systematic approach in anemia evaluation and review of peripheral smears

1. Systematic Approach in Anemia Evaluation and Review of Peripheral Smears Jun W. Kim, MD Family Medicine Residency Dewitt Army Community Hospital

3. Approach to Dx Hx- age, duration, onset, subjacent illness, blood loss (GI, menstruation, surgery�), diet, medications, toxic exposure, occupation, Family Hx, Social Hx PE- complete exam including skin (jaundice, petechiae), HEENT, Abdomen (hepatosplenomegally), lymphatics, rectal, and pelvic

4. Basic Labs to Start Repeat CBC w/ manual differential (WBC, RBC, HCT, HGB, PLT, indices- MCH, MCHC, MCV, RDW) Peripheral Smear Reticulocyte count Examination of smear bya physician who is aware of pt�s clinical condition is very useful. Even highly skilled lab technitians could overlook subtle changes. Indices are machine generated by averaging analysis.Examination of smear bya physician who is aware of pt�s clinical condition is very useful. Even highly skilled lab technitians could overlook subtle changes. Indices are machine generated by averaging analysis.

5. Reticulocyte count Retic count = % immature RBC Normal 0.5-1.5% (for non-anemic) <1% Inadequate production >=1% Increased production (? adequacy)

6. Reticulocyte Correction %Retic count frequently overestimates Retic count should be compared to non-anemic RBC count to assess adequacy of response Corrected Retic count = %Retic X HCT/45

7. Reticulocyte Production Index Correction for left shift � Retic lifespan is increased in blood RPI = % Retic X Hct/45 X 1/CF Hct Correction factor (CF) 40-45 1.0 35-39 1.5 25-34 2.0 15-24 2.5 Normal RPI = 1 (for non-anemic pt) RPI < 2 : hypoproliferative RPI >=2 : hyperproliferative

8. Retic Production Index Hypoproliferative - Iron def. anemia - B12/folate def. - Chronic disease - Sideroblastic anemia - Aplastic anemia - Myeloproliferative Hyperproliferative - Hemolytic disease - Hemoglobinopathy (including thalassemia)

9. Peripheral smear Optimal area for review RBC morphology, WBC differential, PLT (clumping?) Mention on PLT on oil emersion view 7-20. Check for clumping when low PLT (EDTA induced clumping).Mention on PLT on oil emersion view 7-20. Check for clumping when low PLT (EDTA induced clumping).

10. RBC morphology 7-9 ?m with 1/3 central palor Lifespan of 110-120 days About the size of nucleus of normal lymphocyte Poikilocytosis & Anisocytosis

11. Basophilic stippling Precipitated RNA lead or heavy metal poisoning ETOH abuse Hemolytic anemia

12. Burr cells Altered lipid in cell membrane artifact Uremia Renal failure gastric CA transfused old blood

13. Elliptocytes/ovalocytes Abnormal cytoskeletal proteins Hereditary elliptocytosis

14. Howell Jolly body Nuclear remnant - DNA hemolytic anemia absent or hypofunction spleen

15. Schistocyte/helmet cells Fragmented (mechanical or phagocytosis) DIC TTP HUS Vasculitis prosthetic heart valve severe burns

16. Sickle cells Molecular aggregation of Hgb-S SS, SC, S-thal rarely S-trait

17. NRBC Common in newborn severe degree of hemolysis

18. Spherocyte Absent central palor look smaller Hereditary spherocytosis immune hemolytic anemia

19. Stomatocyte Mouth like Membrane defect Smear artifact Hereditary stomatocytosis Liver disease

20. Target cells Increased redundancy of membrane hemoglobinopathies thalassemia liver disease

21. Tear drop cells Distorted drop shaped Smear artifact myelofibrosis promyeloblastic leukemia space occupying lesions of marrow

22. Differentials H&P Indices (MCV, MCHC, RDW) RBC Morphology Retic response Other labs as needed

25. Microcytic anemia Get Iron panel- serum iron, TIBC, ferritin Ferritin sen=90% spec=80% Ferritin sen=90% spec=80%

26. Iron def. Anemia Low Retic count High RDW Due to chronic blood loss Diet deficiency

27. Thalassemia Normal to inc. RPI Normal RDW Target cells Mentzer index <13 =MCV/RBC Youden�s index - using RDW & Mentzer index - sensitivity = 82% - specificity = 80% confirm w/ Hgb electrophoresis

