Approach to Anemia Summary Approach to Anemia Case

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 because of suspected pharyngitis • Complains of weakness and low-grade fever

Approach to Anemia – Case 1 n n n 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

Approach to Anemia – Case 1 n Laboratory evaluation - Set I: - Hemoglobin – 7. 9 gr% - MCV – 100 - RDW – 17 - WBC – normal - Platelets - normal

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

Approach to Anemia – Case 1 n 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)

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

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

Approach to Anemia – Case 1 n 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)

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

Approach to Anemia – Case 1 n Laboratory evaluation – Set V: - Direct anti-globulin (Coombs) test – Ig. G +3

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

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?

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

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

Approach to Anemia n 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)

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

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

Approach to Anemia n 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?

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

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

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

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

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

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.

Approach to Anemia – Case 2 n Laboratory evaluation - Set I:

Approach to Anemia – Case 2 n n Interpretation: macrocytic anemia with thrombocytopenia Differential diagnosis:

Approach to Anemia – Case 2 n Laboratory evaluation - Set II:

Interpretation: High MCV, Low RPI Differential Diagnosis: n Megaloblastic anemia n Myelodysplastic syndrome n Aplastic anemia n Drug-related n Alcoholism

Approach to Anemia – Case 2 n Laboratory evaluation - Set III: - B 12 and Folate levels Thorough history taking: alcohol? medications?

Approach to Anemia – Case 2 n Laboratory evaluation - Set IV:

Approach to Anemia – Case 2 n Laboratory evaluation - Set V:

Ringed Sideroblast Iron

Approach to Anemia – Case 2 n Summary: - Macrocytic anemia - Thrombocytopenia - Low RPI - Dysplastic maturation (peripheral smear, bone marrow) - Normal B 12 and Folate levels Myelodysplastic syndrome

Table 29 -05 Copyright © 2005 Elsevier Inc. (USA) All rights reserved.