approach to a patient with anemia
DESCRIPTION
TRANSCRIPT
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Approach To A Patient With Anemia
Dr. Mohammad Usman Shaikh
Assistant Professor,
Aga Khan University Hospital.
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Hematology
• Study of blood forming tissue and circulating blood component
• Clotting factors • Blood groups• CBC and smear examination regardless of specialty• Accessible, close proximity to tissues, often provide
some information• Important for accurate diagnosis and therapeutics
choices
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Manual Versus AutomationFeasibility:Workload:• Depend on number of samples per day
• Less than 20 samples, prefer manual method
• Tertiary care hospital setting in western hospitals, CBC is mandatory for consultation.
• Rapid analysis
• Require only an appropriate blood sample.
• Measure 8-25 variables, no equivalent manually.
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Principles of Automation
• Electrical Impedance• Light scattering
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Electrical Impedance
Detection & measurement of changes in
electrical resistance produced by cells as
they passes via a small aperture
Electrical resistance between two electrodes,
or impedance in current leads to the formation of
pulses
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A stream of cells passes through aperture across which electrical current is applied. Each cell that passes alters
electrical impedance and can thus be counted and sized.
Good Pulse
Diluent stream
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Sensing Zone
Red Blood Cells
Electrical Impedance
OscilloscopeOscilloscope
Each time a cell passes a pulse is produced.The pulse height is proportional to Cell
volume
Animation by M.A.Ghauri
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Light Scattering
O-3 deg(relative size)
Light Scatter estimates relative cell size based on forward scatter - that is a measurement of cross-sectional diameter
LaserLaser
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Hemogram/ Histogram
• Visual representation of what was counted at the aperture.
• Verify a count that has a typical pattern according to the reference ranges
• Alert for possible interfering particles and abnormalities
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Hematological Variables on Automation
RBCHb, HCT, MCV, MCH, MCHC, RBC count, RDW
WBC
Total count, differential and absolute count
Platelet
Total count
Others: Nucleated RBC, reticulocyte count
flags
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Anemia
– Definition: low Hemoglobin and hematocrit– Results from a wide variety of disorders
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Anemia
• Laboratory data is more informative when considered in the context of history and physical examination
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Approach to Anemia
• History:– Family history– inherited causes such as
thalassemia, sickle cell anemia, G6PD deficiency and hereditary spherocytosis.
– In most of these cases morphological findings of smear are diagnostic
• B symptoms• Systemic or other chronic disorders
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History
• Drug history:
• History of blood loss
• Clinically: Degree of pallor, with or without icterus, angular stomatitis and glossitis,
koilonychia, lymphadenophathy and
hepatoslenomegaly
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Koilonychia
Physical Examination: helps to direct the clinician to the cause of anemiaIron deficiency: koilonychia, glossitis, angular stomatitis.
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Glossitis
B12 deficiency: decrease vibration and postural senseFolate deficiency: glossitis, sign of malabsorption, alcohol abuse and pregnancy
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Angular stomatitis
Angular stomatitis: non specific, can be seen in iron deficiency, B12 and folate deficiency
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Lymphadenophathy
• Bone marrow failure/infiltration: fever, Petechiae, lymphadenophathy, splenomegaly and sternal tenderness
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Splenomegaly
• Bone marrow failure/infiltration: splenomegaly
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Normal RBC
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Normal RBC
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WBC Morphology
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Classification of Anemia on the Basis of MCV
Less than 76fl --- microcyticIron deficiencyThalassemia Anemia of chronic diseaseSideroblastic anemia and lead poisoning
MCV between 76 to 96 flAnemia of chronic diseaseAcute blood loss Chronic renal failureAnemia due to infiltrationAplastic anemia
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Classification of Anemia on the Basis of MCV
• MCV more than 96fl– Macrocytic anemia
• Megaloblastic: B12 and folate deficiency• Non megaloblastic:
– Hemolysis– MDS– Hypothyroidism– Liver disease
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Etiological Classification of Anemia:
• Increase destruction
1-Hemolytic anemia
inherited and acquired• Impaired Production
2-Anemia due to bone marrow failure states
3-Nutritional deficiencies
4-Anemia due to infiltrative disorders
5-Anemia of chronic disorders
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Hemoglobin: 3.5 gm/dlHCT: 12%MCV: 57 fl
MCH: 18 pgTLC: 22,000
Platelets: 155,000
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Hemoglobin: 4.5 gm/dlHCT: 14%MCV: 56 flMCH: 20 pgTLC: 6,000
Platelets: 600,000
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NORMOCYTIC NORMOCHROMIC ANEMIA
MCV between 76 to 96 fl• Anemia of chronic disease• Acute blood loss • Chronic renal failure• Anemia due to infiltration• Aplastic anemia
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Hemoglobin: 8 gm/dlHCT: 25%MCV: 84 flMCH: 27 pgTLC: 5000
Platelets: 205,000
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Sickle Cell
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Sickle Cell Disease
• Rare in Pakistan (Balochistan), common in Middle East, and up to 40% trait in Central Africa
• Qualitative globin chain defect; Homozygous inheritance• Deoxy Hb S--- tendency to aggregate--- sickle cell• Increase blood viscosity --- vascular stasis---tissue
damage + RBC membrane damage• Sickling depend on Hb S concentration• Hb S <50%, usually no symptoms• Hb F---confer protection• Hb: 5-11 g/dl, Normocytic normochromic, Target cells,
reticulocytosis, Increase WBC & Platelets
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Hemoglobin: 7.0 gm/dlHCT: 22%MCV: 89 flMCH: 28 pgTLC: 22,000Platelets: 20,000
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Acute Leukemia
• Presenting count• Age • Cytogenetics
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Hemoglobin: 5.0 gm/dl
HCT: 16%
MCV: 93 fl
MCH: 26 pg
TLC: 500
Platelets: 11,000
Pancytopenia
Cellular Vs hypocellular
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Chronic Leukemias
• Cytogenetics for CML• CLL workup and staging
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Hemoglobin: 5.0 gm/dl
HCT: 16%
MCV: 93 fl
MCH: 26 pg
TLC: 500
Platelets: 11,000
Pancytopenia
Cellular Vs hypocellular
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Normal Marrow
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Bone Biopsy
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• Hemoglobin: 9.5 gm/dlHCT: 30%MCV: 99 flTLC: 2200
Platelets: 10,000
Blood culture: gram negative rods
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Microangiopathy /DIC
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Microangiopathy /DIC
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Macrocytic Anemia
• MCV more than 96fl– Macrocytic anemia
• Megaloblastic: B12 and folate deficiency• Non megaloblastic:
– Hemolysis– MDS– Hypothyroidism– Liver disease
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Hemoglobin: 6.0 gm/dl
HCT: 19%
MCV: 110 fl
MCH: 36 pg
TLC: 2,800
Platelets: 45,000
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Hemoglobin: 7.5 gm/dl
HCT: 23%
MCV: 100 fl
MCH: 28 pg
MCHC 36%
TLC: 5000
Platelets: 100,000
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Reticulocyte
• Reticulocyte: larger than normal RBC
• RNA and Golgi remnants, Ribosome, maturation take another 24 to 48 hours in the blood circulation
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Conclusions
• Peripheral blood smear examination and reporting is one of the most important aspect of hematology.
• It is diagnostic in many hematological and non hematological disorders.
• It is cost effective and non invasive and helps the clinicians in further diagnostic workup