Anemia

• WHO definition: a hemoglobin level <130g/L (13g/dL) in men and <120g/L (12g/dL) in women

• Reduction in below normal in the concentration of hemoglobin or RBC’s in the blood

Clinical Presentation: Acute anemia due to blood loss

• Acute blood loss – hypovolemia, hematocrit and hemoglobin level do not reflect volume loss, compensation due to Bohr effect

• Blood loss of 10-15% of total blood volume – signs of vascular instability

• Blood loss of >30% - remains supine, postural hypotension and tachycardia

• Blood loss >40% (>2L in average sized adult) – hypovolemic shock (confusion, dyspnea, diaphoresis, hypotension and tachycardia)

Clinical Presentation: Anemia due to Hemolysis

• Signs and symptoms dpend on the mechanism that led to the red cell destruction

• Intravascular hemolysis w/ release of free hemoglobin – associated with acute back pain, free hemoglobin in the plasma and urine, and renal failure

Clinical Presentation: Moderate anemia

• Fatigue, loss of stamina, breathlessness and tachycardia (with physical exertion)

Clinical Presentation: Chronic or Progressive anemia

• Depends on the age of the patient and the adequacy of blood supply to critical organs

Disorders commonly associated with anemia

• Chronic inflammatory states

• Lymphoproliferative disorders

3 Functional Categories

• Disorders of Proliferation

• Disorders in Erythrocyte Maturation

• Disorders due Primarily to Erythrocyte Destruction or Red Cell Loss

Approach to the Patient

• Do a careful and thorough history and physical examination

• Determine the Subjective and Objective data pertinent to anemia

Subjective Data

• Severity of the anemia

• Rapidity of onset

• Patient’s age and CV status

• Associated manifestations of the underlying disorder- Endocrine disorder- Renal disorder- Hepatic disorder

• Onset & Duration of symptoms insiduous or acute

• Previous prescription for hematinics & response• Medication history• Occupation, household customs & hobbies• Symptoms of hemolysis- jaundice, changes in

urine color• Symptoms of blood loss - melena,

hematochezia, epigastirc pain

• Geographic backgrounds and ethnic origin

• Obstetric & Gynecologic history – # of pads/day– duration– # of pregnancies, abortions - interval

• Concomitant bleeding manifestations

• Dietary history

• Fever, Weight loss

Objective Data

• Cardiac Signs– Hemic murmurs - mid or holosystolic often in

the pulmonic or apical area, due to increased blood flow and turbulence

– Gallop rhythms– Tachycardia/Cardiomegaly– Strong peripheral pulses with wide pulse

pressure

• Integumentary Manifestation– Pallor: <8 to 10 mg/dL hemoglobin– Affected by:

• state of vasoconstriction/vasodilatation• degree & nature of pigmentation• nature & fluid content of the subcutaneous tissues

– Most constantly detected in:• mucous membranes of the mouth, pharynx, conjunctivae,

lips• Nailbeds• Palamar creases

• Neuromuscular Sign– Headache– Vertigo– Tinnitus– Faintness– Retinal hemorrhage– Paresthesias– Scotomas– Lack of mental concentration– Drowsiness– Restlessness

• GI Manifestations– Glossitis– Atrophy of the papillae of the tongue– Dysphagia– Oral ulcers– Gingival hyperplasia– Hepatosplenomegaly

• Sternal Tenderness– lymphadenopathy

• Genitourinary Sign– Slight proteinuria– Changes in urine color

• Laboratory Evaluation – Complete Blood Count:– Red cell count- hgb, hct, reticulocyte count– RBC indices – MCV, MCH, MCHC, RDW– White Blood cell count- cell differential, nuclear

segmentation of neutrophils– Platelet count– Peripheral smear morphology – cell size, hemoglobin

content, anisocytosis, poikilocytosis, polychromasia– Iron Supply Studies – serum iron, total iron-binding

capacity, serum ferritin– Bone marrow examination – Aspirate: M/E ratio, Cell

Morphology, iron stain; Biopsy: cellularity, morphology

• Physiologic factors affecting CBC– Age– Sex– Pregnancy– Smoking– Altitude

Red Blood Cell IndicesIndex Normal Value

• Mean Cell Volume(MCV):(hematocrit x 10)/(red cell ct. x 106) 90 + 8 fL

• Mean Cell Hemoglobin (MCH):(hemoglobin x 10)/ (red cell ct. x 106) 30 + 3 pg

• Mean Cell Hemoglobin Concentration:(hemoglobin x 10)/ hematocrit, 33 + 2% or MCH/MCV

• MCV – reflects microcytosis and macrocytosis

• MCH and MCHC – reflectsdefects in hemoglobin synthesis

Changes in Normal Hemoglobin/Hematocrit Values with Age and Pregnancy

Age/Sex Hemoglobin g/dl Hematocrit %– At birth 17 52

– Childhood 12 36

– Adolescence 13 40

– Adult man 16(+2) 47(+6)

– Adult woman 13(+2) 40(+6)

– (menstruating)

– Adult woman 14(+2) 42(+6)

– (postmenopausal)

– During pregnancy 12(+2) 37(+6)

Peripheral Blood Smear

• Provides important information about defects in red cell production

• It reveals:– Anisocytosis – variations in cell size; correlates w/

increases in RDW or range of cell sizes– Poikilocytosis – variations in cell shape; suggests a

defect in maturation of red cell precursors in the bone marrow or fragmentation of circulating red cells

– Polychromasia – rbc that are slightly larger than normal and grayish-blue in color on the right-Giemsa stain

Normal Peripheral Smear

Microcytic Hypochromic RBC’s with anisocystosis and poikilocytosis

Macrocytosis

Howell-Jolly Bodies

Tear-drop shape cell and Nucleated RBC

Target Cell

RBC Fragmentation

Burr cell or Echinocytes

Spur Cell