ANEMIA Race or Ethnic Group

Greek word “anaimia” meaning without blood Family History of Disease

Caused by: Insufficient Hemoglobin (More frequent Neurologic Symptoms
cause)
Previous Medication
Hemoglobin with impaired function
Previous episodes of Jaundice
By theses causes, can anemia be also caused by
Other various underlying diseases Symptoms
decreased RBC count?
related to Anemia (For example, Pica)
“Anemia should not be thought of as a disease but
Can a patient be asymptomatic?
rather as a manifestation of an underlying disease
or deficiency”
WHAT CAN AFFECT NORMAL VALUES FOR HGB, AFTER ASSESSMENT OF HISTORY, PATIENT MIGHT
HCT, AND RBC COUNT? BE CHECKED FOR OTHER CLUES
Sex Skin (Petechiae)
Age Eyes (Pallor, Jaundice, Hemorrhage)
Race Mouth (Mucosal Bleeding)
Environmental Conditions Sternal Tenderness
Laboratory Factors Lymphadenopathy
PATIENT HISTORY AND CLINICAL FINDINGS Cardiac Murmurs
WE HAVE NOW ESTABLISHED THAT ANEMIA Splenomegaly Hepatomegaly
INDICATES A PROBLEM WITH HEMOGLOBIN.
VITAL SIGNS = Fast heart rate (Tachycardia) if
WHAT DOES THAT INDICATE FOR THE PATIENT? hemoglobin lowered quickly
Decreased Oxygen Delivery Moderate Anemia = 7-10g/dL
Classical Symptoms = Anemia, Fatigue, Shortness of Severe anemia = <7g/dL (Tachycardia,
Breath Hypotension))
USUAL ASSESSMENT FOR ANEMIA
Diet PHYSIOLOGIC ADAPTATIONS
Drug ingestion •With rapid blood loss, hemoglobin and hematocrit
may be initially unchanged because there is
Exposure to Chemicals
balanced loss of plasma and cells. However, as the
Occupation drop in blood volume is compensated for by
movement of fluid from the extravascular to the
Hobbies
intravascular compartment or by administration of
Travel resuscitation fluid, there will be a dilution of RBCs
and anemia.
Bleeding History
MECHANISMS Microcytosis = Shift of curve to the left
Macrocytosis = Shift of curve to the right
(1) Ineffective Erythropoiesis
Anisocytosis = Widening of the curve
The Bone Marrow can produce cells but
these are DEFECTIVE. RETICULOCYTE COUNT
Often undergo apoptosis before even
Purpose?
maturing
Examples: Megaloblastic Anemia, What are reticulocytes?
Thalassemia, Sideroblastic Anemia
How long do they stay in peripheral blood?
• In these anemias, the peripheral blood Reference interval? For Adults? Children?
hemoglobin is low, which triggers an Newborns?
increase in erythropoietin leading to
What is the difference of Retic count and Absolute
increased erythropoietic activity. Although
retic count? (Normal value?)
the RBC production rate is high, it is
ineffective in that many of the defective Why do we need to correct the reticulocyte count
RBC precursors undergo destruction in the using Hematocrit? (CRC)
bone marrow. The end result is a decreased
Why do we need to correct the reticulocyte count
number of circulating RBCs resulting in
using Maturation time in day? (RPI)
anemia

(2) Insufficient Erythropoiesis

WHAT IS IMMATURE RETICULOCYTE FRACTION
Decrease in erythroid precursors =
(IRF)
Decreased production
Examples: Iron deficiency Ratio of immature reticulocytes to total
Erythropoietin deficiency (Renal disease) reticulocytes
Loss of erythroid precursors due to
• Purpose? assessing early bone marrow response
autoimmunity or infection.
after treatment for anemia
Infiltration of Bone Marrow of granulomas
(sarcoidosis) or Malignant cells (Leukemia)

