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Approach to Anemia Approach to Anemia

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Page 1: Anemia

Approach to AnemiaApproach to Anemia

Page 2: Anemia

Approach to Anemia

Important to Remember:Anemia is a symptom and not a diseaseLook for the Primary Cause!

Page 3: Anemia

First Question:

nAcute vs chronicnClues:

Hemodynamic stabilityPrevious CBCOvert blood loss

Page 4: Anemia

Acute vs Chronic Anemia:

nSymptoms from anemia depend on:Decrease O2 carrying capacityChange in blood volumeRate of developmentAssociated manifestations of underlying diseaseCardiovascular/respiratory capacity

Page 5: Anemia

Acute vs chronic anemia:nEither due to acute blood loss or acute

hemolysisnSymptoms often due to loss of circulating

volume nSymptoms in chronic anemia due to lack

of O2 carrying capacitynTolerated better due to compensatory

mechanisms

Page 6: Anemia

Second question in chronic anemia:

nWhat is the mean corpuscular volume ( MCV ) ?

nClassify chronic anemia as:Microcytic ( decreased MCV )Normocytic ( normal MCV )Macrocytic ( increased MCV )

Page 7: Anemia

Microcytic anemia

nMicrocytic anemias usually as result of defective hemoglobin synthesis

nDifferential:Iron deficiencyThalassemia traitAnemia of chronic diseaseSideroblastic anemiaLead poisoning

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Case Presentation 1n24 year old female, asymptomaticnRoutine bloodwork for health insurancenCBC:

–Hb - 110 gm/dl–WBC- normal–Plats- normal–MCV- 65–RDW- 13

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Iron deficiency vs Thalassemia

nEthnic backgroundnFamily historynHb vs MCVnRDWnPeripheral smear

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Iron deficiency vs Thalassemia

Hb MCV RDW

Thalassemia Normal/Slightlydecreased

65 Normal

Fe deficiency < 80 65 Increased

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Normocytic anemia

nWide differential:Acute blood lossHemolysis ( acute/chronic)Anemia of chronic disease:– chronic inflammation: RA, SLE– chronic infection: TB, SBE, abscess– malignancy

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Normocytic anemian Anemia of renal failuren Liver failuren Endocrinopathies

Addison’shypothyroidismhypogonadotropic states

n Early iron deficiencyn Pregnancyn Bone marrow disorders

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Case presentation 2

n 40 yr female6 mt arthritis small joints of hand1 mt facial rash1 wk increasing fatigue and SOB2 days “ yellow” colour of eyes and skin

nOn examination:BP: 100/70Pulse: 110/minJaundicedSplenomegalyswollen MCP jts

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Case presentation 2

nLaboratory investigations:Hb: 60 gm/dlMCV: 94WBC: 18 x 10/LPlts: 490 x 10/LRDW: 19

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Case presentation 2

nReticulocyte count: 450nTotal bilirubin: 86nDirect bilirubin: 2nLDH: 690nWhat is the differential and next

investigations?

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Case presentation 2

nDirect Anti-globulin Test ( DAT ) :Positive

nDiagnosis:Autoimmune hemolytic anemiaSecondary to SLE

Page 17: Anemia

Hemolytic Anemia: Two components for diagnosis:

n Increased production

Elevated reticulocytecountBone marrow erythroidhyperplasia

nRed cell destruction:

Increased indirect bilirubinLDHdecreased haptoglobinheme-hemopexincomplexeshemoglobinuria

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Differential Diagnosis

n Congenital:Membrane disorders

– Hereditary spherocytosis

Hemoglobinopathies– Thalassemias/Sickle

cell diseaseEnzymes

– G6PD deficiency

nAcquired:Immune

– drugs, autoimmune alloimmune

Non-immune– microangiopathic– infections– toxins: copper– burns– drugs: oxidative hemolysis– liver/renal disease

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Investigations for Hemolytic anemia

nPeripheral smear is the most important initial investigation

nCoombs test with anti-IgG and anti-complement

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Direct Anti-globulin Test ( DAT )

Patient’s Patient’s RBCsRBCs coatedcoatedwith antibodywith antibody

AntiAnti--IgGIgG and antiand anti--C3C3Coombs reagentCoombs reagent

AgglutinationAgglutination

Page 21: Anemia

Indirect Anti-globulin Test ( IAT )

Patient’s serumPatient’s serumRBCsRBCs

IncubatedIncubated

AntiAnti--IgGIgGAntiAnti--C3C3

AgglutinationAgglutination

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Case Presentation 3

n 72 yrs male4 month hx 30 lbs weight lossanorexia, nausea , fatigue

nOn examination:cacheticabdominal mass

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Laboratory investigations:

nCBC:WBC: 1.2Hb: 75 gms/dlplts: 85

nWhat is the next investigation?

Page 24: Anemia

Macrocytic Anemia

nDifferential diagnosis:Megaloblastic anemia

– Vitamin B12, Folate deficiency– Chemotherapeutic drugs

Myelodysplastic syndromesLiver diseaseHypothyroidismIncreased reticulocyte count

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Case presentation 4

n 72 yr maleangina x 3 wksSOB x 1 wkFatigue x 6 wks

nOn examination:BP: 140/70pulse: 100“ lemon-yellow” skinscleral icterusdecreased vibration sense feet

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Case presentation 4

nLaboratory investigations:Hb: 40 gms/dlMCV: 134WBC: 1.6Plts: 45Retics: 25LDH: 1600TBili: 75 ( direct: 4)

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Case presentation 4

nDiagnosis : Megaloblastic anemianLikely B12 deficiency: Why?nWhat should we find on peripheral

smear?