Is a sign of disease Not a final diagnosis

The goal of the diagnostic evaluation is to determine the cause of anemia

Reduction in the hemoglobin concentration or red blood cells per cubic millimeter below the range of values occurring in healthy persons.

ANEMIA (WHO criteria)

Age Hb (g/dl)

6 mo - < 5 yrs < 11

> 5 yrs < 12

Biconcave shaped disc with no nucleus Large surface area facilitates the

uptake of O2 and CO2 25 trillion RBC’s in the human body

NORMAL BLOOD SMEAR

Erythropoetin Metals - Fe, Mangenese, cobalt Vitamins – B12, B6, folate, thiamine,

riboflavin, patethoic acid, C, E Amino acids Hormones – GM-CSF, Stem cell factor,

thyroxine and androgens

Hematopoiesis

It is important to establish : A single cell line problem (red blood

cells)Or

A multiple cell line problem (red cell, white cell, and platelets)

Usually indicates bone marrow involvement, immunologic

disorders, peripheral destruction of cells

1. Disorders of effective red cell productiona. Marrow failureb. Impaired erythropoietin productionc. Abnormalities of cytoplasmic

maturationd. Abnormalities of nuclear maturatione. Dyserythropoietic.

2. Disorders of increased red cell destruction

a. Defects of hemoglobinb. Defects of the red cell membranec. Defects of red cell metabolismd. Antibody-mediatede. Mechanical injury to the erythrocytef. Thermal injury to the erythrocyteg. Oxidant-induced red cell injuryh. Paroxysmal nocturnal hb-uriai. Hypersplenism

3. Blood Loss

1. Detailed history and physical examination2. Complete blood count.3. Determination of morphologic

characteristics and RDW.4. BMP (if required).5. Determination of underlying cause of

anemia by additional test.

1. Maternal history 2. Family history3. Patient history

Pregnancy/delivery complications Anemic during pregnancy Pica/ nonfood product ingestion Drug ingestion

Anemia Jaundice Splenomegaly Gallstones Cancer Transfusion Bleeding disorders

Anemia (acute or chronic) Acute or recent infection, Evidence of chronic disease/ infection, Easy bruising/blood loss, Prematurity, Hyperbilirubinemia, Diet history, Medications, Endocrinopathy, Liver disease

Several clues to the etiology : Tachycardia acute process with

poor compensation. Normal HR more chronic process Jaundice hemolytic process Splenomegaly inherited hemolytic

anemia, malignancy, portal hypertension

BLOOD SMEAR Microcytic Anemia (MCV<80fl) Normocytic Anemia (MCV 80-

100 fl) Macrocytic Anemia (MCV >100

fl)

Age (yrs) MCV (fl)

1 - 3 days 95 - 121

0.5 – 2 70 - 84

2 – 4 73 - 85

5 – 7 75 - 87

8 – 11 77 - 90

12 – 14 78 - 91

15 – 17 78 - 94

18 – 19 80 - 100

ANEMIA

MCV

MICROCYTIC NORMOCYTIC

MACROCYTIC

Iron Deficiency

Thalassemia

Chronic disease

Lead poisoning

Reticulocyte count

High

Bilirubin

Normal

Hemorrhage

High

Hemolytic

Coombs test

Coombs TestNegative Positive

Hb-pathy

Membrane defect

Secondary : drugs, infection

Autoimmune

Isoimmune

ANEMIA

MCV

MICROCYTIC NORMOCYTIC MACROCYTIC

Reticulocyte Leukocyte & Platelets

Low Normal Increased

Malignancy

Aplastic Anemia

Pure red cell aplasia Diamond Blackfan Transient erythroblastopenia

Infection

ANEMIA

MCV

MICROCYTIC MACROCYTIC NORMOCYTIC

Folate deficiency Vit B12 defic. Aplastic anemia Preleukemia Liver disease

RDW (Red cell distribution width) = variation of the erythrocyte volume distribution.

(N = 11.5 – 14.5%)Normal RDW = homogen, slight anisocytosis RDW = heterogen, anisocytosis (++)Reticulocyte = indicator of bone marrow activities

Anisocytosis = variation in sizePoikilocytosis = variation in shape

Look at : RBC count (erytrocyte count), RDW, retyculocytes, blood smear

Erytrocyte RDW Retic Slide

Trait Thal N poikilositosis (+)

ADB N / N / anisositosis (+),

hipokromThal poikilositosis,

anisositosis (++)hipokrom

Defects of hemoglobin : sickle cell Defects of the red cell membrane :

spherocytosis Defects in red cell metabolism : G6PD, pyrivate

kinase deficiency Immune hemolysis Physical / chemical damage to red cells Infectious agent-induced damage : malaria Paroxysmal nocturnal hb-uria (PNH)

History P.E. Lab : - elevated reticulocyte count

- Coombs test - Hb electrophoresis - osmotic fragility - specific enzyme assay - blood smear