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Anemia 101- Case Studies


Title: Case Studies in Anemia Subject: for resident talks Author: Peter A. Kouides M.D. Last modified by: drkhoury Created Date: 8/23/1995 12:21:18 PM – PowerPoint PPT presentation

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Title: Anemia 101- Case Studies

Anemia 101- Case Studies
  • Peter A. Kouides MD
  • Associate Professor of Medicine,
  • University of Rochester School of Medicine
    Attending Physician,
  • The Rochester General Hospital

Anemia classification based on the mechanism
  • Kinetic Classification (based on retic count)
  • Decreased production
  • Morpholgical classification (based on MCV)
  • Microcytic
  • Normocytic
  • Macrocytic
  • Increased destruction
  • Immunological classification (based on Coombs
  • Immune-mediated
  • Non-immune mediated

The Medical Students Approach to Anemia
  • Check the reticulocyte count to determine if the
    anemia is from decreased production
    (hypoproliferative, reticulocytopenic) or
    increased destruction (hemolytic)/acute blood
    loss (reticulocytosis)
  • 2. If decreased production, narrow down the
    causes in terms of the MCV-
  • If the MCV is low, then do iron studies then Hb
  • If the MCV is normal, check the serum creatinine
    and TSH, if they are WNL then consider bone
    marrow exam
  • If the MCV is high check a folate and vitamin B12
  • 3. If the the reticulocyte count is increased-
  • Check a direct Coombs test
  • 4. Look at the peripheral blood smear to
    confirm/support the diagnosis

Anemia Algorithm
  • Patient with anemia and decreased reticulocyte

What is the MCV ??
  • Macrocytic
  • Vitamin-related
  • B12, Folate
  • Non-vitamin
  • MDS
  • EtOH/Liver Disease
  • Hypothyroidism

Fe def.
Systemic Diseases
  • Diseases in Bone Marrow
  • MDS
  • Solid Tumor
  • Myeloma
  • Aplastic anemia

Renal vs. Liver vs. Endocrine vs. Anemia
of Inflammation
Other sideroblastic anemia (meds,PB,Zn
excess,Cu def)
Anemia Algorithm, continued
  • Patient with anemia and increased reticulocyte

Anemia Algorithm, continued
  • Patient with anemia and increased reticulocyte

What is the result of a Coombs test ??
Positive (autoimmune hemolytic
Intrinsic red cell defect
Extrinsic red cell defect
The Attendings Approach to Anemia
  • 1. Stool guiacs x 3
  • 2. If the MCV is low, then prescribe iron
  • 3. If the MCV is high, then check a folate level
    and vitamin B12 level
  • if folate level returns low or indeterminate,
    then begin folic acid 1 mg po qd
  • if B12 level returns low or indeterminate, then
    begin IM vitamin B12

The Pharmacologists Approach to Anemia
Case 1-A 67-year-old man is referred for
evaluation of dyspnea. The hematocrit is 28,
white blood cell count 4500/mm3, platelet count
550,000/mm3, and reticulocyte count 4. The MCV
is 78 and the blood smear reveals basophilic
stippling and a small population of hypochromic
microcytic red cells. Serum Fe 225, TIBC 260,
Ferritin 490
Case 2-Patient H.M.
  • A 57-year-old woman presents to the clinic for
    evaluation of ataxia, weakness, and parathesias.
    The patient has been taking a multivitamin
  • Hematocrit is 38
  • white blood cell count 4,000 platelet count
  • What tests would you order next ?

  • Case 3- A 65-year-old man with a Hematocrit of
    33 and a reticulocyte count of 7 is admitted to
    the hospital with right upper quadrant abdominal
    pain. Peripheral blood smear reveals occasional

Case 4- Patient R.B.
  • A 26-year-old woman presents to the hospital
    with pleuritic chest pain. She gives a history
    of episodic arthralgias for a number of months,
    plus one episode of frank arthritis involving the
    small joints of both hands occurring 2 months
    prior to admission. The patient has a hematocrit
    of 29, a white blood cell count of 4000, and a
    reticulocyte count of 12. The smear reveals
    normocytic, normochromic red blood cells with
    polychromatophilia, and occasional spherocytes,
    occaisonal NRBC.

Case 5- Patient F.D.
  • A 60-year-old woman is hospitalized because of
    severe fatigue and dyspnea of 2 weeks' duration.
    Five years ago, the patient had a total
    hysterectomy and bilateral salpingo-oophorectomy
    for ovarian adenocarcinoma. She received a
    course of oral melphalan as adjuvant chemotherapy.

Patient F.D. continued
  • Three years ago a restaging laparotomy reveals no
    evidence of tumor, and blood counts were normal.
  • Now, except for a temperature of 38.4C (101.1F)
    and pallor, she has normal findings.
  • Laboratory studies Hematocrit 17, MCV 108 fL.
    , WBC 4,500, platelet count 50,000, reticulocyte
    count 0.8

MDS vs. Folate/B12 Deficiency
  • Think of MDS when the anemic patient is elderly
    and the MCV is increased
  • in one study of the elderly, MDS was the fourth
    most common cause of anemia after
  • acute blood loss/Fe Deficiency
  • anemia of chronic disease
  • anemia of renal insufficiency
  • the B12 level can be borderline low in elderly
    patients but it is not true B12 deficiency if-
  • a serum total homocysteine level is normal
  • a urine methylmalonic acid level is normal

Case 6- Patient G.D.
  • A 28 year-old black man plans a trip to India and
    is advised to take prophylaxis for malaria.
    Three days after beginning treatment, he develops
    dark urine, pallor, fatigue, and jaundice
  • Hematocrit is 26 (it had been 43), MCV 100 WBC
    3.4, Platelets 199,000

Patient G.D. continued
  • Reticulocyte count 13
  • What test should be diagnostic?
  • And, why do I say should instead of is

Drugs Causing Anemia
LESS COMMON- Decreased Production Anti-Tb drugs
Sideroblastic Anemia Chloramphenicol, Valproic
acid Pure Red Cell Aplasia AZT,
Dilantin Macrocytic Anemia
MORE COMMON- Increased Destruction
(Hemolytic) Qunidine, PCN, Aldomet
Auto-immune Hemolytic Anemia Primaquine,Nitrofuran
toin, Dapsone, Pyridium G6PD
Case 7
  • A 21-year-old woman with sickle cell anemia has
    had a fever and severe pain in the right shin for
    3 weeks. The painful area is hot, swollen,
    tender and indurated.

Case 8
  • A 66-year-old-man presents with increased fatigue
    and anemia. Hypothyroidism was detected 3 years
    ago and thyroid hormone therapy was administered.
    Anemia was diagnosed 2 years ago, but findings
    on bone marrow examination were normal, and there
    was no response to oral therapy with iron.
    Sexual function has diminished during the last 2
    years. He has a blood pressure of 90 Hg systolic
    and 60 mm Hg diastolic, pallor, absence of
    axillary hair, and sparse pubic hair. There is
    no gynecomastia, but the testicles are soft, and
    the prostate gland is small. The result of an
    examination of the stool for occult blood is
    negative. Laboratory studies hematocrit 36,
    leukocyte count 5800/µL, platelet count
    255,000/µL, peripheral blood film - normochromic
    normocytic erythrocytes with anisocytosis or
    poikilocytosis, MCV 86 fl, serum creatinine -