Getting to know the cbc - it's about time!
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Transcript of Getting to know the cbc - it's about time!
Getting to knowGetting to know
the CBC…the CBC…
It’s about time!It’s about time!
Ma. Ysabel Lesaca-Medina, MDMa. Ysabel Lesaca-Medina, MD
Do you knowDo you know : :
How to evaluate anemia using How to evaluate anemia using MCV, RDW MCV, RDW and RETIC countand RETIC count
the significance of different the significance of different RBC shapesRBC shapes reported in the PBSreported in the PBS
How to deal with How to deal with leukocyte abnormalitiesleukocyte abnormalities seen on PBSseen on PBS
The causes of The causes of thrombocytosis and thrombocytosis and thrombocytopeniathrombocytopenia
Evaluating Anemia Evaluating Anemia -role of -role of MCV, MCH, MCHCMCV, MCH, MCHC
MCV MCV (mean corpuscular volume)(mean corpuscular volume)
Formula Formula (2-10 yrs old)(2-10 yrs old)
– Lower limitLower limit: 70 fL + age in years : 70 fL + age in years
– Upper limit:Upper limit: 84 fL + ( age in yrs x 0.6 ), 84 fL + ( age in yrs x 0.6 ), until upper limit of 96 is reacheduntil upper limit of 96 is reached
MEMORIZE !!MEMORIZE !!
Evaluating AnemiaEvaluating Anemia
MCH (Mean Corpuscular Hb)MCH (Mean Corpuscular Hb)
MCHC (Mean Corpuscular Hb conc)MCHC (Mean Corpuscular Hb conc)
- normo/hyper/hypo chromicnormo/hyper/hypo chromic- Used in Used in
- iron deficiency, thalassemia - iron deficiency, thalassemia - ↓↓- Spherocytosis - Spherocytosis -
MCH/MCHCMCH/MCHC
What’s the MCV range? What’s the MCV range? Give LL and ULGive LL and UL
7 year old7 year old
answeranswer
LL: 77 fL
UL: 88.2 fL
RETICULOCYTE COUNTRETICULOCYTE COUNT
-Expressed as % of circulating rbc’s
-Take up reticulin stain (supravital):
bec of inc RNA
-N = 0.5 % to 1.5 %
or = .005 to .015
RETICULOCYTE COUNTRETICULOCYTE COUNT
Provide crucial info on Provide crucial info on RATERATE of red cell of red cell productionproduction
2 broad classes of anemias2 broad classes of anemias1.1. 2 red cell 2 red cell loss or destructionloss or destruction – inc retic – inc retic
- e.g. hemolysis, blood loss- e.g. hemolysis, blood loss
2.2. Dec red cell Dec red cell productionproduction – dec retic – dec retice.g. aplastic, iron deficiencye.g. aplastic, iron deficiency
Reticulocyte indexReticulocyte index
Anemic patient --> Anemic patient --> increased reticincreased retic
so have to correct: so have to correct: retic observed x retic observed x px Hct / 0.45px Hct / 0.45
Example:Example:
Hb 50 Hb 50 Hct 0.15Hct 0.15
Retic countRetic count=.=.045= 4.5 %045= 4.5 %
Corrected retic =Corrected retic =
retic x (px Hct / 0.45)retic x (px Hct / 0.45)
4.5% x .15/.45 = 4.5% x .15/.45 = 1.5 %1.5 %( N = 0.5-1.5%)( N = 0.5-1.5%)
Absolute Retic CountAbsolute Retic Count
More accurateMore accurate
Compute :Compute :
RBC (in n x 10RBC (in n x 101212 ) )
x # retic/1000 rbcx # retic/1000 rbc
x 1000x 1000 Normal Normal
= 40,000 – 100,000/uL = 40,000 – 100,000/uL
Absolute Retic countAbsolute Retic count
EXAMPLEEXAMPLE
Hb 50 Hb 50 Hct 0.15Hct 0.15
RBC = 1.6 x 10RBC = 1.6 x 101212
Retic countRetic count
=.045 = 4.5 %=.045 = 4.5 %
Compute for absolute Compute for absolute retic countretic count
Formula: Formula:
RBC (in n x 10RBC (in n x 101212 ) )
x # retic/1000 rbcx # retic/1000 rbc
x 1000x 1000
= 1.6 x 45 x 1000= 1.6 x 45 x 1000
= = 72 ,00072 ,000
Normal = 40,000 – 100,000/uLNormal = 40,000 – 100,000/uL
QuizQuiz
Compute for absolute Compute for absolute retic count :retic count :Hb 90Hb 90
RBC 3 x 10RBC 3 x 1012 12 /L /L
Retic .015Retic .015
AnswerAnswer
45,000 retics / uL45,000 retics / uL
Anemia based on MCV and reticAnemia based on MCV and retic