PURPOSE OF RETICULOCYTE COUNT IN

(3) Blood loss and Hemolysis
EVALUATING ANEMIA
-Acute Blood loss
-Chronic Blood loss (This can result to IDA) Determining whether an anemia is due to an RBC
-Hemolytic Anemias production defect or to premature hemolysis and
shortened survival defect
LABORATORY DIAGNOSIS
• Although an increased reticulocyte count is a
CBC WITH RBC INDICES
hallmark of the hemolytic anemias, it can also be
What is included in the CBC and RBC
observed over time in acute blood loss.
Indices?
• Chronic Blood Loss = NO INCREASE IN RETIC
RBC Histogram where Ordinate = Number COUNT
of RBCs

Abscissa = Volume of RBCs

PERIPHERAL BLOOD FILM EXAMINATION
BONE MARROW EXAMINATION
Indicated for a patient with:
UNEXPLAINED ANEMIA
Fever of unknown origin
Suspected hematologic malignancy
What is done in Bone Marrow Examination?
• Evaluates hematopoiesis (cellularity,
megaloblastic changes, lack of iron stains,
• Investigates infiltration (presence of
granulomata, fibrosis, infectious agents, and tumor
cells)
OTHER LABORATORY TESTS
• Routine Urinalysis (Why?)
• Stool analysis
• Serum haptoglobin, hemopexin, Lactate
dehydrogenase, and B1
• Renal and hepatic function tests
• Iron Studies
• Vitamin B12 and Folic acid assays
• Direct antiglobulin test
ANEMIA EVALUATION (MOST IMPORTANT PART)
For Hemoglobin, Hematocrit, RBC Count and MCV
(First step in Lab Diagnosis)
Knowledge of previous hematologic values is
valuable as a reduction of 10% or more in these
values may be the first clue that an abnormal
condition may be present
MORPHOLOGIC CLASSIFICATION OF ANEMIA
BASED ON MEAN CELL VOLUME
MCV is the key in MORPHOLOGIC CLASSIFICATION
of anemia
Microcytic Anemia = <80fL (Associated with
Hypochromia – more central palor)
• Caused by conditions that result in reduced
hemoglobin synthesis (iron deficiency,
anemia of chronic inflammation,
sideroblastic anemia, lead poisoning,
thalassemia, Hb E disease)
Macrocytic Anemia = 100 fL
• arise from conditions that result in
megaloblastic (up to 150fL) or
nonmegaloblastic (usually do not
reach >115fL) red cell development in the
bone marrow
Normocytic Anemia = 80-100fL
• Note: Assure first that a Normocytic MCV is not
due to Macrocytic and Microcytic RBCs being
together (Bimodal distribution on Histogram)
• Hemolytic Anemias (Increased RPI)
• Decreased production of RBCs (Decreased RPI)
MORPHOLOGIC CLASSIFICATION OF ANEMIA AND
THE RETICULOCYTE COUNT
High RPI = >3
Low RPI = <2
MORPHOLOGIC CLASSIFICATION OF ANEMIA AND
RDW
Homogenous (Normal RDW)
Heterogenous (High RDW)
DISORDERS OF IRON KINETICS AND HEME
METABOLISM
A review first.
RPI?
Morphologic Classification?
Iron Deficiency Anemia
There are four reasons for this
• Inadequate intake
• Increased need (Pregnants and Growing
individuals)
• Impaired absorption (May be pathologic or
mutation of proteins needed)
• Chronic Blood Loss (Hookworm, Ulcer, Prolonged
mens)
Iron is distributed among three compartments: the
storage compartment, principally as ferritin in the
bone marrow macrophages and liver cells; the
transport compartment of serum transferrin; and
the functional compartment of hemoglobin,
myoglobin, and cytochromes
3 Stages of IDA: ((Storage muna then transport
then function)
• Stage 1 (Latent or Subclinical) – Ferritin is low.
Asymptomatic.
• Stage 2 – Storage is exhausted. Hgb of retics
begin to decrease. Not evident. Still subclinical
• Stage 3 – Frank anemia. Glossitis (Sore tongue),
Koilonychias (spooning of nails), Pica.
Iron deficiency is also associated with infection
with other parasites, such as Trichuris trichiura,
Schistosoma mansoni, and Schistosoma
haematobium, in which the heme iron is lost from
the body due to intestinal or urinary bleeding.
• An RDW greater than 15% is expected and may
precede the decrease in hemoglobin