28. Thalassemia continues Alpha-thalassemia SE Asia & Africa aaaa - normal aaaa^ - silent carrier aaa^a^ - trait (mild) aa^a^a^ - HbH (Bart) hemolytic disease a^a^a^a^ - hydrops fetalis (stillborn) Beta-thalassemia Mediterranean Beta-thal minor one beta gene, increased HbA2/HbF Beta-thal major 2 beta genes, severe, failure to thrive, sig HbF

29. Sideroblastic anemia Accumulation of mitochondrial iron in erythroblasts �� � Hereditary Drugs - INH, lead, zinc, alcohol, chloramphenicol, cycloserine, plavix Hypothermia Confirm w/ BM Bx Insufficient production of protoporphyrin to utilize the iron or unavailability of ferrous iron for insertion into protoporphyrin Insufficient production of protoporphyrin to utilize the iron or unavailability of ferrous iron for insertion into protoporphyrin

30. Sample question #1 Anemia of chronic disease is due to inadequate production of, or poor response to, which one of the following? A. Iron B. Folate C. Erythropoietin D. Ferritin E. Hemosiderin

31. Anemia of chronic disease Infections: TB, SBE, osteo, chronic UTI or pyelo, fungal Malignancy: mets, leukemia, lymphoma, myeloma Chronic inflammatory disorders: RA, SLE, Sarcoid, collagen vascular disease, polymyalgia rheumatica, chronic hepatitis, decubitus ulcer

32. Macrocytic anemia

33. Macrocytic: RPI < 2

34. Macrocytic: RPI < 2Megaloblastic Anemia B12 Inadequate absorption Synthesized by bacteria Meat, fish, dairy (strict vegans) Absorbed as B12-IF complex in ileum (gastrectomy) Ca++ and pH dependant (PPI) Folate Inadequate intake Synthesized by plants and micro-organism Green leafy vege�s Fruits Absorbed in jejunum

35. Sample question #2 Which of the following tests can be useful in determining if an elderly patient has folate deficiency? A. RBC folate concentration B. Serum homocysteine level C. Serum ferritin level D. Serum methylmalonic acid level

36. Macrocytic: RPI < 2Megaloblastic Anemia Smear Macro-ovalocytic Polychromasia Hypersegmented neutrophil Other Labs Homocysteine � Folate def. Methylmalonic acid � B12 def. Intrinsic Factor Ab test � very specific for pernicious anemia but only 50% sensitive Parietal cell AB test � quite sensitive (90%) but not specific Schilling test Three part (B12; B12 + IF; Antibiotic)Three part (B12; B12 + IF; Antibiotic)

37. Macrocytic: RPI < 2Non-megaloblastic Consider Liver, Renal, Endocrine (thyroid), alcohol, drugs Consider anemia of chronic disease Get Bone Marrow Biopsy Myelodysplastic Myeloproliferative - Leukemia, Lymphoma, Multiple Myeloma Ruloux in MM Auer rods in AML Ruloux in MM Auer rods in AML

38. Macrocytic: RPI < 2 continuesAplastic Anemia Fanconi anemia � congenital Direct stem cell destruction � external radiation Drugs - chloramphenicol, gold, sulfonamides, felbamate Other Toxins - Solvents, degreasing agents, pesticides Viral infection - parvovirus B19, HIV, other Idiopathic

39. Macrocytic: RPI >= 2

40. Sample question #3 Of the following laboratory results, which one does not occur in hemolytic anemia? Reticulocytosis Increased unconjugated bilirubin Increased haptoglobin Increased LDH Hemosiderinuria

41. Macrocytic: RPI >= 2 Hemolytic Anemia Other Lab Characteristics RBC morphology Serum haptoglobin Serum LDH Unconjugated bilirubin Hemoglobinuria Hemosiderinuria

