APPROACH TO ANEMIA¸_พิมพ์ลักษณ์ - Approach to...• Microcytic, hypochromic...
Transcript of APPROACH TO ANEMIA¸_พิมพ์ลักษณ์ - Approach to...• Microcytic, hypochromic...
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Pimlak Charoenkwan, M.D. Division of Hematology and Oncology, Department of Pediatrics
Chiang Mai University, Chiang Mai, Thailand
APPROACH TO ANEMIA
การประชุมโลหติวทิยาสัญจร ครัง้ที ่ 15 โรงพยาบาลน่าน 20 กนัยายน 2562
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Scope
• RBC production and catabolism • Criteria for diagnosis of anemia • Approach to anemia • Hemolytic anemia • Case discussion by blood smear
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Erythroid differentiation
1. Pronormoblast 2. Basophilic normoblast 3. Polychromatophilic normoblast 4. Orthochromatic normoblast 5. Polychromasia 6. Mature RBC
Hoffman Hematology 5th edition
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RBC catabolism
Noronha SA. Pediatr Rev 2016;37:235-46.
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Hoffman Hematology 5th edition
Criteria for diagnosis of anemia
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Hemoglobin level
WHO CDC
Infant 0.5-4.9 y - < 11 g/dL
Children 5.0-11.9 y - < 11.5 g/dL
Menstruating women < 12 g/dL -
Pregnant women in first or third trimester
< 11 g/dL < 11 g/dL
Pregnant women in second trimester
< 11 g/dL < 10.5 g/dL
Men < 13 g/dL -
Killip S, Bennett JM, Chambers MD. Iron deficiency anemia. Am Fam Physician 2007;75:671-8.
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Approach to anemia
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Hoffman Hematology 5th edition
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Origin Disorder Mechanism of destruction
Acquired
Hemolytic disease of newborn Warm AIHA
Mechanical valve HA Hemolytic ureic syndrome
Cold agglutinin disease Malaria
Extravascular Extravascular Intravascular Intravascular Intravascular
Intra/Extravascular
Congenital Thalassemia
Hereditary spherocytosis G6PD deficiency
Extravascular Extravascular
Intra/extravascular
Classification of common hemolytic anemia
Adapted from: Noronha SA. Pediatr Rev 2016;37:235-46.
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1. Anemia
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2. Anemia
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3. Neonatal jaundice
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4. Anemia and jaundice
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5. Neonatal anemia and jaundice
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6. Anemia and jaundice
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7.1 Anemia
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7.2 Anemia
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8. Anemia and thrombocytopenia
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9. Neonatal anemia
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10. Newborn with sepsis
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Summary
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1. Anemia Iron deficiency anemia
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Iron deficiency anemia
• Microcytic, hypochromic anemia (low MCV, MCH) • Alters red cell size unevenly (high RDW) • Poikilocytic changes, seen particularly with severe iron
deficiency • Thrombocytosis with platelet counts in the range of
500,000 to 700,000 cells/fL occurs frequently
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2. Anemia Hypersegmented neutrophil
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Hypersegmented neutrophils
• Presence of one or more six-lobed neutrophils or • Five or more neutrophils with five well-separated
lobes
among 100 segmented neutrophils
Nathan and Oski’s Hematology of Infancy and Childhood. 9th ed. 2015.
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Megaloblastic anemia
• Mostly from vitamin B12 or folate deficiency • Macrocytic anemia, usually accompanied by
leukopenia and thrombocytopenia • Maturation of the nucleus and cytoplasm is
asynchronous, with the nucleus appearing less mature than the cytoplasm.
Nathan and Oski’s Hematology of Infancy and Childhood. 9th ed. 2015.
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3. Neonatal jaundice Hereditary elliptocytosis
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4. Anemia and jaundice Hereditary spherocytosis
Microspherocyte
Mushroom-shaped RBC or “pincered” RBC
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5. Neonatal anemia and jaundice Southeast Asian Ovalocytosis
θ
Theta cell
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Red blood cell membranes
• Membrane: protein-lipid bilayer • Deformable, tolerant against mechanical stress
and various pH and salt concentrations • Cytoskeleton
• spectrin (fibrous polypeptide) • ankyrin (fix spectrin to membrane) • protein band 3 (transmembrane protein)
Nathan and Oski’s Hematology of Infancy and Childhood. 9th ed. 2015.
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Southeast Asian Ovalocytosis (SAO)
SAO/G701D
SAO (27 bp deletion)
G701D
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6. Anemia and jaundice G-6-PD deficiency with acute hemolysis
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Enzyme metabolic activities
• Glycolytic pathway (Embden-Meyerhof): produce ATP
• Oxidative pathway (Hexose monophosphate shunt): produce NADPH
Hoffman R. Hematology: basic principles and practices 2005
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Prevalence of G6PD deficiency
Region Male Female Reference
Northern 14.8-15.7 - Flatz G, et al. Lancet 1963;2:1248-50.
Northern* 16.6 13.4 (I), 1.8 (C) Charoenkwan P, et al. SEA J Trop Med Public Health 2014;45:187-93.
Siriraj hospital 12.08 - Tanphaichitr VS. SEA J Trop Med Public Health 1995;26 Suppl 1:137-41.
Chula hospital* 11.1 5.8 Nuchprayoon I, et al. Hum Mutat 2002;19:185.
*G6PD Mahidol, G6PD Kaiping, G6PD Canton, G6PD Viangchan, G6PD Union, G6PD Chinese 5 **G6PD Viangchan (class II), G6PD Canton, G6PD Mahidol (class III), G6PD Union, G6PD Kaiping
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7.1 Anemia Thalassemia disease
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7.2 Anemia Basophilic stippling
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Basophilic stippling
• Represents aggregated ribosomes • May be observed in
• Thalassemia diseases • Iron deficiency • Ineffective erythropoiesis
• Unstable hemoglobinopathies • Lead poisoning
• Pyrimidine 5′-nucleotidase deficiency
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8. Anemia and thrombocytopenia Autoimmune hemolytic anemia
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9. Neonatal anemia Acid elution test: F cell
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Acid elution test
• Kleihauer-Betke technique of acid elution • Resistance of fetal Hb to acid elution • Interpret with caution in
• Maternal thalassemia minor • Hereditary persistent of fetal hemoglobin • Pregnancy-induced increase in Hb F production
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10. Newborn with sepsis Toxic changes in neutrophils
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