Increased MCVIncreased MCV– High reticHigh retic– Low reticLow retic
Decreased MCVDecreased MCV– High reticHigh retic– Low reticLow retic
Normal MCVNormal MCV– High reticHigh retic– Low reticLow retic
Increased MCVIncreased MCV
Increased ReticIncreased Retic– Acute blood lossAcute blood loss– HemolysisHemolysis
> Increased MCV> Increased MCV
- cased by inc # retics- cased by inc # retics
retics have a large retics have a large cellular volumecellular volume
Anemia based on MCV and reticAnemia based on MCV and retic
Increased MCVIncreased MCV– High reticHigh retic– Low reticLow retic
Decreased MCVDecreased MCV– High reticHigh retic– Low reticLow retic
Normal MCVNormal MCV– High reticHigh retic– Low reticLow retic
Inc MCV, low reticInc MCV, low retic
1.1. Bone Marrow FailureBone Marrow Failure• Retic count greatly dec for degree of anemiaRetic count greatly dec for degree of anemia
----------------------------------------------------------------------------------------------------------------------------------
E.g. Known case of Aplastic anemiaE.g. Known case of Aplastic anemia
RBC 1.73 Hb 52 Hct 0.15 Retic = 1 % or 0.010RBC 1.73 Hb 52 Hct 0.15 Retic = 1 % or 0.010
> Compute for corrected retic count % absolute retic> Compute for corrected retic count % absolute retic
AnswerAnswer
Corrected retic:Corrected retic:
0.33 %0.33 %
( 0.5 – 1.5 %)( 0.5 – 1.5 %)
You got it!You got it!
Absolute Retic Count:
17,300 /uL
(40,000-100,000)
Bone Marrow Failure Bone Marrow Failure
MCV inc bec of production of stress rbc’s MCV inc bec of production of stress rbc’s
Examples of bone marrow failureExamples of bone marrow failureo Aplastic AnemiaAplastic Anemiao Fanconi’s AnemiaFanconi’s Anemiao Diamond-Blackfan anemiaDiamond-Blackfan anemia
(Congenital hypoplastic anemia)(Congenital hypoplastic anemia)
o Transient Erythroblastopenia of Childhood Transient Erythroblastopenia of Childhood (TEC)(TEC)
TEC vs DBATEC vs DBA
Diamond Blackfan Anemia
- Congenital- 90% cases < 6 mos- Some recover by 7 years old- ADA increased
Transient Transient erythroblastopenia erythroblastopenia of childhoodof childhood– AcquiredAcquired– 90% cases in > 1 y.o.90% cases in > 1 y.o.– Recovery within 2 mosRecovery within 2 mos– In recovery phase, inc In recovery phase, inc
MCV bec inc reticsMCV bec inc retics– ADA normalADA normal
Inc MCV, Dec ReticInc MCV, Dec Retic2. 2. Megaloblastic Megaloblastic
disordersdisorders Folate and Vit B 12 Folate and Vit B 12
deficiencydeficiency Other things seen :Other things seen :
Hypersegmentation of Hypersegmentation of PMN’sPMN’s
Giant segmenters, Giant segmenters, stabs stabs
MacroovalocytosisMacroovalocytosis Megaloblastic changes Megaloblastic changes
in BMin BM
hypersegmentationhypersegmentation
Inc MCV, Dec ReticInc MCV, Dec Retic
3. 3. AlcoholAlcohol direct toxic effect on BMdirect toxic effect on BM Induces folate deficiencyInduces folate deficiency
Inc MCV, dec reticInc MCV, dec retic
4.4. Anti-metabolitesAnti-metabolitesa.a. Methotrexate (folic acid anti-metabolite)Methotrexate (folic acid anti-metabolite)
b.b. Co-trimoxazoleCo-trimoxazole
5.5. HypothyroidismHypothyroidisma. Causes red cell hypoplasiaa. Causes red cell hypoplasia
b.b. Usually normocytic/normochromicUsually normocytic/normochromic
c.c. Macrocytosis may developMacrocytosis may develop
Next …Next …DECREASED MCVDECREASED MCV
Decreased MCVDecreased MCV
Caused by Caused by insufficient insufficient Hb synthesisHb synthesis
Mostly caused by:Mostly caused by:– Iron deficiencyIron deficiency– Inability to use ironInability to use iron
Chronic diseaseChronic disease
ThalassemiaThalassemia
