The future belongs to those who believe in the beauty of their dreams' Eleanor Roosevelt

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The future belongs to those who believe in the
beauty of their dreams. Eleanor Roosevelt
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No doubt knowledge is valuable..,but above it
are power, goodness most important Character
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HEMATOLOGY Anemia

• Dr. Venkatesh M. Shashidhar
• Associate Professor of Pathology
• Fiji School of Medicine

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Normal Blood Cells
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Blood Smear - Normal
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Haemopoiesis
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Steps in Erythropoisis
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RBC disorders (Anemias)

• Anemia is decreased red cell mass affecting
  tissue oxygenation
• Practical - Low Hb or Low Hematocrit

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C.B.C

• Haemoglobin - 152.5, 14 2.5 - g/dl
• PCV - 0.47 0.07, 0.42 0.05 - l/l ()
• Haematocrit, effective RBC volume - better
• RBC count - 5.5 1, 4.8 1 x1012/l
• MCHC - Hb/PCV - 30-36 - g/dl
• Hb synthesis within RBC
• MCH - Hb/RBC - 29.5 2.5 pg/l
• Average Hb in RBC
• MCV - PCV/RBC 85 8 - fl

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Mechanism of Anemia

• Decreased Production
• Nutrient Deficiency.
• Iron, B12/Folate
• Hemopoietic cell damage
• Aplastic, Hypoplastic Neoplasms, radiation,
  drugs
• Increased loss / destruction
• Blood loss anemias - parasites, bleeding
• Hemolytic anemias Autoimmune, mechanical,
  drugs, parasites.

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Iron Deficiency Anemia

• Most abundant metal but most common deficiency..!
• Common in developing world,
• Parasitic Worm infestation Malnutrition
• Chronic blood loss ? only Iron Deficiency
• not other deficiency.. Why ?

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Iron Metabolism

• Limited absorption and no proper excretory
  mech.
• Recycling of iron dead cells to new cells
• 1mg/day ? 3-6G body ? 1mg/day
• 10 of the 10 to 20 mg of dietary iron.
• Iron is absorbed in Jejunum.
• Stored as Ferritin Hemosiderin.
• Laboratory tests
• Serum iron(1mg/l)
• Serum iron binding capacity (3mg)
• Serum ferritin (gt20ug)

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Transferrin

• Transport Protein For Iron In Blood
• Fully Saturated Transferrin TIBC
• 300 - 350ug/dl Fe
• Normal Transferrin - 1/3 Filled With Iron
• 100 - 120ug/dl Fe (Serum Iron)

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IDA - Etiology

• Blood loss
• Bleeding Parasites, Gynecologic, ulcers
• Increased need
• Pregnancy, children
• Poor diet / poor absorption
• Malnutrition (greens meat), malabsorption,
  intestinal surgery, gastric atrophy.

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IDA - Pathogenesis

• Decreased Iron stores
• Decreased Hb Synthesis
• Delayed maturation of erythroblasts (cytoplasmic)
• Decreased cytoplasm, more division (microcytes)
• Decreased hb content (hypochromia)
• Anemia.

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Microcytic Anemia (IDA)
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Clinical Features

• General features of Anemia
• Pallor, Weakness, Lethargy,
• Breathlessness on exertion
• Palpitations ? heart failure ? pedal edema
• Special features in IDA
• Angular cheilitis, atrophic glossitis,
• Oesophageal atrophy/web ? dysphagia,
• Koilonychia, brittle nails, gastric atrophy.

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Angular cheilitis
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Angular cheilitis Glossitis
Why?
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Koilonychia in Iron def.
Why?
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Koilonychia in Iron def.
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Hypochromic Microcytic RBC
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Iron Deficiency Anemia
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IDA on Treatment
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Seeing much, suffering much and studying much
are the three pillars of learning. Benjamin
Disraeli
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Megaloblastic anemia

• Vitamin B12/Folic acid deficiency
• Second most common type of anemia.
• Multi System disease All organs with increased
  cell division.
• Macrocytic anemia, pancytopenia.
• Pernicious anaemia
• autoimmune, Gastric atrophy, VitB12 def.

