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Approach to Anemia - Summary

Approach to Anemia - Summary. Approach to Anemia – Case 1. 37 year old female patient of Caucasian origin referred to the Emergency Room because of anemia Medical background: generally healthy, normal diet; during the last week treated with an antibiotic

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Approach to Anemia - Summary

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  1. Approach to Anemia - Summary

  2. Approach to Anemia – Case 1 • 37 year old female patient of Caucasian origin referred to the Emergency Room because of anemia • Medical background: generally healthy, normal diet; during the last week treated with an antibiotic because of suspected pharyngitis • Complains of weakness and low-grade fever

  3. Approach to Anemia – Case 1 • On examination: pallor, slight jaundice; spleen mildly enlarged, soft, tender • No lymphadenopathy, no bleeding tendency, no glossitis • Pulse 100, regular, blood pressure and oxygen saturation normal

  4. Approach to Anemia – Case 1 • Laboratory evaluation - Set I: - Hemoglobin – 7.9 gr% - MCV – 100 - RDW – 17 - WBC – normal - Platelets - normal

  5. Approach to Anemia – Case 1 • Interpretation: macrocytic anemia • Differential diagnosis: - Megaloblastic anemia - Hemolytic anemia - Myelodysplastic syndrome/Aplastic anemia - Other

  6. Approach to Anemia – Case 1 • Laboratory evaluation - Set II: - Reticulocytes –14% - Corrected reticulocyte count: /%Retics X (measured to the expected Hb ratio)/ 14% x 7.9/15 = 7.4% - Reticulocyte Production Index (RPI): /Corrected reticulocyte count/shift correction factor/ 7.4 / 2 = 3.7 (>2)

  7. Approach to Anemia – Case 1 • Interpretation: hyperproliferative anemia • Differential diagnosis: -Megaloblastic anemia? No - Myelodysplastic syndrome/Aplastic anemia? No - Hemolytic anemia? Yes

  8. Approach to Anemia – Case 1 • Laboratory evaluation - Set III: - LDH – high - Bilirubin – high (unconjugated) - Haptoglobin – low • Diagnosis confirmed: Hemolytic anemia

  9. Approach to Anemia – Case 1 • Hemolytic anemia – differential diagnosis: - Intra-corpuscular (hemoglobinopathy, enzymopathy) - Red cell membrane (cytoskeleton, PNH, spur cell anemia) - Extra-corpuscular (hypersplenism, mechanic hemolysis, immune hemolysis, toxic/infectious agents)

  10. Approach to Anemia – Case 1 • Laboratory evaluation - Set IV: Blood smear - Anisocytosis (high RDW) - Polychromasia (reticulocytosis) -Spherocytes? - Ellyptocytes? -Bite cells? - Spur cells? -Schistocytes? - Sickle cells?

  11. Approach to Anemia – Case 1 • Laboratory evaluation – Set V: - Direct anti-globulin (Coombs) test – IgG +3

  12. Approach to Anemia – Case 1 Summary: - Mild splenomegaly, fever, jaundice - Macrocytic anemia - Reticulocytosis - Spherocytosis - Positive direct anti-globulin test Warm-type immune hemolytic anemia, possibly – drug related

  13. Approach to Anemia An approach to anemia is based on asking 3 main questions: 1. MCV? 2. Reticulocyte count? (Bone marrow function) 3. Involvement of additional lineages?

  14. Approach to Anemia • MCV: - Low: Iron deficiency Thalassemia trait Chronic disease Sideroblastic anemia - Normal: Iron deficiency (early) Chronic disease Renal failure

  15. Approach to Anemia - High: Megaloblastic anemia Hemolytic anemia MDS / Aplastic anemia Drug-related Hypothyroidism Alcoholism Liver disease

  16. Approach to Anemia • Reticulocyte count: - Adequte (RPI>2): Hemolytic anemias (most) Acute blood loss Liver disease - Inadequate (RPI<2): Iron deficiency Megaloblastic anemia Anemia of chronic disease Bone marrow failure (malignancy, chemotherapy, MDS/Aplastic anemia)

  17. Approach to Anemia • Additional lineage(s) involvement: - Leukopenia: Malignancy Chemotherapy Hypersplenism Drug-related Megaloblastic anemia Aplastic anemia

  18. Approach to Anemia - Thrombocytopenia: Malignancy Chemotherapy Hypersplenism Drug-related Megaloblastic anemia Aplastic anemia TTP DIC

  19. Approach to Anemia • In addition, blood smear always needs to be carefully assessed: Schistocytes? Spherocytes? Target cells? Normoblasts? Spur cells (acanthocytes)? Burr cells? Malignant cells (leukemia, lymphoma)? Malaria parasites? Sickle forms?

  20. Anemia With Low MCV and Low Reticulocytes • Iron deficiency • Hereditary defects in hemoglobin synthesis (thalassemia trait) • Defects in heme synthsis (sideroblastic anemia) • Anemia of chronic disease

  21. Anemia With Normal MCV and Low Reticulocytes • Early or mild iron deficiency anemia • Chemotherapy • Anemia of chronic disease • Anemia of renal failure

  22. Anemia with High MCV and Low Reticulocytes • Megaloblastic anemia • Myelodysplastic syndrome / Aplastic anemia • Drug-related anemia • Hypothyroidism • Alcoholism

  23. Anemia with High Reticulocytes • Low MCV: - Thalassemia Major (some cases) - Spherocytosis • High MCV: - Sickle cell anemia - G-6PD deficiency - Immune hemolytic anemia - Malaria infection

  24. Anemia with Leukopenia and/or Thrombocytopenia • Low reticulocytes: - Aplastic anemia/Myelodysplastic syndrome - Chemotherapy - Alcoholism - Megaloblastic anemia • High reticulocytes: - TTP / DIC - Hypersplenism

  25. Approach to Anemia – Case 2 63 year old male patient presented to your clinic with weakness and anemia; generally healthy, no permanent medications. On examination: afebrile, normal pulse and blood pressure. No hepatosplenomegaly and lymphadenopathy. Scattered purpura over lower extremities and chest.

  26. Approach to Anemia – Case 2 • Laboratory evaluation - Set I:

  27. Approach to Anemia – Case 2 • Interpretation: macrocyticanemia with thrombocytopenia • Differential diagnosis:

  28. Approach to Anemia – Case 2 • Laboratory evaluation - Set II:

  29. Interpretation: High MCV, Low RPIDifferential Diagnosis: • Megaloblastic anemia • Myelodysplastic syndrome • Aplastic anemia • Drug-related • Alcoholism

  30. Approach to Anemia – Case 2 • Laboratory evaluation - Set III: - B12 and Folate levels Thorough history taking: alcohol? medications?

  31. Approach to Anemia – Case 2 • Laboratory evaluation - Set IV:

  32. Approach to Anemia – Case 2 • Laboratory evaluation - Set V:

  33. Ringed Sideroblast Iron

  34. Approach to Anemia – Case 2 • Summary: - Macrocytic anemia - Thrombocytopenia - Low RPI - Dysplastic maturation (peripheral smear, bone marrow) - Normal B12 and Folate levels Myelodysplastic syndrome

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