Lead poisoningLead poisoning
Sideroblastic anemiaSideroblastic anemia
Decreased MCVDecreased MCV
Increased reticIncreased retic
– Thalassemia Thalassemia majormajor
Normal /decreased Normal /decreased reticretic
Thalassemia majorThalassemia major
PresentsPresents : 6 to 24 months old : 6 to 24 months old
SymptomsSymptoms– Profound anemiaProfound anemia– HepatosplenomegalyHepatosplenomegaly– JaundiceJaundice– Growth retardationGrowth retardation
Decreased MCVDecreased MCV
Increased reticIncreased retic
– Thalassemia majorThalassemia major
Normal /decreased Normal /decreased reticretic– Iron deficiencyIron deficiency– Thalassemia TraitThalassemia Trait– Anemia of chronic Anemia of chronic
diseasedisease– Lead poisoningLead poisoning– Sideroblastic anemiaSideroblastic anemia
hardest differentials !
1. Iron deficiency1. Iron deficiency
Common cause in 1-3 years of ageCommon cause in 1-3 years of age
As iron stores become depleted:As iron stores become depleted:
– ↑↑RRDW DW
↓↓serum serum FFe e
↓ ↓ MMCV CV ↓ Hb↓ Hb
Remember!Remember!
First manifestationFirst manifestation : : RDWRDW
1. Iron deficiency1. Iron deficiency
Reasonable Reasonable approach: Oral iron approach: Oral iron replacementreplacement
(+) response: (+) response:
Hb by 15-20 in 1 monthHb by 15-20 in 1 month
PRESUMPTIVE DX MADE !
2. Thalassemia trait2. Thalassemia trait
Microcytosis +/- mild anemiaMicrocytosis +/- mild anemia– 1 of 2 B-globin genes are intact 1 of 2 B-globin genes are intact – or 2 of 4 alpha-globin genes are intactor 2 of 4 alpha-globin genes are intact
Often confused with iron deficiencyOften confused with iron deficiency
Thal trait vs Iron deficiencyThal trait vs Iron deficiency
Thal traitThal trait Iron deficiencyIron deficiency
Mentzer indexMentzer index(MCV/RBC count)(MCV/RBC count)
< 12< 12 Smaller cells,Smaller cells,
More rbc numberMore rbc number
>13>13Bigger cells, less rbc Bigger cells, less rbc numbernumber
Poikilocytosis;Poikilocytosis;
Basophilic stipplingBasophilic stipplingMore More
RDWRDW NormalNormal increasedincreased
RED CELL DISTRIBUTION WIDTHRED CELL DISTRIBUTION WIDTH
Quantitative measure of anisocytosisQuantitative measure of anisocytosis
The greater the # of sizes of rbc’s, the The greater the # of sizes of rbc’s, the higher the RDWhigher the RDW
Normal = 11.5-14.5Normal = 11.5-14.5
No subnormal values have been reportedNo subnormal values have been reported
RDWRDW
HIGH ( HIGH ( HIGH-F HIGH-F ))
– IIron deficiencyron deficiency– Hb Hb HH disease disease– FFragmentationragmentation– GG-6PD-6PD– Chronic disease Chronic disease
3. Anemia of Chronic Disease3. Anemia of Chronic Disease
Mild to moderate anemia (Hb 100 – 110)Mild to moderate anemia (Hb 100 – 110)
Slight inc RDW; dec Fe, inc FerritinSlight inc RDW; dec Fe, inc Ferritin
Px has chronic Px has chronic INFLAMMATIONINFLAMMATION
Disturbs iron recycling Disturbs iron recycling iron left trapped iron left trapped in RESin RES– Cytokines IL-1, IL-6 Cytokines IL-1, IL-6 inc ferritin syn inc ferritin syn
empty ferritin shells provide excess iron empty ferritin shells provide excess iron storage capacity storage capacity iron sequestered in RES iron sequestered in RES
Decreased MCVDecreased MCV
4. 4. Lead poisoningLead poisoning
Inhibits enzymes Inhibits enzymes involved in heme involved in heme synthesissynthesis
Reduction of Reduction of intracellular iron intracellular iron
5. 5. Sideroblastic Sideroblastic AnemiaAnemia
Rare in childhoodRare in childhood
Failure to incorporate Failure to incorporate iron into hemeiron into heme
Causes:Causes:– Inherited (XL)Inherited (XL)– MDSMDS– Drugs ( INH, ethanol)Drugs ( INH, ethanol)
NEXT. ..NEXT. ..
