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Anaemia

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Anaemia Prof. A. B. Skotnicki M.D. Ph.D. Anaemia Decreased haemoglobin concentration and/or PCV Internal iron exchange. Absorption - about 1 mg/d is required from the ... – PowerPoint PPT presentation

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Title: Anaemia


1
Anaemia
  • Prof. A. B. Skotnicki M.D. Ph.D.

2
Anaemia
  • Decreased haemoglobin concentration and/or PCV

3
Internal iron exchange.
  • Absorption - about 1 mg/d is required from the
    diet in men, 1.4 mg/d in women
  • transferrin saturation 20 to 60

4
Iron storage and transport
Tissue ferritin
Serum transferin 20 umol/l
Bone Marrow Erythroblasts
5
Classification of anaemia
  • Morphological
  • Based on red cell measurement
  • Aetiological
  • Based on cause

6
Aetiological classification of anaemia
7
Morphological classification of anaemia
Acute blood loss Haemolysis Bone marrow
aplasia Bone marrow infiltration
? Fe
? B12 ? fol.ac.
Chronic disease
? MCV ? MCH
? MCV ? MCH
MCV and MCH normal
Macrocytic hyperchromic Megaloblastic anaemia
Microcytic hypochromic anaemia
Normocytic normochromic anaemia
8
Anaemia signs and symptoms
  • General signs and symptoms universal for all
    anaemias
  • Signs and symptoms specific for a particular cause

9
General symptoms of anaemia
? O2 carrying capacity of blood TISSUE HYPOXIA
? Hb
Compensatory mechanisms mobilised to contract
hypoxia
Clinical manifestations
Palpitations Tachycardia Heart murmurs
Cardiac overactivity
Cadiorespiratory insufficiency
dyspnoea
Skin vasoconstriction redistribution of blood
flow (brain, heart)
pallor
10
Anaemia general signs and symptoms
  • CSN
  • Headaches
  • Tinnitus

Pale skin mucous membranes
  • General
  • Shortness of breath
  • Fatigue
  • Weakness
  • Susceptibility to infections
  • CVS
  • Tachycardia
  • Functional murmur
  • Stenocardiac pain

11
Anaemia major types
  • Iron deficiency anaemia
  • Megaloblastic anaemia
  • Haemolytic anaemia
  • Aplastic anaemia
  • Anaemia of chronic disease

12
Normal erythropoiesis
Fe
B12
haemoglobinisation
MCV90 fl
HB
N

MCHC32 g/l
N
E
RBC production
MCH32 pg
13
Erythropoiesis in IDA or after bleeding
Fe
B12
haemoglobinisation
MCV70 fl
HB
ltN

MCHC28 g/l
N/gtN
E
RBC production
MCH25 pg
14
Iron deficiency anaemia (IDA) - causes
Increased requirement
Inadequate intake
  • Chronic blood loss
  • GI
  • Urinary Tract

Iron malabsorbtion
15
IDA causes of chronic blood loss
Haematemesis Haemoptysis
  • Gastrointestinal tract bleeding
  • Hiatus hernia
  • Gastritis haemorrhagica
  • Peptic ulcer
  • Gastric cancer
  • Intestinal polyposis
  • Colonic cancer
  • Colitis ulcerosa
  • Haemorrhoidal varices
  • Urinary tract
  • bleeding haematura
  • Renal disorders
  • Inflammation
  • Tumour
  • Urinary tract
  • Calculosis
  • Polyps
  • Urinary bladder tumours
  • Genital tract bleeding
  • Menorrhagiae
  • Metrorrhagiae
  • Uterine myoma
  • Melaena

16
IDA - signs and symptoms
General signs and symptoms PLUS tissue asiderosis
  • Hair
  • Fragility, coming out
  • Early gray
  • Skin
  • Dry, cracked
  • Cheilitis angularis
  • rhagades
  • Eyes
  • Bluish sclera
  • Nails
  • Brittle, spoon nails
  • Atrophic changes
  • Tongue
  • Glossitis anaemica

Dysphagia Plummer-Vinson syndrome
Pica
Gastric troubles
Neurovegetative dystonia
17
Moderately severe iron deficiency anaemia
  • This example of moderately severe iron deficiency
    anaemia shows anisocytosis, anisochromasia,
    hypochromia, microcytosis and poikilocytosis. The
    poikilocytes include several particularly long
    elliptocytes, sometimes referred to as 'pencil
    cells'. Elliptocytes are characteristic of iron
    deficiency but not pathognomonic.

