Wichai PrayoonwiwatNovember 24, 2017

Anemia

2

Definition of Anemia

• WomenHb <12 g/dL

• MenHb <13 g/dL

3

Definition of Anemia

• Mild Hb >10-12 g/dL

• ModerateHb 7-10 g/dL

• SevereHb <7 g/dL

Automated CBC• Sample collection: Room temp within 8 h

8-24 h in refrigeratornot recommended > 36 h

• Direct measurement: red cell count, Hb, MCV• Calculated: Hct, MCH, MCHC• Hct = (RBC count (million/µL) x MCV)/10• MCV = Hct x 10/RBC count• MCH (pg) = Hb(g/dL) x 10• RBC (million/µL)• MCHC (g/dL) = Hb (g/dL) x100/Hct (%)• Hct = Hb x 3 (+2%)

5

Diagnosis of Anemia

• Symptoms Weakness, fatigue, lethargy, palpitations, angina pectoris,dyspnea, headaches,visual disturbances

6

Diagnosis of Anemia• Signs

Pallor, tachypnea, dyspnea, tachycardia, confusion, cardiac failure, bounding pulse, systolic murmur, sign of specific causes of anemia

7

Diagnosis of Anemia

• Laboratory diagnosis CBCReticulocyte count Peripheral blood smearBone marrow examination

8

Normocytic red cells

Reticulocytes: Supravital Staining

Supravital stain: Blue-stained residual reticulin(ribosomal RNA) in reticulocytes

Polychromatophilia: Reticulocytes

Mature red cells

Small lymphocyte

Reticulocytes

Reticulocytes

11

Classification by RBC Indices

Normocytic (MCV 80-100 fL) Normochromic (MCHC 32-36 g/dL)• Anemia of chronic disease• Bone marrow failure, • Hemolytic anemia • Chronic kidney disease,• Leukemia,• Metastatic malignancy

12

Macrocytic (MCV >100 fL)Normochromic (MCHC 32-36 g/dL)• Megaloblastic and nonmegaloblastic

• Macrocytic anemias- liver disease- myelodysplasias- PRCA, AA, PNH- hypothyroidism

Classification by RBC Indices

13

Microcytic (MCV <80 fL)Hypochromic (MCH <32 pg)• Iron deficiency,• Sideroblastic anemia• Thalassemia• Lead poisoning• Chronic diseases• Chronic infection or inflammation• Ustable hemoglobins

Classification by RBC Indices

Pathophysiology of ACD • Multifactorial • Reduced efficiency of iron recycling • Functional iron deficiency• Enhanced apoptosis of erythroid

progenitors• Inadequate production of EPO• Impaired response to EPO• Elevated pro-inflammatory cytokines

(TNFα, IL-6, IL-1 and MIF) • Induction of hepcidin synthesis by IL-6

15

Hepcidin & ACDInflammation Macrophage

Hepatocyte

Hepcidin

IL-6

MacrophageIron release

IntestinalIron absorption

Differentiation of ACD and IDA

Laboratory Test Normal IDA ACD

SI, μg/dL 60-100 < 60 < 60

TIBC, μg/dL 250-400 > 400 < 250

% saturation 20-60 < 16 < 20

Ferritin, ng/mL 100-300 < 100 > 100

Sensitivity and Specificity of Serum Ferritin Values in Iron Deficiency Anemia

Ferritin, ng/mL

Sensitivity (%)

Specificity (%)

Likelihood ratio*

< 100 94 71 3.2

< 45 85 92 11.1

< 15 59 99 54.5

*A serum ferritin < 15 ng/mL “rules in” IDA whereas > 100 ng/mL rules out IDA

Interpretation of Hematologic Test Results

Test Finding EtiologyReticulocyte count <1% Inadequate production

≥1% Increased production Reticulocyte index ≥2 Reticulocyte release

appropriate for anemia<2 Inadequate response to

anemia

RPI = Hct/45 x % retie/maturation

Maturation = 1.0 สําหรบั Hct ≥40%Maturation = 1.5 สําหรบั Hct 30-39.9%Maturation = 2.0 สําหรบั Hct 20-29.9%Maturation = 2.5 สําหรบั Hct <20%