NORMAL MCVNORMAL MCV
MCV NORMALMCV NORMAL
MCV NORMAL
INC RETIC DEC RETIC N OR DEC RETIC
1. HEMOLYSIS2. BLOOD LOSS
MCV NORMALMCV NORMAL
MCV NORMAL
INC RETIC DEC RETIC N OR DEC RETIC
1. BALANCED2. PRCA/TEC3. APLASTIC4. HYPOTHYROIDISM5. REPLACEMENT OF MARROW
MCV NORMALMCV NORMAL
Normal or decreased retic
Renal diseaseHyperparathyroidism
Liver diseaseChronic Inflammation
Renal DiseaseRenal Disease
Cause:Cause:– erythropoeitin erythropoeitin
insufficiencyinsufficiency– Serum inhibitors of Serum inhibitors of
erythropoeisis erythropoeisis accumulate in uremic accumulate in uremic patients patients shortened shortened rbc lifespanrbc lifespan
– AcanthocytosisAcanthocytosis
When BUN > 150 mg/dL
HyperparathyroidismHyperparathyroidism
Fibrosis in marrow Fibrosis in marrow cavitycavity
Decreased erythropoeisis
Liver diseaseLiver disease
Anemia is due toAnemia is due to– HypersplenismHypersplenism– Vitamin-nutritional Vitamin-nutritional
deficiencies (lipid deficiencies (lipid soluble)soluble)
– Blood lossBlood loss
PLATELETSPLATELETS
Cytoplasmic fragments ; no nucleusCytoplasmic fragments ; no nucleusLife span = 7-10 daysLife span = 7-10 days1/3 in spleen, 2/3 in circulation1/3 in spleen, 2/3 in circulationSize= 1 – 4 umSize= 1 – 4 um– Large Large
YoungYoung2 peripheral destruction2 peripheral destruction
– Small or normalSmall or normalProduction defectProduction defect
THROMBOCYTOSISTHROMBOCYTOSIS
Platelet count > 600,000Platelet count > 600,000
Rarely causes complications !Rarely causes complications !– Therefore, antiplatelet tx is rarely indicatedTherefore, antiplatelet tx is rarely indicated– Kawasaki is an exceptionKawasaki is an exception
THROMBOCYTOSISTHROMBOCYTOSIS
Hemolytic anemiaHemolytic anemia
HemorrhageHemorrhage
InfectionInfection
Iron def anemiaIron def anemia
Vit E deficiencyVit E deficiency
Vascular Collagen Vascular Collagen disordersdisorders
Post-splenectomyPost-splenectomy
Post-opPost-op
Inflammatory Bowel DisInflammatory Bowel Dis
TraumaTrauma
TumorsTumors
Syndrome, kawasakiSyndrome, kawasaki
Syndrome, nephroticSyndrome, nephrotic
Syndrome, myeloprolifSyndrome, myeloprolif
HIV is the PITS !