18
Severe iron deficiency anaemia
  • Blood film from a patient with severe iron
    deficiency anaemia. The film shows anaemia,
    microcytosis, hypochromia, anisocytosis,
    anisochromasia and poikilocytosis.

19
Pallor in iron deficiency anaemia
  • The hand of a patient with iron deficiency
    anaemia showing pallor. The hand of a non-anaemic
    person is pictured for comparison. Pallor is a
    non-specific feature of anaemia.

20
Pale conjunctiva in iron deficiency anaemia
  • The best places to check for pallor that may
    indicate anaemia are the conjunctiva, the nail
    beds and the palms of the hands. This patient
    with iron deficiency anaemia has conjunctival
    pallor.

21
Pallor in iron deficiency anaemia
  • Pallor in a patient with iron deficiency anaemia.
    The patient's hand is pictured together with the
    hand of a healthy person.(Courtesy of Dr D.
    Samson.)

22
Oral changes in iron deficiency anaemia
  • Angular cheilosis and atrophic glossitis in iron
    deficiency anaemia. These features are typical of
    moderately severe iron deficiency anaemia and
    indicate the effect of iron deficiency on tissues
    other than the bone marrow.(Courtesy of Dr D.
    Samson.)

23
Cheilitis Angularis in IDA
24
Koilonychia in iron deficiency anaemia
  • Koilonychia or spoon-shaped nails in iron
    deficiency anaemia. Koilonychia has a high degree
    of specificity for iron deficiency but it is a
    relatively uncommon feature, occurring only in
    severe chronic iron deficiency.

25
Typical changes in blood count in IDA
  • Normal Blood Count
  • Hb 14 g/dl
  • RBC 4,50 x 1012/l
  • PCV 40
  • MCV 90 fl
  • MCH 30 pg
  • Ret 0,5
  • WBC 7,5 x 109/l
  • Differential normal
  • Platelets 400x109/l
  • Blood Count in IDA
  • Hb 7,5 g/dl
  • RBC 4,05 x 1012/l
  • PCV 26
  • MCV 64 fl
  • MCH 18,5 pg
  • Ret 2,6
  • WBC 7,5 x 109/l
  • Differential normal
  • Platelets 530x109/l

26
Iron deficiency is NOT a diagnosis but a symptom
Iron Deficiency anaemia
Aetiology ?
Clinical laboratory findings
27
Iron deficiency anaemia
  • 53 old male
  • Tiredness
  • Hb 7 g/l
  • MCV 69 fl
  • Serum ferritin 8ug/l
  • Occult faecal blood test positive ()
  • Colonoscopy
  • Carcinoma of the colon

28
22 years old patient with ACD (Hodgkins lymphoma)
29
Megaloblastic Anaemia
  • Abnormal changes in blood cell formation leading
    to macrocytic anaemia and varying degrees of
    pancytopenia as a result of abnormal DNA
    synthesis because of single or combined
    deficiency of folate and/or vitamin B12

30
Normal erythropoiesis
Fe
B12
haemoglobinisation
MCV90 fl
HB
N

MCHC32 g/l
N
E
RBC production
MCH32 pg
31
Erythropoiesis in B12 deficiency
Fe
B12
haemoglobinisation
MCV100 fl
HB
N

MCHC32 g/l
ltN
E
RBC production
MCH40 pg
32
Megaloblastic anaemia - causes
Inadequate intake
Increased requirement
Malabsorbtion
  • Disturbed metabolism

