Low Hb, No Problem:

When To Pay Attention

to Anaemia

Noor Farid (F1)

Case
● Case admitted to Fleming from 18/8/2022 to 1/9/2022
● 77-year-old lady was referred by GP due to low Hb 55. She complained of lethargy and
weight loss for past 3 months. Was previously fit and well.
● 12% weight loss for past 3 months
● Loss of appetite
● Productive cough with white sputum for 2 months
● Relevant past medical history: CKD stage 3, no history of previous hospitalisation.
● Never smoked, no pets
● Examination findings: fine crepitation at left mid & lower zone, and right lower zone
What would you do next?
She would need
1. If unstable, fluid resuscitation.
2. Blood transfusion (Hb <70g/L as per NICE)
3. Investigation of the cause of anaemia
What are the causes of anaemia?

1. Hypoproliferative
a. Production defects: e.g. aplastic, renal failure, hypometabolic state → reticulocyte low
b. Maturation defects: haemoglobin [haem - iron deficiency; globin - (thalassaemia)]; nucleus
(low vitamin B12/ folate)
2. Survival defects
a. Intrinsic: [membrane: spherocytosis], [enzyme (G6PD)], [haemoglobin: sickle cell disease]
b. Extrinsic: autoimmune (autoimmune haemolytic anaemia, TTP), mechanical injury (prosthetic
heart valve)
3. Sequestration - hypersplenism in portal hypertension
4. Blood loss - acute
Blood Test
FBC on admission ● U&E shows AKI on CKD
● CRP 49 on admission → reducing trend
● Hb 57 ● Ferritin 356 [5-204]
● WBC 12 [4-11], Neut 6 [2-7.5], Lympho ● Iron 12 [9-30]
4.96 [1-4] ● Vitamin B12 >2000 [187-883]
● Platelet 149 [150-450] ● Folate 6 [3.1-20]
● Hct 0.191 [0.35-0.47] ● TSAT 27% [female: 15-50%]
● MCV 75.2 [84-102] ● Iron 12 [9-30]
● MCHC 298 [300-350] ● LFT normal
● Reticulocyte 48 [10-100] ● TSH normal
● Film: Microcytic hypochromic picture with
poikilocytes suggestive of iron deficiency.
Some reactive lymphocyte
Chest X-ray (19/8/2022)

● Interstitial changes are

seen of the left mid zone
and of the right lower
zone.
● Infection remains a
possibility, although an
underlying sinister cause
cannot be excluded at this
stage
CT TAP on 24/8/2022
There are multiple nodular areas of peribronchovascular consolidation throughout the lungs, predominantly within the right lower lobe
and left upper lobe, with surrounding ground-glass change and intra- and interlobular septal. thickening. There is the impression of a
component which is nodular with surrounding ground glass.

There is small volume mediastinal and hilar lymphadenopathy, a lymph node in station 4L measuring up to 10 mm in short axis (series 2,
image 89). A right hilar lymph node measures up to 9 mm in short axis (series 2, image 111). Partially calcified prominent subcarinal lymph
node. Hypoenhancing lesion in segment IVb of the liver has benign appearances. Otherwise unremarkable appearances of the liver,
spleen, pancreas, gallbladder, adrenal glands, kidneys, urinary bladder and unprepared bowel. No abdominal or pelvic lymphadenopathy.
Bilateral pelvic sterilisation clips in situ. There is the impression of subtle, global increased density of the bones, without focal lesion.