• Iron studies remain the backbone for diagnosis of
iron deficiency. They include assays of serum iron,
total iron-binding capacity (TIBC), transferrin
saturation, and serum ferritin
• Transferrin levels increase when the hepatocytes
detect low iron levels, and research shows that this
is a transcriptional and posttranslational response
to low iron levels.
• Transferrin decreases during inflammation
• During treatment, Reticulocyte hemoglobin
content will correct within 2 days. Reticulocyte
counts (relative and absolute) begin to increase
within 5 to 10 days. The anticipated rise in
hemoglobin appears in 2 to 3 weeks
Anemia of Chronic Inflammation
• The central feature of anemia of chronic
inflammation is sideropenia in the face of
abundant iron stores.
• During inflammation, the liver increases the
synthesis of hepcidin (Hepcidin is an acute phase
reactant in response to interleukin-6 produced by
activated macrophages)
• This response of hepcidin during inflammation is
likely a nonspecific defense against invading
bacteria. • (A second acute phase reactant)
Lactoferrin is an iron-binding protein in the
granules of neutrophils. Its avidity for iron is
greater than that of transferrin.
• Lactoferrin is important intracellularly for
phagocytes to prevent phagocytized bacteria from
using intracellular iron for their metabolic
processes.25 During infection and inflammation,
however, neutrophil lactoferrin also is released
into the plasma. There it scavenges available iron,
at the expense of transferrin. When it is carrying
iron, the lactoferrin becomes bound to
macrophages and liver cells that salvage the iron.
RBCs are deprived of this source of plasma iron,
however, because they do not have lactoferrin
receptors
• Ferritin (3rd acute phase reactant) in the plasma
also bind some iron. Because developing RBCs do
not have a ferritin receptor, this iron is also
unavailable
Sideroblastic Anemia
• Prevents production of protoporphyrin or
incorporation of iron into it
• As in iron deficiency, the anemia may be
microcytic and hypochromic. In contrast to iron
deficiency, however, iron is abundant in the bone
marrow (Dimorphic)
• A Prussian blue stain of the bone marrow shows
normoblasts with iron deposits (Sideroblasts)
• Its presence in the mitochondria shows that the
iron is awaiting incorporation into heme
• These ring sideroblasts are the hallmark of the
sideroblastic anemias
• A diverse group of diseases. Can be Hereditary
and Acquired (Primary/Refractory and Secondary)
• EXAMPLE: LEAD POISONING AND PORPHYRIAS
Along with Lead Poisoning and Porphyrias
LEAD POISINING
Although anyone can experience lead poisoning, it
is of special concern in children because the metal
affects the central nervous system and the
hematologic system, leading to impaired mental
development as well as anemia. In children and
adults with lead poisoning, a peripheral
neuropathy can be seen with abdominal cramping
and vomiting or seizures
Lead interferes with porphyrin synthesis at several
steps. The most critical are as follows:
1. The conversion of aminolevulinic acid (ALA) to
porphobilinogen (PBG) by ALA dehydratase (also
called PBG synthase); the result is the accumulation
of aminolevulinic acid.
2. The incorporation of iron into protoporphyrin IX
by ferrochelatase (also called heme synthase); the
result is accumulation of iron and protoporphyrin
(NORMO/NORMO in LEAD) Chronic leads to
Microhypo
PHORPHYRIAS
diseases characterized by impaired production of
the porphyrin component of heme
When an enzyme in heme synthesis is missing, the
products from earlier stages in the pathway
accumulate in cells that actively produce heme,
such as erythrocytes and hepatocytes. The excess
porphyrins leak from the cells as they age or die.
Some of the accumulated products are fluorescent.