33
Megaloblastic anaemia - causes
  • FOLIC ACID DEFICIENCY
  • Inadequate intake unbalanced diet (common in
    alcoholics, teenagers, some infants)
  • Increased requirements Pregnancy, Infancy,
    Malignancy, Increased hematopoiesis, Chronic
    exfoliative skin disorders
  • Malabsorption Tropical sprue, Nontropical
    sprue, others
  • COBALAMIN DEFICIENCY.
  • Inadequate intake vegetarians (rare)
  • Malabsorption Defective release of cobalamin
    from foodGastric achlorhydria, Partial
    gastrectomy, Drugs that block acid secretion
  • Inadequate production of intrinsic factor (IF)
    Pernicious anemia Total gastrectomy Congenital
    absence or functional abnormality of IF Disorders
    of terminal ileum
  • Competition for cobalamin
  • Other

34
Megaloblastic anaemia - causes
Cause B12 deficiency Folic acid deficiency
1. Dietary deficiency   2. Malabsorbtion Atrophic gastritis Hipochlorchydria Lack of intrisinc factor Small bowel diseases Post gastrectomy   3. Increased demands Pregnancy   4. Disturbed metabolism anticonvulsives cytostatics rarely         -     - often (alcohol abuse, parenteral nutrition, age)   - - -        
35
Megaloblastic anaemia symptoms and signs
  • CSN
  • Headaches
  • Tinnitus
  • Visual disturbances
  • Optic nerve disturbances
  • Psychiatric disturbances
  • Irritability
  • Sleepiness
  • Dementia
  • Peripheral neuropathy
  • Paresthesia
  • Pins and needles
  • Unsteady gait
  • Reduced Sensation
  • Imbalance
  • Dysuria
  • Reduced heat and cold sensibility
  • Glossitis Hunteri
  • smooth
  • Reddened
  • Burning
  • Reduced in size
  • Loss of appetite
  • Loss of taste
  • Loss of body weight
  • Abdominal pains
  • Atrophic gastritis
  • Diarrhoea
  • Achlorchyrdia

Average age 60 Often - women
Specific PLUS General signs and symptoms
36
Blood film in megaloblastic anaemia
  • In megaloblastic anaemia the most characteristic
    features in the peripheral blood film are
    hypersegmented neutrophils and macrocytes,
    particularly oval macrocytes arrow. The
    neutrophil shown has six lobes and is therefore
    classified as hypersegmented    

37
Haemolytic anaemia
  • Decrease in the total number of circulating
    erythrocytes that is caused by premature
    destruction or removal of red cells from the
    circulation

38
Haemolytic anaemia
  • Classifications of HA according to
  • Type of defect
  • Site of defect
  • Site of haemolisis

39
Classification of HA according toType of defect
  • Hereditary
  • Membrane defect
  • Metabolic defect
  • Hemoglobinopathies
  • Acquired
  • Immunologic defect
  •  Mechanical defect
  • Intravascular coagulopathy
  •  March hemoglobinuria
  • Infection
  • Membrane abnormality

40
Classification of HA according toType of defect
  • Hereditary
  • Membrane defect
  • HS
  • Hereditary elliptocytosis
  • Metabolic defect
  • GdPD deficiency
  • PK deficiency
  • Hemoglobinopathies
  • Thalassemias
  • Sickle cell diseases
  • Other hemoglobinopathies
  • Acquired
  • Immunologic defect
  • Drug-induced hemolysis
  • Isoimmune and alloimniune hemolysis (neonatal and
    delayed transfusion reactions)
  •  Mechanical defect
  • Rapid turbulent flow of blood, tumors,
    hypertension, aortic stenosis, Prosthetic valve
    leaks
  • Intravascular coagulopathy
  •  March hemoglobinuria
  • Infection
  • Membrane abnormality (stem cell abnormality)

41
Classifications of HA according toSite of defect
  • Extracorpuscular factors
  • Antibodies (Autoimmune hemolytic anaemia,
    transfusion-related haemolytic reactions,
    Drug-related hemolytic reactions)
  • Mechanical or traumatic factors (Prosthetic heart
    valves, High-flow red cell damage, Intravascular
    coagulopathy)
  • Infections (Bacterial, Parasitic)
  • Cell membrane lipids (Liver disease, Lipid
    disorders)
  • Intracorpuscular factors
  • Red cell membrane abnormalities (HS and related
    abnormalities PNH)
  • Hemoglobinopathies (Thalassemias, Sickle cell
    disease and related hemoglobinopathies,
    Methemoglobinemia, Unstable hemoglobin diseases )
  • Enzymopathies (G6PD deficiency Others)