Impression:
The appearances in the lungs are extensive and a little non specific.
Atypical infection and in particular fungal/angioinvasive aspergillosis should be excluded, although there is no indication that this is an at
risk patient. Possible causes of immune suppression should perhaps be sought.
A vasculitis should be ruled out. Suggest also reviewing the drug chart.
Malignancy is thought less likely but follow up imaging at least should be undertaken. MDT discussion could be considered. Slight
increased bone density. I note presentation with AKI. Renal osteodystrophy is possible but the appearance is very mild and may not be
significant. A respiratory opinion is advised.
More blood tests
● Blood culture: no growth ● Cerebellum/ Neuronal antibodies: negative
● Haptoglobin: 4.67 [0.3-2] ● Total IgE normal
● LDH: 276 [125-220]
Free light chains:
● EPO: 2.3 [4.3-29]
● Free kappa light chain 112 [3.3-19.4] ● CMV serology: positive IgG (past infection)
● Free lambda light chain 67 [5.7-26.3] ● EBV: positive IgG (past infection)
● Kappa: Lambda ratio 1.68 [0.26-1.65 ● HIV: negative
● Hepatitis C negative
● Hepatitis B negative
● Immunoglobulins: within normal ranges, no serum ● Aspergillus precipitin 87 [cut-off for non-CF 40]
paraproteins detected ● Aspergillus galactomannan: not detected
● ANA negative ● Beta D Glucan negative
● C3 &C4 normal ● Sputum TB not detected
● ANCA negative
● tTg antibody
● GBM antibody <2.9 (neg)
Bronchoscopy
● Bronchial washing cytology: alveolar macrophages, mixed inflammatory cells,
mature squamous cells, benign endobronchial cells. No malignant cells seen.
● BAL microscopy, MC&S, TB: negative
Haematology Advice (August 2022)
● If Hb <70, RBC transfusion

● Iron deficient – Ferrinject

● Send peripheral blood for immunophenotyping (purple bottle & handwritten) to

see what the lymphocytosis is.
● Depending on the immunophenotyping result, may need bone marrow biopsy.
Immunophenotyping Report
In keeping with Myelodysplasia picture.
● A referral to Haematology was made for myelodysplasia.
● She was subsequently discharged and had an outpatient bone marrow biopsy
scheduled.
Bone marrow biopsy report (23/9/2022)

Consistent with Acute myeloid leukemia with myelodysplasia-related changes

(AML-MRC)

She has been started on chemotherapy: venetoclax, azacitidine

Readmitted to Toghill Ward from 21/10/2022 - 25/11/2022

● Worsening breathlessness – had levofloxacin

● CT chest (26/10/2022):

Comparison with the previous CT dated 24/08/2022.

Interval progression of multifocal consolidation. New dense consolidation

within the left upper lobe, lingula and left lower lobe with surrounding
ground glass opacification and interlobular septal thickening. There has been
slight interval improvement in the right lower lobe consolidation. The right
upper and middle lobes are relatively spared.
Admission in Toghill
● Aspergillus galactomannan & Beta D Glucan: negative
● Legionella Ag: negative
● BAL (1/11/2022 ): negative for Gram stain, WBC , Aspergillus galactomannan,
TB, respiratory viruses, atypical pneumonia PCR
● BAL Cytology: no malignant cells seen.
Lung MDT (9/11/2022)

Factors considered:

1. Myelodysplastia ; PH AML
2. Interval CT; worsening features, but also migrated (i.e. not all the same areas) ?
Cryptogenic organising pneumonia. Cancer seems less likely.
3. Bronchial wash: no malignancy or inflammation

MDT recommendations:

4. Current inpatient with neutro sepsis

5. Consider repeat bronchoscopy when / if fit
Organising Pneumonia (OP) in MDS
● Bilateral or multiple recurrent or migratory lung lesions were observed over
time.
● OP is defined histopathologically by intra-alveolar buds of granulation tissue.
● Proposed theories on the relationship between MDS and OP: deregulation of
innate immune and inflammatory signalling is described.
● The standard treatment of OP is corticosteroids
● The prognosis of idiopathic OP is usually not poor; however the mortality of
secondary OP is higher than idiopathic OP.
Patient’s current management
● Chemotherapy

● Antimicrobial prophylaxis: acyclovir, co-trimoxazole

● Nutritional support
Lessons
● Not all anaemias are caused by nutritional deficiency.
● Other causes of ground glass changes on CT Chest:
○ infections (PCP, viruses)
○ chronic interstitial diseases (eosinophilic pneumonia)
○ acute alveolar diseases (cardiogenic pulmonary oedema, ARDS)
○ others (neoplasm, drug toxicity).
● Importance of communicating with other specialities.
Thank you.