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Anaemia Comprehensive by DR Sarma
Anaemia Comprehensive by DR Sarma
Approach to Anemia
Important to remember
• Anemia is a clinical sign of disease
• It is not a single disease by itself
• Need to look for the underlying cause !
• Will we ignore a fever with out investigation ?
• Its diagnosis is not that simple !! We’ll make it
• Its very common and imp. in our practice
• Drug Rx. depends on the cause
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Definition of Anaemia
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Erythron
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The RBC Lineage
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Pro Erythroblast
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Early Normoblast
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Intermediate Normoblast
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Late Normoblast
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Reticulocyte
No definite nucleus
Reticulum of RNA
Deep blue staining
Light blue cytoplasm
Cell size about 10 µ
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Normal Red Cells
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Normal Red Cells
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Hemoglobin (Hb)
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First Question
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Types of Anaemia
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Screening Tests – Anaemia
• 57% Plasma
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The Three Basic Measures
MCV C ÷ A x 10 = 90 fl
MCH B ÷ A x 10 = 30 pg
MCHC B ÷ C x 100 = 33%
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Causes of Anaemia
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Hypoproliferative Anaemias
Failure of cell
maturation
Nuclear Cytoplasmic
breakdown breakdown
RETICULOCYTE COUNT %
• ‘RBC to be’ or Apprentice RBC
• Fragments of nuclear material
• RNA strands which stain blue
Normal
Less than 2%
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Reticulocytes
Supravital Leishman’s
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Reticulocyte Production Index
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Anaemia
Hypoproliferative Hemolytic
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Normal CBC
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Workup – Second Test
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Red Cell Size
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Mean Cell Volume (MCV)
MCV
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Red cell Distribution Width - RDW
MCV
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Anaemia Workup - 4th Test
Peripheral Smear Study
• Are all RBC of the same size ?
• Are all RBC of the same normal discoid shape ?
• How is the colour (Hb content) saturation ?
• Are all the RBC of same colour/ multi coloured ?
• Are there any RBC inclusions ?
• Are intra RBC there any hemo-parasites ?
• Are leucocytes normal in number and D.C ?
• Is platelet distribution adequate ?
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IDA -CBC
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Severe Hypochromia
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Microcytic Hypochromic - IDA
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Microcytic Hypochromic Anaemia
Serum Ferritin
TIBC
HIGH N or ↓
- BM Fe +
Iron Deficiency Anaemia IDA Not IDA, Other Mi A
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IDA – Special Tests
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Macrocytic Anaemias
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Macrocytosis of Alcoholism
• 25-96% of alcoholics
• MCV elevation usually slight (100-110 fl)
• Minimal or no anemia
• Macrocytes round (not oval)
• Neutrophil hyper segmentation absent
• Folate stores normal
Smoking increases the Red Cell Mass
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Megaloblastic Hematopoiesis
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Macrocytosis -MBA
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Anisocytosis - Macrocytic Anaemia
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HSN - MBA
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HSN - MBA
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Basophilic Stippling - MBA
BS occurs in Lead poisoning also
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Megalocyte in PS
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MBA - BM
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MBA - BM
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Megaloblast – FA deficiency
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Pernicious Anaemia - Tongue
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Normocytic Anaemias
1. Chronic disease
2. Early IDA
3. Hemoglobinopathies
4. Primary marrow disorders
5. Combined deficiencies
6. Increased destruction
7. Anaemia of investigations -ICU
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Anaemia of Chronic Disease
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‘Dimorphic’ Anaemia
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Poikilocytosis
Different Shapes of RBC
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Polychromasia - Spherocytosis
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Target Cells
1. Liver Disease
2. Thalassemia
3. Hb D Disease
4. Post splenectomy
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Tear Drop Cells
1. Myelofibosis
2. Infiltration of BM
3. Tumours of BM
4. Thalassemia
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Hair on end - Thalassemia Major
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Drepanocytes - SS
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Sickle Cell Anaemia
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Autosplenectomy - SS
Normal spleen is 8 to 12 cm
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Hemolytic Anaemia
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Tests Used to Diagnose Hemolysis
1. Reticulocyte count
2. Combined with serial Hb
3. Serum LDH
4. Serum bilirubin
5. Haptoglobin
6. Urine hemosiderin
7. Hemoglobinuria
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Findings in Hemolytic Anaemia
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MAHA
Micro Angiopathic Hemolytic Anaemia
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Hyperactive BM – Skull
Hemolytic Anaemia
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Spherocytosis
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Spherocytosis
Hereditary Spherocytosis
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Spherocytosis
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Elliptocytes
Hereditary Elliptocytosis, B12 or Folate↓
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Stomatocytes
Slit like central pallor in RBC
1. Liver Disease
2. Acute Alcoholism
3. H Stomatocyosis
4. Malignancies
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Echinocytes
Evenly distributed spicules > 10
1. Uremia
2. Peptic ulcer
3. Gastric Ca
4. PK-D
Called Burr Cells
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Acanthocytes
5-8 spikes of varying length, irregular intervals
Called Spur Cells, Occur in A H A
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Shistocytes
Fragmented, Helmet or triangle shaped RBC
1. MAHA
2. Prosthetic valves
3. Uremia
4. Malignant HT
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Leukoplakia - Aplastic Anaemia
1. Chloramphenicol
2. Neomercazole
3. Sulfonamides
4. Analgin
5. Phenytoin
6. Butazolidin group
7. Anti Ca drugs
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Normal BM High Power
E:G=1:3
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Shift in E : G Ratio
E:G=2:1
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BM - Aplastic Anaemia
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Myelofibrosis
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Post transfusion - CBC
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Howell-Jolly Bodies
Absence of Splenic function; Nuclear chromatin in RBC
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Pelger-Huet Anomaly
• Inherited condition
• PMN - Spectacles
• Heterozygous
• Homozygous fatal
• Neutrophil Bands ↑
• Normal WCC
• No e/o infection
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Anaemia Diagnosis -Algorithm
Anaemia Suspected
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Anaemia - Summary
• If Hb% is low – Do not start on Iron straight away
• Ask for RCC, Hematocrit – Derive MCV, MCH, MCHC
• Order for Reticulocyte count – Is RPI < 2 % or > 2%
• Thoroughly look for blood loss – acute / chronic / occult
• Is it hypo-proliferative or hemolytic or hemorrhagic anaemia
• If hypo proliferative – Microcytic or Macrocytic? (MCV, RDW)
• If microcytic – IDA or others – Spl. Iron tests, BM Iron
• If macrocytic – Megaloblastic (B12, FA) or Normoblastic BM
• If normocytic – Anaemia of chr. Disease – Liver, MRD, Ca
• Peripheral smear study for RBC size, shape, colouration etc.
• If retic. count is ↑- HA work up; Hb EP, spl. tests
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Thank You ALL
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