APPROACH TO

ANEMIA

What is CBC?

Complete Blood Count :

Hb, RBC, MCV, MCH, MCHC, WBC & Diff, Platelet,

Reticulocyte

Anemia

• RBC mass

• ed level of Hb more than 2SD of mean normal of Hb according to age

Age Hb level

• New born <13 gr/dl

• 2-3 months < 9 FT

< 7 premature

• 6m-2y <9.5

• 2y – 6 years old <10.5

• 6 – 12 y/o <11.5

• >12 y/o Male < 14

Female < 12

MCV

• Mean corpuscular volume: 100 (fl)

• Age: 2-10 y/o MCV= Age (year) + 70

• Age ≥ 10 y/o MCV < 80: Microcytosis

MCH

• Mean corpuscular hemoglobin: 100 (Pg)

• More sensitive than MCV

• MCH 25- 27 hypochromia

Rbc

HCT

MCHC

• Mean corpuscular hemoglobin concentration:

100 100

• It is important in diagnosis of congenital

Spherocytosis (MCHC > 35)

: Rbc

Hb

Rbc

HCT

PCV or Hematocrit

•57% Plasma

•1% Buffy coat – WBC

•42% Hct (PCV)

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Measurement Normal Range

A. RBC count 5 million 4 to 6

B. Hemoglobin 15 g% 12 to 17

C. Hematocrit 45 38 to 50

A x 3 = B x 3 = C - This is the rule of thumb

Check whether this holds good in given results

If not -indicates micro or macrocytosis or hypochro.

RETICULOCYTE COUNT %

Normal

Less than 2%

• ‘RBC to be’ or Apprentice RBC

• Fragments of nuclear material

• RNA strands which stain blue

The reticulocyte count

(kinetic approach)

• Increased reticulocytes (greater than 2-3% or

100,000/mm3 total) are seen in blood loss and

hemolytic processes, although up to 25% of

hemolytic anemias will present with a normal

reticulocyte count due to immune destruction of red

cell precursors.

• Retic counts are most helpful if extremely low

(<0.1%) or greater than 3% (100,000/mm3 total).

The reticulocyte count

• To be useful the reticulocyte count must be adjusted for the patient's hematocrit. Also when the hematocrit is lower reticulocytes are released earlier from the marrow so one can adjust for this phenomenon. Thus:

• Corrected retic. = Patients retic. x (Patients Hct/45)

• Reticulocyte index (RPI) = corrected retic. count/Maturation time

(Maturation time = 1 for Hct=45%, 1.5 for 35%, 2 for 25%, and 2.5 for 15%.)

• Absolute reticulocyte count = retic x RBC number.

Types of Anaemia www.drsarma.in

Workup – Second Test

• The next step is ‘What is the size of RBC’ ?

• MCV indicates the Red cell volume (size)

• Both the MCH & MCHC tell Hb content of RBC

• If the RPI is 2 or less

• We are dealing with either

• Hypoproliferative anaemia (lack of raw material)

• Maturation defect with less production

• Bone marrow suppression (primary/ secondary)

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Red Cell Size www.drsarma.in

Anaemia Workup - MCV www.drsarma.in

Microcytic

MCV

Normocytic Macrocytic

Iron Deficiency IDA

Chronic Infections

Thalassemias

Hemoglobinopathies

Sideroblastic Anemia

Chronic disease

Early IDA

Hemoglobinopathies

Primary marrow

disorders

Combined deficiencies

Increased destruction

Megaloblastic

anemias

Liver disease/alcohol

Hemoglobinopathies

Metabolic disorders

Marrow disorders

Increased destruction

CLASSIFICATION

• Classification by Pathophysiology

• Blood Loss

• Decreased Production

• Increased Destruction

• Classification by Morphology

• Normocytic

• Microcytic

• Macrocytic

Anaemia Workup – 3rd Test

Red cell Distribution Width – RDW

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RDW < 13

Mean 90 fl

RDW is 13

MCV 90 fl

• Red cell distribution width = anisocytosis

• RDW = 11-14.5%

• IDA: RDW

• -thalassemia minor: RDW

• Are all RBC of the same size ?

• Are all RBC of the same normal discoid shape ?

• How is the colour (Hb content) saturation ?

• Are all the RBC of same colour/ multi coloured ?

• Are there any RBC inclusions ?

• Are intra RBC there any hemo-parasites ?

• Are leucocytes normal in number and D.C ?

• Is platelet distribution adequate ?

Macrocytic Anaemias

A. Megaloblastic Macrocytic – B12 and

Folate↓

B. Non Megaloblastic Macrocytic Anaemias 1. Liver disease/alcohol

2. Hemoglobinopathies

3. Metabolic disorders, Hypothyroidism

4. Myelodystrophy, BM infiltration

5. Accelerated Erythropoesis - ↑destruction

6. Drugs (cytotoxics, immunosuppressants, AZT,

anticonvulsants)

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Occult

Blood Loss?