Their deposition in skin can lead to photosensitivity
with severe burns upon exposure to sunlight.
Accumulation during childhood leads to
fluorescence of developing teeth and bones.
Acute Porphyrias (Acute Intermittent Porphyria,
Variegate Porphyria,
Hereditary Coproporphyria and ALA-dehydratase
Deficiency Porphyria)
• Commonly suffer from attacks of – severe
stomach pain, or pain in back, legs or arms,
constipation, nausea, vomiting, dark, purple-red or
brown coloured urine, and sometimes - muscular
weakness (from nerve damage) particularly in arms
is common – but this can progress to complete
paralysis, psychiatric symptoms, convulsions.
Cutaneous Porphyrias (Porphyria Cutanea Tarda,
Erythropoetic
Protoporphyria and Congenital Erythropoetic
Porphyria)
• photosensitivity leading to burning and itching or
skin lesions and fragile skin after exposure to the
sun, many people with PCT suffer from liver cell
damage. Two of the acute porphyrias, Variegate
Porphyria and Hereditary Coproporphyria, also
suffer from skin problems when exposed to
sunlight.
•Most porphyrias are INHERITED, except for
PORPHYRIA CUTANEA TARDA
• Iron Overload - Body’s first reaction is to store
excess iron in the form of ferritin and, ultimately,
hemosiderin within cells leading to
Hemochromatosis. Also called Bronze diabetes
ANEMIA CAUSED BY DEFECTS OF DNA
METABOLISM
•The hematologic effects, especially megaloblastic
anemia, have come to be recognized as the
hallmark of the diseases affecting DNA metabolism.
• Vitamin B12 has 2 biochem reactions in humans
• Methylmalonyl coenzyme A (CoA) > Succinyl
CoA (Methylmalonic acid is the
intermediate) (JUST REMEMBER THAT MMA
INCREASES)
• Transfer of a methyl group from 5-
methyltetrahydrofolate (5-methyl THF) to
homocysteine, which thereby generates
methionine
• Folate circulates in the blood predominantly as 5-
methyl THF. Inactive until demethylated to THF.
Folate has an important role in DNA synthesis.
• Folate deficiency has the more direct effect.
• The effect of vitamin B12 deficiency is more
indirect, preventing the production of THF from 5-
methyl THF
• When vitamin B12 is deficient, progressively
more and more of the folate becomes
metabolically trapped as 5-methyl THF. This
constitutes what has been called the folate trap
• The slower maturation rate of the nucleus
compared with the cytoplasm is called nuclear-
cytoplasmic asynchrony.
• Other Causes of megaloblastic anemia:
• Dysplastic erythroid cells (MDS)
• CDA Type 1 and 3 (In CDA I, internuclear
chromatin bridging of erythroid cells or
binucleated forms are observed, and in CDA
III, giant multinucleated erythroblasts are
present)
• FAB M6.
•general symptoms related to the anemia (fatigue,
weakness, and shortness of breath) and symptoms
related to the alimentary tract. The loss of
epithelium on the tongue results in a smooth
surface and soreness (glossitis). In vitamin B12
deficiency, neurologic symptoms may be
pronounced and may even occur in the absence of
anemia.5 These include memory loss, numbness
and tingling in toes and fingers, loss of balance, and
further impairment of walking
Causes
• Folate
• Inadequate intake, Increased need,
Impaired absorption, Impaired use of drugs
(Chemo), Excessive loss (Dialysis)
• B12
• Same sa folate + Pernicious anemia,
Helicobacter pylori infection, lack of
intrinsic factor, Gastrectomy, D. latum
• Impaired absorption
• Five tests used to screen for megaloblastic
anemia are the
1. complete blood count (CBC)
2. reticulocyte count
3. white blood cell (WBC) manual differential
4. serum bilirubin
5. lactate dehydrogenase.
• CBC and Retic Count – Oval Macrocytes, Low
reticulocytes, No polychromasia, Pancytopenia
• WBC Differential - Hypersegmentation of
neutrophils with 6 or more lobes.
• Bilirubin and LD Levels – Increased

