Download - Chittima Sirijerachai
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Chittima Sirijerachai
Approach to AnemiaApproach to Anemia
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วั�ตถุ�ประสงค์�วั�ตถุ�ประสงค์�
• ให้�การวั�นิ�จฉั�ยและวั�นิ�จฉั�ยแยกโรค์ผู้��ป�วัยที่��มี�ภาวัะโลห้�ตจางได้� โด้ยอาศั�ยข้�อมี�ลจากประวั�ต� การตรวัจร(างกาย
• แปลผู้ล CBC, blood smear, red cell
indices และ reticulocyte count ได้�
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• ให้�การวั�นิ�จฉั�ยโรค์ที่��เป*นิสาเห้ต�ข้องภาวัะโลห้�ตจางที่��บ่(อยได้� เช่(นิ– iron deficiency anemia,
– thalassemia,
– Autoimmune hemolytic anemia (AIHA)
– aplastic anemia (AA)
– G-6-PD deficiency
วั�ตถุ�ประสงค์�วั�ตถุ�ประสงค์�วั�ตถุ�ประสงค์�
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Recommended bookRecommended book
• Bloodphysi ol ogy andpathol ogy : Chris Pallister.
1994
• Williums Textbookof hematology 5 th ed.
1995
• 9Wintrobe Textbookof hematology th 1993ed.
• อาการวั�ที่ยาที่างอาย�รศัาสตร� : มีข้ .2539
• Short note in medicine : มีข้ .2543
• ต-าราโลห้�ตวั�ที่ยา : ถุนิอมีศัร� ศัร�ช่�ยก�ล บ่ก .2537
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Criteria for Diagnosis AnemiaCriteria for Diagnosis Anemia
Hb.( g/dl)Hb.( g/dl) Hct (%) Hct (%)
Children 11.0 33
Male 13.0 40
Female ( 15-50 ) 12.0 36
Female ( > 50 ) 13.0 40
Pregnant women 11.0 33
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Mechanism of anemia
1. Decreased RBC production
- Nutritional deficiency
- Aplastic anemia
- Myelophthisis anemia
- Chronic renal failure
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2. Increased RBC destruction
• Intravascular hemolysis
• Extravascular hemolysis
Mechanism of anemia
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Mechanism of anemia
3. Blood loss
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- dizziness
- confusion
- coma
- fatigue- dyspnea- edema- chest pain
Anemic symptoms
CNSCVS
- onset
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การวั�นิ�จฉั�ยโรค์ที่��เป*นิสาเห้ต�ข้องภาวัะโลห้�ตจาง
•ประวั�ต�
•การตรวัจร(างกาย
•การตรวัจที่างห้�องปฏิ�บ่�ต�การ
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History
•Duration, onset
•Severity
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AnemiaAnemiaAnemiaAnemia
AcuteAcuteAcuteAcute ChronicChronicChronicChronic
( ( << 7 Days ) 7 Days ) ( > 2 Months )( > 2 Months )
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Acute anemiaAcute anemia
Acute blood lossAcute blood loss Acute hemolysisAcute hemolysis
History of History of
• GI bleedingGI bleeding
•
hypermenorrheahypermenorrhea
History of History of
• GI bleedingGI bleeding
•
hypermenorrheahypermenorrhea
History of History of
• dark urinedark urine
• jaundicejaundice
History of History of
• dark urinedark urine
• jaundicejaundice
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Acute anemiaAcute anemia
Acute blood lossAcute blood loss Acute hemolysisAcute hemolysis
- G-6-PD def- Mis-match - G-6-PD def- Mis-match
- Hb H with crisis- HS with crisis- AIHA
- Hb H with crisis- HS with crisis- AIHA
IntravascularIntravascular ExtravascularExtravascular
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Chronic anemia
• AA
• Myeloph.
• Iron def.• CRF• Megaloblastic
• PNH• MAHA
• Thalassemia• HS
BM failure Precursors
RBC productionHemolysis
• Dietary intake
• Absorption
• Chronic blood
loss
• Bleeding Bleeding
tendencytendency
IVH EVH
• Family historyFamily history
• Hx of blood Hx of blood
transfusiontransfusion
• Hx of Hx of
dark dark
urineurine
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อาการแสด้งที่��พบ่ในิภาวัะโลห้�ตจาง
•อาการแสด้งที่��วัไป
•อาการแสด้งเฉัพาะโรค์ที่��เป*นิสาเห้ต�
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อาการแสด้งที่��วัไป
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Anemia
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Not pale conjunctiva
Pale conjunctiva
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อาการแสด้งที่��วัไป• Systolic hypertension
• tachycardia
• bounding pulse
• Systolic ejection murmur
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อาการแสด้งเฉัพาะโรค์
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glossitis
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Koilonychia - spoon shaped nail
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Iron deficiency anemia
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Angular stomatitisglossitisglossitis
Nutritional deficiency anemiaNutritional deficiency anemia
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anemiaanemia petechialpetechial
Bone marrow failureBone marrow failure
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jaundice Hemolytic anemia
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anemiaanemia jaundicejaundice Splenomegaly Splenomegaly
Chronic extravascular Chronic extravascular
hemolytic anemiahemolytic anemia
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Mongoloid facies
Thalassemia
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Investigation: initial
•CBC, blood smear
•red cell indices
•reticulocyte count
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Red cell indices
• MCV -mean corpuscular volume
-normal 85-95 fl
• MCH -mean corpuscular hemoglobin
• MCHC -mean corpuscular
