Professional Documents
Culture Documents
Section of Hematology-Oncology
Department of Medicine
University of Santo Tomas
Faculty of Medicine and Surgery
Case 1-01-01: 35 year old pre-
menopausic female with menorrhagia
housewife
complains of progressive easy fatigability of
about 3 months duration.
(-) epigastric pain, (-) hematochezia nor
melena
menses – 28 days cycle, 7 days duration,
3 days profuse flow , 5-6 fully soaked
pads/day
(-) bruises/ecchymoses
P.E. Pale, no jaundice
(-) hepatosplenomegaly
Case 1-01-01
duration
# of pregnancies, abortions -
interval
Concomitant bleeding manifestations
Dietary history
Back to questions
Fever, Weight loss
Vital signs
Blood pressure
Hypotension
Orthostatic hypotension
Cardiac/pulse rate
Tachycardia
Respiratory rate
Tachypnea
Body temperature
Cardiac Signs
Hemic murmurs: mid or
holosystolic often in the pulmonic
or apical area, due to increased
blood flow and turbulence
Gallop rhythms
Tachycardia/Cardiomegaly
Strong peripheral pulses with wide
pulse pressure
Skin
Pallor: <8 to 10 mg/dL hemoglobin
Affected by:
state of vasoconstriction/vasodilatation
degree & nature of pigmentation
nature & fluid content of the subcutaneous
tissues
Most constantly detected in:
mucous membranes of the mouth, pharynx,
conjunctivae, lips
nailbeds
Back to questions
Complete blood count
Red cells
Hemoglobin
Hematocrit
Morphology
Differential count
Platelet count
Changes in Normal
Hemoglobin/Hematocrit Values with
Age and Pregnancy
Age/Sex Hgb (g/dl) Hct (%)
At birth 17 52
Childhood 12 36
Adolescence 13 40
Adult man 16(+2) 47(+6)
Adult woman 13(+2) 40(+6)
(menstruating)
Adult woman 14(+2) 42(+6)
(postmenopausal)
During pregnancy 12(+2) 37(+6)
Back to questions
Red cell indices
Index Normal Value
5 – 15 x 10-3 (SI)
Corrected Reticulocyte
ct
=Patient’s Hct x
Reticulocyte 45
count (%)
Reticulocyte production
index
Corrected Reticulocyte
2
Back to Algorithm
Back to case 1
Diagnosis of microcytic anemias
Tests Iron Inflammatio Thalassem Sideroblas
deficiency n ia tic anemia
Smear Micro/hypo Normal, Micro/hypo variable
micro/hypo with target
Serum <30 <50 Normal to Normal to
iron high high
TIBC >360 <300 normal norml
TIBC
Serum ferritin: estimate of iron
stores
Stages of Iron Deficiency
Normal Negative Iron deficient Iron
iron erythropoiesi deficiency
balance s anemia
Marrow iron 1–3+ 0-1+ 0 0
stores
Serum ferritin 50- 200 <20 <15 <15
(ug/L)
TIBC (ug/dL) 300-360 >360 >380 >400
SI (ug/dL) 50-150 NL <50 <30
Saturation 30-50 NL <20 <10
(%)
Marrow 40-60 NL <10 <10
sideroblasts
(%)
RBC NL NL NL Microcytic
morphology hypochrom
ic
Treatment
Severity and cause determine
approach to treament
Elderly+/- cardiovasular
Increased
INCREASED Normal/Decreased
NORMAL/DECREASED
bone marrow
• prior hemolysis megaloblasti
• prior hemorrhage YES c NO
• treated disease • deficiency of Vit. • hypothyroidism
• deficiency of B12, Folate
- Vit. B12
• hypoplastic
• disorders of DNA
- Folate marrow and misc.
synthesis
- drug-induced
- inherited Back to Questions
Diagnostic Tests: Megaloblastic
Anemia
Reticulocyte index
Unconjugated bilirubin may be increased
LDH may be increased
Serum levels of
Cobalamin (Vitamin B12) (NV: 300 – 900
pg/mL)
Folate (6 – 20 mg/mL)
Malabsorption
resection, tumors
Competition of cobalamin: fish
hemolysis of RBC
Ham’s test (acid hemolysis); sucrose
hemolysis test screens for paroxysmal
nocturnal hemoglobinuria
Flow cytometry diagnostic
Back to Questions
HEMOLYTIC ANEMIA
COOMB’S TEST
NEGATIVE POSITIVE
EXTRACORPUSCULAR
COOMB’S TEST
NEGATIVE POSITIVE
CORPUSCULAR EXTRACORPUSCULAR
Hemoglobinopathies Idiopathic
Enzymopathies Secondary
Membrane Defects Drugs
Morphology Infection
Autohemolysis Microangiopathic
Osmotic Fragility
Immune-mediated
hemolysis
Usually due to IgG or IgM antibodies
with specificity to antigens on red cell
membrane(autoantibodies) or with
alloantigens on transfused RBC
(alloantibodies)
Diagnostic tool: Coomb’s antiglobulin
test
Direct: ability of anti-IgG or anti-C3
hemoglobinuria
Treatment: Autoimmune
hemolytic anemia
Glucocorticoids: Prednisone
Splenectomy
Immunosuppressive drugs
Blood transfusion for severe
anemia
Case 1-04-01
48 year old male farmer with
progressive weakness and pallor
no jaundice nor
hepatosplenomegaly
petechiae noted on both L.E.’s
Case 1-04
CBC:
Hb:7 gm/dl Hct:
21
WBC: 3,000
lymph: 48%
segs:
52%
Platelet count:
80,000
Reticulocyte
Count:5 x 10-3
Interpretation?
Pancytopenia (anemia, leukopenia,
thrombocytopenia)
Reticulocyte index low
Peripheral smear: normocytic,
slightly hypochromic RBC,
leukopenia, platelets nil
Bone marrow
aspiration
Smear for
morphology
Flow cytometry
Cytogenetics
Bone marrow
biopsy
cellularity
Normal bone marrow
Drugs/chemicals Shwachman-Diamond
Viruses syndrome
Reticular dysgenesis
• EBV
Amegakaryocytic
• Hepatitis (non-A,
non-B, non-C) thrombocytopenia
Familial aplastic
• Parvovirus B19
• HIV1 anemias
Immune diseases
• Eosinophilic
fascitis
• Hypoimmunoglob
ulinemia
• Thymoma/thymic
ca
• GVHD
PNH
Pregnancy
Idiopathic
Treatment: Aplastic
Anemia
Treatment of identifiable cause
Supportive care
Blood component therapy
Treatment of infections
Immunosuppression
Moderate
Androgens
Summary
History and Physical examination are essential in the
assessment of a patient who may have anemia
CBC, done and reported correctly is an important tool in
anemia
Confirms presence of anemia
Iron studies
Hemoglobin electrophoresis
Blood chemistries
Coomb’s test
Others