Yes

Investigate

source

No

Coombs’

(DAT)

Check for

Hemolysis

Peripheral

smear

Hypoproliferative Hemolytic

Blood Loss

• Acute

• Traumatic

• Variety of sources

• Melena, hematemesis, menometrorrhagia

• Chronic

• Occult bleeding

• Colonic polyp/carcinonma

INCREASED DESTRUCTION

•Immune Mediated

•Non-immune Mediated

Anaemia of Chronic

Disease

•Thyroid diseases

•Malignancy

•Collagen Vascular Disease

•Rheumatoid Arthritis

•SLE

•Polymyositis

•Polyarteritis Nodosa

• IBD

– Ulcerative Colitis

– Crohn’s Disease

• Chronic Infections

– HIV, Osteomyelitis

– Tuberculosis

• Renal Failure

• WBCs are involved in the immune response.

• The normal range: 4 – 11x10^9 /L

• Two types of WBC:

1) Granulocytes consist of: – Neutrophils: 50 - 70%

– Eosinophils: 1 - 5%

– Basophils: up to 1%

2) Agranulocytes consist of:

- Lymphocytes: 20 - 40% – Monocytes: 1 - 6%

The type of cell affected depends upon its primary

function:

In bacterial infections, neutrophils are most

commonly affected

In viral infections, lymphocytes are most

commonly affected

In parasitic infections, eosinophils are most

commonly affected.

• polymorphneuclear leukocytes (PMN,s)

• Nucleus 3-5 lobes.

• Diameter 10-14 µm

• 50-70% WBC

=2.5-7.5x10^9/ L

• Function: Phagocytosis of bacteria and cell debris

• Numbers rise with all manner of stress, especially bacterial infections

• Neutrophil disorders

– Neutrophilia – an increase in neutrophils

– Conditions associated with neutrophilia are:

1-Bacterial infections (most common cause)

2-Tissue destruction

e.g. tissue infarctions, burns.

3- leukemoid reaction

4-Leukemia

– Neutropenia – this may result from

1-Decreased bone marrow production

e.g. BM hypoplasia.

2-Ineffective bone marrow production

– E.g. megaloblastic anemias and

myelodysplastic syndromes.

3- post acute infection

_ e.g. typhoid fever, brucellosis.

• Bilobed nucleus

• 1-5% of WBC

=0.04-0.4x10^9/L

• Diameter about 10-14 µm

• Function: Involved in allergy, parasitic infections

• Contains: eosinophilic granules

– Eosinophilia may be found in

• Parasitic infections

• Allergic conditions and

hypersensitivity reaction

• No specific granules

• 20-40% of WBC

=1.55-3.5x10^9/ L

• Diameter 8-10 µm

• T cells: cellular

• (for viral infections)

• B cells: humoral (antibody)

• Natural Killer Cells

• Lymphocytosis – may indicate _ Viral infection

e.g. Infectious mononucleosis, CMV or pertussis.

_ Bacterial infection

e.g. TB

• Lymphopenia – caused by

_Stress.

_Steroid therapy

_ Irradiation

• (Leukocytosis) may indicate:

_ Infectious diseases

_Inflammatory disease (such as rheumatoid arthritis or allergy)

_Leukemia

_Severe emotional or physical stress

_Tissue damage (e.g. necrosis,or burns)

• (Leukopenia) may result from:

_ Decreased WBC production from BM.

_ Irradiation.

_ Exposure to chemical or drugs.

• Fever

• Malaise

• Weakness

• Others depend on each system which is involved

e.g. » chest: cough, SOB and chest pain

» abdomen: diarrhea, vomiting, dehydration.

»CNS: headache, visual disturbance,

Neck stiffness

and so 0n.

• Infection of the mouth and throat.

• Painful skin ulceration.

• Recurrent infection.

• Septicemia.

•Small granular non-nucleated

discs.

•Diameter about 2-4 µm

•Normal range; 150-300x10^9 /L

•Destroyed by macrophage cells in

the spleen.

•Function; involved in coagulation

and blood haemostasis.

•Life span 7-10 days

• Numbers of platelets – Increased (Thrombocythemia)

• Pregnancy.

• Exercise.

• High attitudes.

• splenectomy

– Decreased (Thrombocytopenia) • Menstruation.

• Haemorrhage.

• Bone marrow destruction or suppression e.g. leukemia

• The values have to fit the clinical situation.

• Petechial hemorhage.

• Easy bruising.

• Mucosal bleeding

e.g. _ epistaxes.

_ gum bleeding