42. Macrocytic: RPI >= 2 Hemolytic Anemia

43. Coombs� positive with SpherocytesAutoimmune hemolytic anemia Warm AIHA Abrupt onset IgG Anti-Rh, e, C, c, LW, U Jaundice Splenomegaly SLE, CLL, Lymphoma Drugs: methyl-dopa, mefenamic acid, cimetidine, cefazolin Cold AIHA Insidious onset IgM, complement Anti-I, I, Pr Cold agglutinin titer Absent jaundice Mycoplasma Virus

44. Coombs� positive with SpherocytesOther immune hemolytic anemia Alloantibody hemolytic anemia Transfusion reaction Feto-maternal incompatibility (Kleihauer-Betke test) Drug related Hemolytic anemia Toxic immune complex (drug+Ab+C3) - Quinine, Quinidine, Rifampin, INH, Sulfonamides, Tetracyclin Hapten formation (anti-IgG) - PCN, methicillin, ampicillin

45. Coombs� Negative Hemolytic anemia Episodic - G6PD def., PNH Hemoglobinopathy - Sickle, crystals or target cells Elliptocytosis Spherocytosis DIC, TTP

46. Coombs� Negative Hemolytic AnemiaMembrane Defects Spherocytosis Common among Northern European Autosomal dominant Decreased spectrin Osmotic fragility test Autohemolysis test Elliptocytosis 90% with no clinically significant hemolysis Abnormal membrane protein

47. Coombs� Negative Hemolytic AnemiaDeficiency of RBC Enzymes Pyruvate Kinase Def. Severe anemia in newborns Adults symptomatic Jaundice Splenomegaly Fluorescent screening test Quantitative test G6PD Def. X-linked Mediterranean, African American, and Asian Oxidant drugs � ASA, quinine, primaquine, chloroquine, sulfacetamide, sulfamethoxazole, nitrofurantoin, chloramphenicol, procainamide, quinidine Infections Quantitative test

48. Coombs� Negative Hemolytic AnemiaHemoglobinopathy HbS disease Valine substitution for Glutamic acid at the 6th position of b-chain Sickle crises Severe anemia Screening test - Na Metabisulfite solubility Hgb electrophoresis

49. Coombs� Negative Hemolytic AnemiaHemoglobinopathy continues HbC disease Mild hemolysis Splenomegaly Lysine substitution HbC crystals �bar of gold� Hgb electrophoresis HbSC disease Sickle and SC crystals �Washington monument� Less crises More retinopathy/aseptic necrosis

50. Coombs� Negative Hemolytic AnemiaParoxysmal Nocturnal Hemoglobinuria Rare chronic condition Recurrent abdominal pain, vomiting, headaches, eye pain, thrombophlebitis Episodic Hgb in urine, Hemosiderinuria Abnormal cell membrane - increased lysis by complement Screening - Sucrose hemolysis test Confirm - Acid hemolysis test (Ham�s test)

51. Coombs� Negative Hemolytic AnemiaFragmented RBC�s & Thrombocytopenia TTP-HUS Thrombocytopenia Microangiopathic hemolytic anemia Neurologic symptoms and signs Renal failure Fever Idiopathic - 37 % Drug-associated - 13 % Autoimmune disease - 13 % Sepsis - 9 % Pregnancy - 7 % Bloody diarrhea - 6 % Hematopoietic cell transplantation - 4 % DIC Depletion of clotting factor (TTP � normal) Thrombocytopenia Bleeding (64%) Renal dysfunction (25%) Hepatic dysfunction (19%) Respiratory dysfunction (16%) Shock (14%) Thromboemboli (7%) Central nervous system involvement (2%) Sepsis, trauma, malignancy

52. TTP-HUS / DIC

53. Normocytic AnemiaHyperproliferative (RPI >= 2) Use same flow chart as macrocytic hyperproliferative

54. Normocytic AnemiaHypoproliferative (RPI < 2) 1. Get iron panel (ferritin)/B12/folate - some clue from RBC indices to check early disease, high RDW, peripheral smear. 2. Consider liver, renal, drugs, toxin, endocrine (thyroid), and anemia of chronic disease. 3. Get BM bx - Leukopenia, thrombocytopenia, CRI < 0.1 - Aplastic anemia/pancytopenia - Abnormal (immature) cells on smear