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Megaloblastic anemia - Etiology

• Malnutrition
• Intrinsic factor Ab - Pernicious anemia
• Gastrectomy, Ileal resection
• Inflammatory bowel disease
• Malabsorption syndromes - Sprue
• Blind loop syndrome

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Megalobl - Pathogenesis

• Decreased Vit B12 / Folate
• Decreased DNA Synthesis
• Delayed maturation of erythroblasts (Nucleus)
• Increased cell size (macrocytes)
• Normal hb content (Normochromia)
• Decreased RBC number
• Decreased WBC number (pancytopenia)
• Anemia Pancytopenia.

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Vitamin B12 Absorption
B12
Parietal cells - produce IF
B12
Stomach
IF
Ileum - IF receptors
IF
B12IF
B12
IF
B12
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Macrocytic Anemia (Meg.)
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CWM-20353-Meg.An
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Macroovalocytes Macropoly
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Megaloblastic Anemia
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CWM-20353-Meg.An
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The only person who never makes a mistake is a
person who never does anything- Theodore
Roosevelt
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Congenital RBC Disorders

• Membrane Disorders
• Spherocytosis, Elliptocytosis
• Hemoglobin Disorders
• Hemoglobinopathies - Sickle cell, HbC etc.
• Thalassemia Syndromes - ?, ?, ?
• Enzyme disorders
• G6PD, PK deficiency

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Differential diagnosis of Anemia
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Low HbAnemia MCV
Low microcytic
Normal normocytic
High macrocytic
Measure Ferritin
Measure B12 folate
Normal/high
Low
Low Megaloblastic anemia
Normal
Anemia of chronic disease/ Congenital Hb dis.
Iron def Anemia
Reticulocyte count
Anemia of chronic disease Renal failure Marrow
failure
high
low
Hemolytic anemia or blood loss
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Anemia with Low MCV and Low Retics

• Differential diagnosis
• Iron deficiency (Micro Hypo - severe)
• Anemia of chronic disease (mild micro/hypo)
• Laboratory evaluation
• Iron, iron-binding capacity, and ferritin
• Blood smear Micro/hypo, Pencil cells.

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Anemia with High MCV

• Differential diagnosis
• Megaloblastic anemia B12, Folate
• Nonmegaloblastic anemia No def.
• High retics bleeding, hemolysis
• Laboratory evaluation
• Serum B12, RBC folate levels.
• Blood film macroovalocytes, pancytopenia
• Bone marrow dysplasia, neoplasia.

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Anemia with Normal MCV

• Differential diagnosis
• Primary bone marrow failure
• Aplastic anemia, drugs, chemotherapy
• Secondary bone marrow failure
• Uremia, Endocrine disorders, AIDS,
• Anemia of chronic disease
• Laboratory evaluation
• Blood smear Iron, TIBC, Ferritin.
• Bone marrow smear and iron stores
• Kidney, Thyroid liver function tests, Cortisol
  levels
• Erythropoietin level

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Anemia with high Retics

• Differential diagnosis
• Bleeding blood loss internal/external
• Hemolysis immune, mechanical, toxic, inf.
• Laboratory evaluation
• Blood film, nRBC, spherocytes, Parasites, Retics.
• Hemolysis indirect Bilirubin, Haptoglobin,
• Direct and indirect Coombs test
• Hemoglobin electrophoresis, G6PD screen etc.

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Bone Marrow Cellularity
Normal Hypercellular Hypocellular
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ß Thalassemia Major
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Sickle Cell Disease
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Polychromasia - Hemolytic An.
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Warm Ab IHA
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Microangiopathic Hemolytic A.
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Thalassemia Trait
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Thalassemia Major
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Her. Spherocytosis
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Hereditary Elliptocytosis
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G6PD Deficiency Anemia
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Causes of High Hct/polycythemia

• Relative or spurious erythrocytosis
• Hemoconcentration secondary to dehydration
• (diarrhea, diaphoresis, diuretics, deprivation
  of water, emesis, ethanol, etc.)
• Absolute erythrocytosis (True )
• Tissue hypoxia Smoking (Co), High altitude,
  Pumonary disease, respiratory def. Cardiac
  shunts, High oxygen-affinity Hb.
• High EPO - Tumors eg. HCC.
• Androgen therapy
• Primary - Polycythemia vera

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The only person who never makes a mistake is
the person who never doesanything!- Theodore
Roosevelt