Morphologic Approach

PBS in iron deficiency anemia showing microcytic, hypochromic red blood cells

21

Macrocytic red cells Macroovalocyte

Teardrop-shaped RBC (dacrocytes)

Burr Cells (Echinocytes) Crenated cells

uremia or pyruvate kinase deficiency

central pallor

excess EDTAslow dryingdrying in a humid environment, alkaline pH from glass slides

artifact

less numerous

Microangiopathic Hemolytic Anemia

helmet cells

microspherocytes

large platelet

helmet cells

microspherocytes

Bite cells and Heinz bodies

Megaloblastic Blood Picture

7-lobes PMN & macroovalocytes

27

Megaloblastic anemia

Malaria: Ring forms (trophozoites)

Case 1 แมบ่า้น อาย ุ28 ปี จ. ขอนแกน่

3 วนักอ่น มไีขส้งู ปวดเมือ่ยตามตวั ซดี เหลอืงออ่นเพลยี คลืน่ไสอ้าเจยีน ปสัสาวะเหลอืงเขม้ เคยมีอาการซดีเหลอืง ตอนเด็ก ไปตรวจทีโ่รงพยาบาลแหง่หนึง่ ไมไ่ดบ้อกวา่เป็นอะไร ไมเ่คยไดร้บัเลอืดมากอ่น

• BT 38oC, PR 100/min, RR 18/min, BP 110/80 mmHg

• Good consciousness, moderately pale, mild jaundice

• Abdomen: soft, liver 2 cm and mild tender, spleen 3 cm

Question1. Describe peripheral blood smear 2. Diagnosis3. Further investigation

Hb 5.0 g/dLHct 20%MCV 60 fLMCH 16.6 pgMCHC 24 g/dLWBC 2x109/LPlt, 10x109/L

Case 1• RBC: hypochromia 2-3+, microcyte 2-3+,

anisopoikilocyte 2+, occasional polychromasia

• WBC: 1,000-1,500/mm3, PMN 30%, M 10%, L 50%, atypical lymphocyte 10%

• Platelet: 0-1 /OF• Reticulocyte count 2%• Hb typing: A2AH• Alb 44 g/L, glo 23 g/L, AST 110 U/L, ALT

40 U/L, TB 28 mmol/L, DB 8 mmol/L• Hemoculture: no growth

Case 1

Diagnosis: Hb H disease - Pancytopenia,- Viral infection- Hypersplenism

Treatment:• Transfusion• Iron chelation• Genetic counseling

Case 2ชายไทย อาย ุ21 ปีอาชพีรบัจา้ง

2 วนักอ่นไขส้งู บางคร ัง้หนาวส ัน่ คลืน่ไสอ้าเจยี

ปวดแนน่ทอ้ง ชายโครงขวา มารดามซีดี ตาเหลอืง

ต ัง้แตเ่ด็ก

• BT 39oC, PR 90/min, RR 24/min,BP 110/80 mmHg

• Alert, not pale, moderate jaundice, no petechial hemorrhage

• Abdomen: Tender RUQ with Murphy’s sign +ve, liver not palpable, spleen just palpable

Case 2

• CBC: Hct 37%, WBC 13x109/L, PMN 90%,L 10%, platelet 250x109/L,

• MCV 81 fL (80-95) • MCH 27 pg (27-34) • MCHC 37 g/dL (30-35)

10/6/2011 35

Case 2

Question1. Describe peripheral blood smear 2. Diagnosis3. Further investigation

Case 21. Describe peripheral blood smear

• RBC: microspherocyte 3+ , normochromia, anisocytosis 2+

• WBC: 10,000/mm3, PMN 70% , E 10%, M 5%, L 15%

• Platelet: 10-12/OF

Case 2

2. DiagnosisHereditary spherocytosis with acute cholecystitis

3. Further investigation• Osmotic fragility test• ตรวจ PBS บดิามารดา และบตุร• Hemoculture• Ultrasound upper abdomen

Case 3

ชายไทยโสด อาย ุ20 ปี

ไขส้งูมา 4 วนั

4 วนักอ่นมา รพ. เร ิม่มไีขส้งู ไมห่นาวส ัน่ ปวดศรีษะเล็กนอ้ย ไอแหง้ ไมม่นํีา้มกู ซือ้ยามารบัประทานเอง

2 วนักอ่นมาร.พ. ออ่นเพลยีมาก ปสัสาวะดาํ เหนือ่ยงา่ย จงึมาร.พ.

