level, as in low B12 state, it may precipitate, or worsen,
subacute combined degeneration of the cord.
• Role of blood transfusion *slide
• Assess for an underlying cause, e.g. poor diet, malabsorption.
• Treat the cause of folate deficiency
• In pregnancy, prophylactic doses of folate (400mcg/day) are given
from conception until at least 12wks; this helps prevent spina bifida,
as well as anaemia.
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HAEMOLYTIC ANAEMIA
 APPROACH TO HAEMOLYTIC ANAEMIA
Symptoms of anaemia
Pallor + Jaundice

• History *slide
• Physical examination *slide
• Investigations
• Management
• Treat the underlying cause
HAEMOLYTIC ANAEMIA
 AUTOIMMUNE HAEMOLYTIC ANAEMIA
• This results from increased red cell destruction due to red cell autoantibodies.
• The antibodies may be IgG or IgM, or more rarely IgE or IgA.
• If an antibody avidly fixes complement, it will cause intravascular haemolysis, but if
complement activation is weak, the haemolysis will be extravascular (in the reticulo-
endothelial system). Antibody-coated red cells lose membrane to macrophages in the
spleen and hence spherocytes are present in the blood.
• The optimum temperature at which the antibody is active (thermal specificity) is used to
classify immune haemolysis/
Warm antibodies Cold antibodies
Bind best at 37°C Bind best at 4°C but can bind up to 37°C in some cases.
The majority are igg and often react against rhesus antigens. They are usually igm and bind complement.
Account for 80% of cases 20% of cases
To be clinically relevant, they must act within the range
of normal body temperatures.
HAEMOLYTIC ANAEMIA
 GLUCOSE-6-PHOSPHATE DEHYDROGENASE
(G6PD) DEFICIENCY
• X-linked
• The chief RBC enzyme defect, affects 100 million (mainly male) in Mediterranean,
Africa, Middle/Far East
• Most are asymptomatic, but may get oxidative crises due to decreased glutathione
production, precipitated by drugs (e.g. primaquine, sulfonamides, aspirin), exposure to
Vicia faba (broad beans/favism), or illness.
• In attacks, there is rapid anaemia and jaundice.
Investigations
• FBC: anaemia during attack
• Liver function test: unconjugated bilirubin increased during attack
• FBP: bite cells, blister cells
Confirmatory test
• G6PD Enzyme assay (>8wks after crisis as young RBCs may have enough enzyme so
results normal).
Management
• Avoid precipitants (e.g. henna)
• Transfuse if severe anaemia
 HEREDITARY SPHEROCYTOSIS HEREDITARY ELLIPTOCYTOSIS
Autosomal dominant Autosomal dominant
Less deformable spherical RBCs, so trapped in spleen 
extravascular haemolysis
Clinical Splenomegaly, jaundice Mostly asymptomatic
features Gallstones (increased bilirubin) (somewhat protects from malaria).
10% display a more severe phenotype
(±death in utero).
Investigation Hb: low FBP: elliptocytes
Reticulocyte count: high
Serum uncojugated bilirubin: high
FBP: spherocytes
Coombs test: negative
Osmotic fragility tests: RBCs show increased fragility in
hypotonic solutions.
Management Folate Folate
Splenectomy helps some.
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 β THALASSAEMIA
INVESTIGATION
• FBC: Hb low; MCV low
• FBP: microcytic hypochromic anaemia, anisopoikilocytosis, target cells, basophilic
stippling, nucleated red cells
• Reticulocyte count: high
Confirmatory testing
Thalassemia is diagnostically confirmed via hemoglobin analysis and genetic testing.
Hemoglobin analysis
• High-performance liquid chromatography (HPLC) or hemoglobin electrophoresis
• β thalassemia intermedia  elevated levels of HbF and HbA2
• β thalassemia major  elevated levels of HbF; HbA2 variable; HbA absent
Genetic testing
• Diagnosis of beta thalassemia intermedia does not always require DNA-based
genotyping, but such analysis may aid in recognizing complex thalassemias such as
delta-beta and gamma-delta-delta thalassemia.
 REFERENCES
• Penman, I.D., Ralston, S.H., Strachan, M.W. and Hobson, R., editors.,
2022. Davidson's Principles and Practice of Medicine. 24th Edition.
Elsevier Health Sciences.
• Wilkinson, I., Wilkinson, I.B., Raine, T., Wiles, K., Goodhart, A., Hall, C.,
O'Neill, H., 2017. Oxford handbook of clinical medicine. 10th Edition.
Oxford university press.
• UpToDate