hemoglobin
concentration
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CBC and RBC indices
80-96 fl.27-33 pg.33-36 g/dl
12.0-13.6%
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MCV
• Iron deficiency
• thalassemia• lead
poisoning• B6 deficiency
• reticulocytosis• megaloblastic
anemia• AA• liver disease
MCVMCV MCVMCV
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Corrected Reticulocyte count
= retic. Count X Pt . Hctnormal Hct
Normal Hct. : male = 45 % : female = 40%
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Blood smear
•การต�ด้ส� ข้นิาด้เซลล�• anisocytosis, poikilocytosis
• hemolysis? - microspherocyte
• abnormal red cell: target,
schistocyte etc
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normochromicnormochromicnormocyticnormocytic
hypochromichypochromicmicrocyticmicrocytic
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anisocytosis, poikilocytosisanisocytosis, poikilocytosis
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microspherocytemicrospherocyte
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Hypochromic Hypochromic microcyticmicrocytic
Hypochromic Hypochromic microcyticmicrocytic
Normochromic Normochromic normocyticnormocytic
Normochromic Normochromic normocyticnormocytic
IDAIDAIDAIDA thalthalthalthal NonNonhemolytichemolytic
NonNonhemolytichemolytic hemolytichemolytichemolytichemolytic
- AA- AA- CRF- CRF- AA- AA- CRF- CRF
- AIHA- AIHA- G-6-PD def- G-6-PD def- MAHA- MAHA
- AIHA- AIHA- G-6-PD def- G-6-PD def- MAHA- MAHA
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Investigation : for definite diagnosis
• Inclusion body - thalassemia
• saline agglutination - AIHA
• Hb typing - thalassemia
• Coomb's test - AIHA
• Bone marrow - AA
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inclusion bodiesinclusion bodies
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Heinz bodyHeinz body
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Case
discussio
n
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22-year-old femaleanemia with jaundice for 2 wkno hepatosplenomegaly
Hemolytic anemia
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ผู้ลการตรวัจที่างห้�องปฏิ�บ่�ต�การ
ผู้ลการตรวัจที่างห้�องปฏิ�บ่�ต�การ
• CBC:- Hb 8 gm%, WBC 12,000 /mm3
Plt-adq, N 78%, L 22 %
• MCV 102 fl
• Reticulocyte count 10.2 %
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polychromasiapolychromasia
NRCNRCmicrospherocytemicrospherocyte
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autoagglutinationautoagglutination
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22-year-old femaleanemia with jaundice for 2 wkno hepatosplenomegaly
Hemolytic anemia
investigationinvestigation
Autoimmune hemolytic anemia
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AIHAAIHA
Secondary Secondary AIHAAIHA
Treatment
InvestigationInvestigation
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ผู้��ป�วัยช่ายอาย� 16 ป1 มี�อาการเห้นิ2�อยเพล�ยมีาก มีา 1 ส�ปด้าห้� ป3สสาวัะส�ด้-าpale, jaundice, no hepatosplenomegaly
Anemia + Anemia + jaundice
Acute hemolysis
Acute intravascular hemolysis
Dark urine
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ผู้ลการตรวัจที่างห้�องปฏิ�บ่�ต�การ
• CBC:- Hb 7 gm%, WBC 12,500 /mm3,
plt-adq, N 90 %, L 10 %
• UA:- sp.gr. 1.020, blood 3+, cell 0
• MCV 102 fl
• Reticulocyte 9.5 %
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Hb contracted cellHb contracted cell
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ผู้��ป�วัยช่ายอาย� 16 ป1 มี�อาการเห้นิ2�อยเพล�ยมีาก มีา 1 ส�ปด้าห้� ป3สสาวัะส�ด้-าpale, jaundice, no hepatosplenomegaly
G-6-PD deficiency with
acute hemolysis
investigation
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G-6-PD deficiency
complication
Treatment
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ผู้��ป�วัยห้ญิ�งอาย� 25 ป1 มี�อาการเห้นิ2�อยเพล�ยมีา 4-5 เด้2อนิ
Chronic anemiaประวั�ต�เพ��มีเต�มี ประวั�ต�เพ��มีเต�มี ??
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ประวั�ต�เพ��มีเต�มี
• ประจ-าเด้2อนิมีามีาก• ไมี(มี�อาเจ�ยนิเป*นิเล2อด้ ห้ร2อถุ(ายด้-า
•ป3สสาวัะปรกต�
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ผู้ลการตรวัจที่างห้�องปฏิ�บ่�ต�การ
• CBC: HCT 20 %, WBC 6700 /mm3,
plt - adequate, N 56 %, L 30 %, E
14%
• MCV 73 fl
• reticulocyte count 1.2 %
• stool exam - hook worm egg
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hypochromic, microcytichypochromic, microcytic
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ผู้��ป�วัยห้ญิ�งอาย� 25 ป1 มี�อาการเห้นิ2�อยเพล�ยมีา 4-5 เด้2อนิ
Iron deficiency anemia
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Iron deficiency anemia
สาเห้ต�Treatment
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ผู้��ป�วัยห้ญิ�งอาย� 20 ป1 มี�ประวั�ต�ซ�ด้เห้ล2องมีาต�5งแต(เด้6ก ตรวัจพบ่วั(ามี�ต�บ่และมี�ามีโต
Chronic hemolytic anemia
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Investigation • CBC: HCT 23 %, WBC 5600 /mm3,
plt - adequate, N 65 %, L 35 %
• MCV 65 fl
• reticulocyte 9 %
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HCMC, aniso-poikilocytosisHCMC, aniso-poikilocytosis
microspherocytemicrospherocyte
polychromasiapolychromasia
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Thalassemia
Treatment
Genetic counselling
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