IN THE NEXT SLIDE, Take note of Oval Macrocytes
and Hypersegmented Neutrophils
Sequence of Development of Megaloblastic
Anemias
1. Decrease in Vitamin Levels
2. Hypersegmentation
3. Oval Macrocytes
4. Megaloblastosis in Bone Marrow
5. Anemia
OTHER TESTS
• Folate and B12 Levels can be measured using
immunoassays. B12 – also by chemiluminescence.
• Gastric analysis to test for achlorhydria (expected
finding in pernicious anemia)
• Test for Antibodies to Intrinsic Factor and Parietal
Cells
• Holotranscobalamin Assay
• Deoxyuridine Suppression test
• Stool Analysis for Parasites (D. LATUM)
What happens after treatment?
1 week – Reticulocyte response is substantial
2 weeks – Hypersegmentation disappears
3 weeks – Hemoglobin increases towards normal
Macrocytic Nonmegaloblastic Anemias
• Macrocytic anemias in which DNA synthesis is
unimpaired.
1. NO hypersegmented neutrophils
2. NO OVAL macrocytes
3. NO megaloblasts in Bone Marrow.
Causes include:
• Newborns
• Reticulocytosis
• Liver Disease
• Chronic Alcoholism
• BM Failure
BONE MARROW FAILURE
•Reduction or cessation of blood cell production
affecting one or more cell lines.
APLASTIC ANEMIA
• Acquired – Drugs/Chemicals/Radiation/Viruses
(EBV, HIV, Hepa, Parvovirus B19)/Other conditions
like PNH, Autoimmune diseases, and Pregnancy.
Most are acquired PLEASE TAKE NOTE OF PNH,
PARVO)
• Inherited – Fanconi’s, Dyskeratotis congenita,
Swachman-Bodian-Diamond syndrome.
Laboratory Results:
• Elevated levels of Erythropoietin,
Thrombopoietin and colony stimulating factors.
However, despite their elevated levels, growth
factors are generally unsuccessful in correcting the
cytopenias found in acquired aplastic anemia.
• No splenomegaly
• Pancytopenia
• Normo/Normo
• Hypocellular Bone Marrow (Biopsy)
• Increased Iron
Fanconi’s Anemia
• A chromosome instability disorder
• Aplastic anemia, Physical abnormalities, Cancer
susceptibility
• Chromosome breakage analysis is the diagnostic
test
DKC (Dyskeratosis Congenita)
• Mucocutaneous abnormalities, BM Failure,
Pancytopenia
• Clinical presentation: Abnormal skin
presentation, dystrophic nails, and oral leukoplakia
Shwachman-Bodian-Diamond Syndrome
• Pancreatic insufficiency, Cytopenia, Skeletal
abnormalities
• Predisposition for hematologic malignancies
MYELOPHTHISIC ANEMIA
•Infiltration of abnormal cells into the bone
marrow and subsequent destruction and
replacement of normal hematopoietic cells
• Teardrop erythrocytes and Hypercellular BM
ANEMIA OF CHRONIC KIDNEY DISEASE
• Complication of Renal disease a positive
correlation between anemia and renal disease
severity
• Inadequate renal production of Erythropoietin •
Uremia also inhibits erythropoiesis and increases
RBC fragility
• Burr Cells common peripheral blood film findings
in cases complicated by uremia

PURE RED CELL APLASIA

• Selective and severe decrease in erythrocyte
precursors in an otherwise normal bone marrow.
• Severe anemia and reticulocytopenia with normal
WBCs and platelets
• Acquired – Transient erythroblastopenia of
childhood (TEC)
• Congenital – Diamond-Blackfan Anemia

CONGENITAL DYSERYTHROPOIETIC ANEMIA

– Hypercellular BM but ineffective erythropoiesis
• CDA I – Spongy heterochromatin with Swiss
Cheese appearance
• CDA II – Most common subtype. HEMPAS
(Hereditary erythroblastic multinuclearity with
positive acidified serum) Circulating RBCs hemolyze
with the Ham acidified serum test but not with the
sucrose hemolysis test
• CDA III – Least common. BM has megaloblastic
changes. Giant erythroblasts with up to 12 nuclei
are a characteristic feature