42
Classifications of HA according toSite of
Haemolysis
  • Extra vascular hemolysis
  • Autoimmune hemolytic anemia
  • Red cell membrane defects
  • Spur cell anaemia
  • Red cell metabolism defect
  • Unstable haemoglobin diseases
  • Intravascular hemolysis
  • Traumatic hemolysis
  • Immune hemolysis
  • Infections

43
Clinical signs and symptoms of haemolytic anaemia
  • General signs and symptoms universal for all
    anaemia
  • Signs and symptoms specific haemolysis
  • Jaundice
  • Increased billirubin (unbound)
  • Increased reticulocitosis

44
Example of blood film in HA
  • Microangiopathic haemolytic anaemia
  • Blood film showing the features of
    microangiopathic haemolytic anaemia in haemolytic
    uraemic syndrome. There are schistocytes
    including one microspherocyte

45
Aplastic anaemia
  • Acellular or hypocellular marrow that causes bone
    marrow failure and lower level of cell
    production, leading to pancytopenia.
  • Etiology
  • Idiopathic
  • Secondary

46
Causes of Secondary Aplastic Anaemia
  • Drugs and toxins
  • Chloramphenicol
  • Cancer chmotherapy
  • Chemicals
  • Infections
  • Viral hepatitis
  • CMV
  • Infectious mononucleosis
  • Parvovirus 19
  • Proleukaemic and leukaemic conditions
  • Paroxysmal nocturnal haemoglobinuria
  • Genetic or constitutional conditions

47
Bone marrow in AA
  • Normal Bone marrow
  • Bone marrow in AA

Residual haemopoesis
Fat cells
48
Signs and symptoms of AA
  • The results of pancytopenia
  • Anaemia (general signs)
  • Thrombocytopenia (bleeding tendency)
  • Granulocytopenia (infections)

49
Normal bone marrow (right) and in aplastic
anaemia (left) trephine biopsies
AA
normal
50
Anaemia of chronic disease (ACD)
  • Common type of anaemia that occurs in patients
    who present with any of several chronic
    inflammatory and malignant diseases

51
Anaemia of chronic disease (ACD)
  • Anaemia of chronic disease
  • caused by a defect in incorporation of iron into
    haemoglobin as a consequence of infection,
    inflammation or malignant disease.
  • Bone marrow iron stores are usually normal or
    increased. The anaemia is initially normocytic
    and normochromic but when it becomes severe is
    hypochromic and microcytic.

52
Signs and symptoms of ACD
  • General signs and symptoms of anaemia
  • Blood film as in IDA
  • No tissue asiderosis

53
ACD IDA clinical laboratory differences
Feature ACD IDA
Severity
Tissue asiderosis -
Chronic disorder
? ESR fever ?WBC ?PLT pain lymph nodes ? -

Serum iron ? ??
Serum ferritin ? ?
Serum transferin ? ?
TIBC ? ?
54
Signs and symptoms in anaemia
Anaemia Signs and symptoms
Aplastic Marrow failure
Iron deficiency Tissue asiderosis
B12 follic acid deficiency Neuro gastrointestinal
Chronic disease Without tissue asiderosis
Haemolytic Haemolysis
55
Anaemia of chronic disease -bone marrow
56
Comparison of blood films in anaemias
Normal
Macrocytic
IDA
Haemolytic
57
Fe, TIBC and UIBC
TIBC 60 umol/l
UIBC
Fe 20 umol/l
NORMAL
Fe overload
IDA, pregnancy
Infections cancers
58
Oral iron absorbtion test
59
MCV in anaemia
Microcytic (MCVltN) Normocytic (MCVN) Macrocytic (MCVgtN)
Iron deficiency FeltN, FerritinltN, TIBCgtN Aplastic Reticulocytes lt N B12 ltN
Chronic disease FegtN, Ferritin,gtN Haemolytic Reticulocytes gt N Folic acid ltN
Talasemia Fe gtN, Ferritin gtN Acute blood loss Reticulocytes gt N
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