THROMBOCYTOPENIATHROMBOCYTOPENIA
Immune Platelet DestructionImmune Platelet Destruction
InfectionsInfections
Platelet clumpingPlatelet clumping- falsely low - falsely low
- 2 inadequate coagulation- 2 inadequate coagulation
RBC abnormalitiesRBC abnormalities
AnisocytosisAnisocytosis– MicrocytesMicrocytes– MacrocytesMacrocytes– NormocytesNormocytes
PoikilocytosisPoikilocytosis– Different shapesDifferent shapes
Spherocytes Spherocytes
– Hereditary spherocytosisHereditary spherocytosis– ABO incompatibilityABO incompatibility– Hemolytic anemiaHemolytic anemia– HypersplenismHypersplenism– MalariaMalaria– HemoglobinopathiesHemoglobinopathies– Post-transfusion !Post-transfusion !– Liver diseaseLiver disease
AcanthocytesAcanthocytes
– AbetalipoproteinemiaAbetalipoproteinemia– Hemolytic anemiasHemolytic anemias– ThalassemiaThalassemia– Liver diseaseLiver disease– Severe burnsSevere burns– Post splenectomyPost splenectomy– Renal diseaseRenal disease– Enzyme deficienciesEnzyme deficiencies
SchistocytesSchistocytes
- Hemolytic anemia- Hemolytic anemia– HypersplenismHypersplenism– Megaloblastic Megaloblastic
anemiaanemia– ThalassemiaThalassemia– Acute LeukemiaAcute Leukemia– Post severe burnsPost severe burns
OvalocyteOvalocyte
Normochrom ovalocyteNormochrom ovalocyte– OvalocytosisOvalocytosis– ThalassemiaThalassemia
Hypochrom ovalocyteHypochrom ovalocyte– Iron deficiencyIron deficiency
Macrocytic ovalocyteMacrocytic ovalocyte– Megaloblastic anemiaMegaloblastic anemia
ElliptocytesElliptocytes
– ElliptocytosisElliptocytosis– Megaloblastic Megaloblastic
anemiaanemia– MyelofibrosisMyelofibrosis– ThalassemiaThalassemia
TARGET CELLSTARGET CELLS
– Liver diseaseLiver disease
– ThalassemiaThalassemia
– Iron deficiencyIron deficiency
– Post-Post-splenectomysplenectomy
Abn RBC shapesAbn RBC shapes
Blister cellBlister cell– Microangiopathic Microangiopathic
hemolytic anemiahemolytic anemia
Tailed RBCTailed RBC– Megaloblastic anemiasMegaloblastic anemias– Iron deficiencyIron deficiency
Tear dropTear drop– HypersplenismHypersplenism– ThalassemiaThalassemia– Hemolytic AnemiaHemolytic Anemia
BURR CELLSBURR CELLS
– Hemolytic Hemolytic anemiasanemias
– Iron deficiencyIron deficiency
– Megaloblastic Megaloblastic anemiaanemia
– ThalassemiaThalassemia
– HypersplenismHypersplenism
STOMATOCYTESSTOMATOCYTES
– Hereditary Hereditary stomatocytosisstomatocytosis
– ArtefactArtefact
– Acute leukemia, Acute leukemia, treatedtreated
– Alcoholics with Alcoholics with liver diseaseliver disease
The following scale is used by many laboratories in the delta region of the U. S.morphology normal 1+ 2+ 3+ 4+characteristics limitsMacrocytes (>9 μ dia.) 0 - 5 5 - 10 10 - 20 20 - 50 >50Microcytes (<6 μ dia.) 0 - 5 5 - 10 10 - 20 0 - 50 >50Hypochromia 0 - 2 3 - 10 10 - 50 50 - 75 >75Poikilocytosis 0 - 2 3 - 10 10 - 20 20 - 50 >50Anisocytosis 0 - 2 3 - 10 10 - 20 20 - 50 >50Acanthocyte none 1 - 5 5 - 10 10 - 20 >20Burr Cell 0 - 2 3 - 10 10 - 20 20 - 50 >50Target cell (codocyte) 0 - 2 3 - 10 10 - 20 20 - 50 >50Tear drop cell (dacryocyte) 0 - 2 2 - 5 5 - 10 10 - 50 >50Sickle Cell (depranocyte) none (If present in any number, report as positive.)Elliptocyte/Ovalocyte 0 - 2 2 - 10 10 - 20 20 - 50 >50Helmet cell / Bite cell none 1 - 5 5 - 10 10 - 20 >20Schistocytes none 1 - 5 5 - 10 10 - 20 >20Spherocytes 0 - 2 2 - 10 10 - 20 20 - 50 >50Stomatocytes 0 - 2 2 - 10 10 - 20 20 - 50 >50Basophilic stippling 0 - 1 1 - 5 5 - 10 10 - 20 >20Polychromatophilia, adult 0 - 1 2 - 5 5 - 10 10 - 20 >20Polychromatophilia, infant 1 - 6 7 - 15 15 - 20 20 - 50 >50Howell-Jolly (HoJo) body none 1 - 2 3 - 5 5 - 10 >10Pappenheimer body (siderocyte) none 1 - 2 3 - 5 5 - 10 >10