Case 3

• T 38 oC, RR 26/min, PR 120/min, BP 100/70 mmHg

• Moderately pale, mild jaundice• Pharynx and tonsils: mild injection• Lung: clear• Abdomen: liver & spleen can’t be

palpable

Case 3• CBC: Hb 7 g/dL, Hct 21%,

WBC 20,000/mm3, N 40%, band 10%, metamyelocyte 5%, myelocyte2%, Platelet count 240,000/mm3

• RBC indices: MCV 100 fL (80-95), MCH 29 pg (27-34), MCHC 34 g/dL(30-35)

10/6/2011 41

คาํถาม:1. จงใหก้ารวนิจิฉยัแยกโรค2. ความผดิปกตทิีเ่ห็นใน blood smear3. บอก investigations เพิม่เตมิ4. จงใหก้ารวนิจิฉยัโรค5. จงใหก้ารรกัษา

Case 3

1. Differential diagnosis:Acute intravascular hemolysis• G6PD deficiency with

hemolytic crisis• Clostridium perfringen

Case 3

2. Blood smear:anisocytosis 3+, poikilocytosis3+, defected spherocyte 2+, polychromasia 1+, hemoglobin leakage cell +, fragmented RBC few, hemoglobin contacted cell

Case 33. Further investigations

– Reticulocyte count: 15%– Na+ 145 mmol/L, K+ 6.0 mmol/L,

Cl- 109 mmol/L, HCO3- 26 mmol/L

– BS 4.0 mmol/L (3.8-6.1)– BUN: 9 mmol/L (3.6-9.2),

Cr 120 umol/L (62-124)

– Hemoculture: no growth– G-6-PD : 200 IU/100 mL

RBC (159-297)

Case 3

4. DiagnosisG-6-PD deficiency with hemolytic

crisis5. Treatments:

– No specific treatment– Supportive treatment

• Adequate dehydration • PRC transfusion

3-9-2011 46

ชายอาย ุ23 ปี มซีดีเหลอืงมา ต ัง้แตเ่ด็ก ตรวจรา่งกาย ซดีปานกลาง เหลอืงเล็กนอ้ย มรีอยแผลผา่ตดัทีห่นา้ทอ้งตบัโต 2 FB ตํา่จากชายโครงขวา

Case 4

3-9-2011 47

Case 4

48

Case 4

3-9-2011 49

Case 4

Diagnosis1. CLL2. Thalassemia3. Postsplenectomy

50

ชาย อาย ุ56 ปี ไดร้บัวนิจิฉยัวา่เป็น ESKD ไดร้บัการทาํ hemodialysis มา 6 เดอืน

มโีลหติจางและฉดี erythropoietin แลว้ไม่ดขี ึน้

CBC : Hb 7.0 g/dL, Hct 22%, WBC 5.5x109, PMN 75%, L 20%,M 5%, platelet 140x109

Case 5

Case 5

3-9-2011 52Multiple Myeloma

Case 5

A 15-year-old man presented with fever for3 days. He had acute anemia and jaundice.On physical examination revealed moderately pale, mild jaundice, injected pharynx, and splenomegaly (1 FB below left costal margin)

Case 6

CBC: Hb 8.1 g/dL, Hct 26%, MCV 80 fL,WBC 9.5x109/L, PMN 80%,L 12%, M 8%, platelet 212x109/L

LFT: alb 4.1 g/dL, glo 3.7 g/dL,DB 0.9 mg/dL, TB 4.5 mg/dLAST 47 U/L, ALT 15 U/L, AP 90 U/L

Basophilic stippling

CS

Hb analysis

ChromatogramAA2CS

A2

A

Homozygous Hb Constant Spring

Homozygous Hb Constant Spring• a-thalassemia syndrome• Decreased a-globin chain synthesis• Clinically like Hb H disease• Mild to moderate anemia• Mild jaundice• Mlid splenomegaly• Normochromic normocytic RBC• Basophilic stippling

