anemia - dr. muncie

7/30/2019 Anemia - Dr. Muncie

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AnemiaA Finding, not yet a diagnosis

Herbert L. Muncie, J r., MD


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zUnder what clinical circumstances

would you order a CBC for anoutpatient?


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When to order a CBC

z Order if suspect patient could be anemic

or infected based upon:z History

z

Symptomsz Signs or physical findings


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When to order a CBC

z Do not order CBC as a screening test

z Baseline values are not necessary todiagnosis anemia

z Variations in Hgb/Hctwithin the normalrange have not been associated withincreased morbidity or mortality


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Case FindingCase Finding -- physical examphysical exam

z

Absence of pallor does not rule outanemia

z Pallor of conjunctivae, face & palms - if

all 3 present helps confirm anemiaz Pallor of nail beds/skin creases - of no

value in assessing presence or absenceof anemia


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zWhat laboratory values are used to

define anemia?


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What Defines Anemia

z Look at hemoglobin & hematocrit

z Anemia is diagnosed if Hgb & Hct arebelow normal

z NormalHgb and Hct ranges change:z throughout childhood

z during pregnancy

z higher for men than women


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What Defines Anemia

z Normal H & H should be adjusted for

smoking, altitudez smokers have higher values due to carbon

monoxide in smoke

z > 3,000 feet - lower oxygen tensions, highervalues


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zOn the CBC results, what value on

the report assists you in decidingthe type of anemia?


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1st Diagnostic Step

Look at MCV -

Microcytic - < 80flNormocytic 80 100 fl

Macrocytic - > 100 fl


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Differential Diagnosis based on

MCVMicrocytic Normocytic Macrocytic

Iron deficiency Chronic disease Folate defic.

Thalassemia B12 defic.

Lead poisoning Liver disease

Hypothyroid


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Tests for Fe Deficiency

MCV - changes occur late

z < 70 probably iron deficiencyz MCH, MCHC - no useful info

RDW - reflects anisocytosis

z helps to differentiate from thalassemia


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zYou suspect iron deficiency anemia in

your next patient.z What test(s) will you order to make that

diagnosis?


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Tests for Fe Deficiency

Serum iron - level alone of little valuez

low in anemia of chronic disease

Iron binding capacity - high in Fe deficiencyz usually low in anemia of chronic disease


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Tests - Ferritin

z Best single test rule in or out Fe

deficiencyz levels < 15 uG/L - diagnostic

z levels > 100 uG/L - Fe deficiency veryunlikely

z Acute phase reactant

z may be elevated in inflammatory,malignant or liver disease


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Iron Deficiency

Causes:

children, teens - inadequate diet

young women menorrhagia &

inadequate dietolder women -

Neoplasm

GI blood loss

Angiodysplasia


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Iron Deficiency - therapy

zTreat with ferrous salts

z Sulfatez Gluconate

z

Start qd, increase to t.i.d. with mealsz Frequent GI distress


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MicrocyticMicrocytic AnemiaAnemia ThalassemiaThalassemia

Definition:

z

hereditary microcytic anemiaz carrier state: thalassemia minor

z Anemia with low MCV & normal RDW


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ThalassemiaThalassemia MinorMinor -- treatmenttreatment

z No disease specific treatment available

z Adjunctive treatment not needed formost cases

z Diagnosis has genetic ramificationsz May suggest prenatal screening


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z What is anemia of chronic disease?

z What causes anemia of chronic disease?


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Normocytic -Anemia of Chronic

diseasez Misnomer - can see in acute illness

z

Another name anemia of chronic inflammationz Occurs in infection/ inflammation/ neoplasia

and unknown other conditions

z Anemia can be first clue to diseasez Without known disease pursue further

evaluation


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Anemia of Chronic disease

Pathogenesis:

z Impaired release of Fe from RE cells

z Increased Fe stores

z Results in

z Low serum iron

z Low TIBC

z Low transferrin saturation


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Anemia of Chronic disease

Diagnosis:

z Ferritin level helpful - increased

zTransferrin receptor levelz raised in Fe deficiency, highly sensitive & specific

z

normal in anemia of chronic diseasez Normo/normo anemia then is either:

z Anemia of chronic disease

z Acute blood lossz Fluid overload (eg. Pregnancy)


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z What are the most common etiologies of

macrocytic anemia?


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Macrocytic anemia

z Etiology

z B12 (cobalamin Cbl)

z Folate deficiency

zTypically presents as MCV > 110 fL

z MCV 100-110 common, often unexplainedwith no specific diagnosis found


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Cbl Deficiency

z Level < 100 pg/ml confirm deficiency

z With levels > 100 & < 400 pg/mlz Measure MMA & homocysteine levels

z

Either will be elevated with deficiencyz Levels > 400 pg/ml rule out deficiency


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B12 Deficiency

z Etiologies of B12 deficiency

z Nutritional intake deficiency

z Unless strict vegetarian, Cbl deficiency impliesreduced absorption

z

Reduced absorptionz Loss of intrinsic factor; achlorhydria -

Pernicious anemia

z Drugs, blind loop, gastrectomy etczTakes 2-5 years to develop deficiency

even with severe malabsorption


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Folate Deficiency

z Etiologyof folate deficiency

z Usually nutritional

z Nutritional deficiency can occur quickly

z In 2-3 weeks with very poor diet


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z What is the treatment of B12 deficiency?

z What is the treatment of folate

deficiency?


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Treatment of B12 Deficiency

z Vitamin B12 IM or oral (preferred)

z Oral 1000 - 2000 uG qd equally effective [Kuzminski

1998] four randomized trialsz Minimum dosage 600 ug daily [Eussen 2005]

z 1000 uG IM q month


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Treatment of Folate Deficiency

z Folate oral supplements

z 1 mg qd

z CAUTION - folate may correct anemia of B12deficiency but not the neurologic sequelae

z before initiating folate therapy verify normal B12level


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Who reads which paper?

1. The Wall Street Journal is read by the people whorun the country.

2. The New York Times is read by people who thinkthey run the country.

3. The Washington Post is read by people who think

they ought to run the country.4. USA Today is read by people who think they ought

to run the country but don't understand the

Washington Post.5. The Los Angeles Times is read by people who

wouldn't mind running the country, if they could spare

the time.


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Who reads which paper?

6. The Boston Globe is read by people whose parentsused to run the country.

7. The New York Daily News is read by people whoaren't too sure who's running the country.

8. The New York Post is read by people who don't care

who's running the country, as long as they dosomething scandalous.

9. The San Francisco Chronicle is read by people who

aren't sure there is a country, or that anyone isrunning it.

10. The Miami Herald is read by people who are

running another country.

anemia - dr. muncie

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