RBC abnormalitiesRBC abnormalities
Severe hemolysisSevere hemolysis– Nucleated rbc’sNucleated rbc’s– Schistocytes: helmet cells, triangle cells, bite Schistocytes: helmet cells, triangle cells, bite
cellscells– Spherocytes (immune mediated)Spherocytes (immune mediated)– acanthocytesacanthocytes
RBC InclusionsRBC Inclusions
Howell-Jolly bodiesHowell-Jolly bodies– Nuclear remnants not Nuclear remnants not
extruded from mature extruded from mature erythrocyteserythrocytes
– Indicate splenic Indicate splenic hypofunctionhypofunction
– Seen in Seen in Post-splenectomyPost-splenectomy
LeukemiaLeukemia
Hemolytic Hemolytic
thalassemiathalassemia
RBC InclusionsRBC Inclusions
Basophilic stipplingBasophilic stippling– Caused by aggregated Caused by aggregated
ribosomes in rbcribosomes in rbc– Seen in Seen in
ThalassemiaThalassemia
Lead intoxication Lead intoxication /heavy metal/heavy metal
WBC abnormalitiesWBC abnormalities
Toxic changesToxic changes– Toxic granulesToxic granules– Dohle bodiesDohle bodies
Dark blue cytoplasmic Dark blue cytoplasmic inclusionsinclusions
Seen in neutrophilsSeen in neutrophils
Seen in : infection, Seen in : infection, burns, MDS, pregnancyburns, MDS, pregnancy
– VacuolationsVacuolations
Toxic granulesToxic granules
DOHLE BODIESDOHLE BODIES
remnants of free remnants of free ribosomes of RERribosomes of RER
Single or multiple, Single or multiple, blue, grayish-blue, blue, grayish-blue, or greenish or greenish inclusions.inclusions.
VacuolizationVacuolization
QUIZ SHOWQUIZ SHOW
10 year old with Hb 80, WBC 9 plt 350. 10 year old with Hb 80, WBC 9 plt 350. On co-tri for repeated UTI. MCV 102 On co-tri for repeated UTI. MCV 102 MCH 340 Retic ct 0.002MCH 340 Retic ct 0.002
What is most likely diagnosis ?What is most likely diagnosis ?a.a. Fe deficiencyFe deficiency
b.b. Megaloblastic anemiaMegaloblastic anemia
c.c. Diamond Blackfan AnemiaDiamond Blackfan Anemia
d.d. Hemolytic anemiaHemolytic anemia
AnswerAnswer
BB
MEGALOBLASTICMEGALOBLASTIC
ANEMIAANEMIA
(Prob 2 folate def)(Prob 2 folate def)
The ff is a cause of thrombocytosisThe ff is a cause of thrombocytosis
A. Immune thrombocytopenic purpuraA. Immune thrombocytopenic purpura
B. PregnancyB. Pregnancy
C. Iron deficiency anemiaC. Iron deficiency anemia
D. Renal failureD. Renal failure
ANSWERANSWER
CC
Iron deficiency Iron deficiency anemiaanemia
Compute absolute retic countCompute absolute retic count
Hb 45Hb 45 RBC 1.5 x 10RBC 1.5 x 101212 / L / L
Retic count: 0.016Retic count: 0.016
ANSWERANSWER
24,000 / uL24,000 / uL
4/4 Quiz show4/4 Quiz show
Which presents as a microcytic anemiaWhich presents as a microcytic anemiaA.A. B-thalassemiaB-thalassemia
B.B. Hemolytic AnemiaHemolytic Anemia
C.C. Aplastic AnemiaAplastic Anemia
D.D. Anemia 2 blood lossAnemia 2 blood loss
ANSWERANSWER
AA
B- ThalassemiaB- Thalassemia
Which is the pbs of px with vit B12 Which is the pbs of px with vit B12 deficiency?deficiency?
AnswerAnswer
77
Which is pbs of px with iron Which is pbs of px with iron deficiency?deficiency?
12
AnswerAnswer
1