Case 6

A 54-year-old man with severe abdominal pain, GU, thrombosis in portal/splenic vein and chronic anemia for 4 yearsPhysical examination: • Mildly pale, no jaundice • No hepatosplenomegaly• No lymphadenopathy

Case 7

• CBC: Hb 8.6 g/dL, Hct 27.4%,WBC 5.0x109/L, PMN 47%, L 42%, M 10%, E 1%,

platlets 90x109/L,MCV 97.1 fL, RDW 20.6%

• Coagulogram: Normal• LFT:

TP 9.7 g/dL, albumin 4.3 g/dL, TB 3.0 mg/dL, DB 0.6 mg/dL, AST 108 U/L, ALT 38 U/L

• Reticulocyte count 6.0%

• Two cell population• Normochromic normocytic RBC• Hypochromic microcytic RBC• Macrocytes• Polychromasia

• Anticardiolipin Ab: Negative• Ham acid serum test: Positive• Hemosiderin test: Positive• Flow cytometry:

- CD55 and CD59 deficient in bothRCB and WBC cell lines

• Protein C 196.7% (70-140)• Protein S 159 % (60-140)• Antithrombin 123.7% (70-140)

Case 7

PNH with portal vein thrombosissplenic vein thrombosisTreatment:

- Prenisolone- Warfarin- Iron- Folic acid

Case 7

ชายอายุ 33 ปี ซดีออ่นเพลยีมานานเคยไดร้บัเลอืดตอนเด็กปีละ 1-2 คร ั้งPhysical examination: • Moderately pale, mild jaundice • Spleen 4 FB • No lymphadenopathy

Case 8

• CBC: Hb 8.2 g/dL, Hct 27.7%,WBC 4.7x109/L, PMN 62%, L 31%, M 1%, E 3%, B 2%

platlets 90x109/L,MCV 58.5 fL, RDW 23%MCH 20.2 pg, MCHC 34.5 g/dL

•LFT:TP 9.2 g/dL, albumin 4.0 g/dL, TB 3.0 mg/dL, DB 0.6 mg/dL, AST 108 U/L, ALT 38 U/L

• Reticulocyte count 6.7%• Hb typing: E 62.3%, F 30%

Case 8

Diagnosis: β-thalassemia Hb E disease

Treatment:• Transfusion• Iron chelation• Genetic counseling

ชายอายุ 53 ปี known case alcoholic hepatitis ชว่งนีซ้ดีเหลอืงออ่นเพลยีจนตอ้งไดร้บัเลอืดบอ่ยตรวจรา่งกาย moderately pale and jaundice, spleen 2 FB, no lymphadenopathy

Case 9

CBC: Hb 7.2 g/dL, Hct 23.0%, WBC 4.0x109/L, PMN 77%, L 12%, M 10%, E 1%, platlets 88x109/L,MCV 94.1 fL, RDW 14.6%

Spur cell anemia

หญงิอายุ 38 ปี เหนือ่ยงา่ยออ่นเพลยี 2-3 สปัดาห์ตรวจรา่งกาย markedly pale, mild jaundice, no hepatosplenomegaly, no lymphadenopathyCBC: Hb 3.8 g/dL, Hct 11.1%,

WBC 9.2x109/L, PMN 81%, L 14%, M 4%, E 1%, platlets 577x109/L,MCV 115 fL, MCH 39.1 pg, MCHC 34 g/dL, MPV 6.2 fLRDW 25.2%

Case 10

Case 10

Diagnosis: Autoimmune hemolytic anemia

PRC transfusion in AIHA

• Severe anemia: Impending CHF or alteration of consciousness

• Most compatible blood• One unit at a time, Diuretic,

Slowly and Close observation• High dose corticosteroids

Conditions Mistaken for Hemolytic Anemia• Anemia and reticulocytosis

- Hemorrhage- Recovery from iron, folate, B12 deficiency- Recovery from marrow failure

• Anemia and jaundice- Intramedullary hemolysis- Bleeding in body cavity or muscle

• Jaundice without anemia- Defective bilirubin conjugation- Crigler-Najjar syndrome- Gilbert syndrome

Thank you for your attention