CLUES TO THE DIAGNOSIS IN ANEMIA

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CLUES TO THE DIAGNOSIS IN ANEMIA
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PRINCIPLES

• Anemia is not a disease
• There is usually a cause
• investigation should be logical
• Start with CBC and Blood film
• Leads to other tests
• non specific
• specific
• Guides therapy

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Further Principles

• Symptoms are more related to rate of fall in
  hemoglobin not level.
• Non specific symptoms
• More specific symptoms
• Drug History
• Physical examination
• splenomegaly

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Starts With CBC

• High yield parameters
• Hgb
• MCV
• RBC
• Morphology
• Confirmatory tests
• Lets apply

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This is a 55 year old woman who has fatigue. Her
only other symptom is a craving for chewing ice
cubes. Apart from being pale her examination is
normal.

• Test results
• Hgb 77 g/L
• MCV 66??f/L
• RBC 3.2 x1012/L
• WBC 5.6 x106/L
• Plat 525 x109/L

• Blood film

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Microcytic, hypochromic
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STAGES OF IRON DEPLETION
Loss of body stores Fall in serum
iron Anemia develops Microcytosis Hypochromasia
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ASSESSMENT OF IRON STATUS

• Identify high risk groups
• Children
• Menstruation
• Pregnancy - Lactation
• Frequent Blood Donors
• Chronic GI loss
• Malabsorption
• Diet

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IRON BALANCE

• Ingest 10-20 mg. per day
• Absorb 1-3 mg. per day
• Lose 1 mg per day
• menstrual loss 30-50 ml
• Total iron 35-50 mg/kg
• Stores 1 gram
• Easy to achieve negative balance

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Dx of IRON DEFICIENCY

• Symptoms and signs
• CBC - Anemia - microcytosis - Hypochromia
• Blood Film - Oval - pencil - Tear
• Serum Fe and TIBC Fe low TIBC high
• Serum Ferritin
• Cause of Iron Deficiency

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INVESTIGATION OF CAUSE

• Investigate when cause not Clear
• Symptoms of cause often unreliable
• Upper GI cause higher Yield
• If upper GI lesion found then a colonic
  lesion unlikely
• TESTS - Radiologic, Endoscopic Biopsy,
  Angiographic.

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THERAPY

• Replace iron

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Anemia of Chronic disease

• Usually mild to moderate anemia
• normocytic normochromic
• low retic count
• Low serum Fe and low TIBC sat 15-20
• Ferritin normal or high
• A responsible disease is present
• Usually a systemic disorder

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Very High Iron
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Hemochromatosis
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Hemochromatosis

• Fe overload
• Genetic predisposition to increased Fe absorption
• Common
• Screen with Fe saturation (ferritin)
• Confirm with Genetic testing
• 2 genes 282Y H63D
• Treatment - phlebotomy

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A 65 year old woman is referred to you because
of memory loss. Her family physician had received
tests which included bilirubin of 28 ? mol/L and
an LDH of 1560 U/L. He was puzzled by these
results.

• Test results
• Hgb 85 g/L
• MCV 110 ?fL
• RBC 3.9 x1012/L
• WBC 2.4 x106/L
• Plat 89 x109/L

• Blood Film

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Oval Macrocytes Hypersegmented neutrophils
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Megaloblastic Anemias

• Vitamin B12
• Folic Acid

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Reasons for measuring B12

• Investigation of macrocytic anemia
• Investigation of any anemia
• Investigation of fatigue
• Routine Geriatric Screen
• Investigation of neurologic symptoms

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Symptom Complex

• Classic presentation uncommon
• Often a screen in older patients
• Memory loss prominent
• Neuropathy
• Changes in evoked potential
• Non specific symptoms of anemia

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Causes

• Pernicious anemia
• 10 of all cobalamin deficiencies
• Majority are due to malabsorption

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Causes of Low Serum B12

• Malabsorption of free cobalamin
• Pernicious anemia
• Post gastrectomy state
• Small bowel diseases

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Causes of Low Serum B12

• Malabsorption of food cobalamin
• Atrophic gastritis
• Postgastrectomy state
• Chronic nonspecific gastritis (H pylori ?)
• H2 receptor blocking agents

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Tests

• CBC - RBC indices
• Most are macrocytic
• Blood film
• Macro-ovalocytes - hypersegmented polys
• Biochemical abnormalities
• LDH bilirubin
• Serum B12
• Schilling test (never done)

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Folic acid deficieny

• Dietary source is vegetables
• Absorption no specific carrier
• Deficiency mainly dietary.
• Alcoholism a risk
• Anemia macrocytic
• No neurologic symptoms
• Measure Serum folate (food supplementation)

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Therapy

• Replace B12 - folic acid

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Therapy

• Vitamin B12
• IM
• Oral
• Folic acid
• pregnancy
• treatment

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Hemolytic anemias

• History of jaundice and anemia
• May have splenomegaly
• May have a family history
• anemia with reticulocytosis
• specific morphologic changes
• serum bilirubin and LDH as markers
• Specific tests follow morphology

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What is the abnormality ?
Spherocytes
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What is the abnormality ?
Oxidative hemolysis
Bite cells
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What is the abnormality
fragment
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Which anemia is this ?
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A Common Condition
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Common anemias

• Iron deficiency
• Megaloblastic anemias
• Secondary anemias of chronic diseases
• Anemia of chronic disease
• Hemolytic anemias
• Spherocytic
• fragmentation

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PRINCIPLES

• Anemia is not a disease
• There is usually a cause
• investigation should be logical
• Start with CBC and Blood film
• Leads to other tests
• non specific
• specific
• Guides therapy