Patama Gomutbutra Consultant : Lect. Lalita Norasetthada

Anemia

Ambulatory setting

Challenge of anemia in real life

Case

• A Thai male 74 year-old UD: HT, DLP,Gouty arthritis• CC: Transient loss of conscious and palpitate• PI : progressive fatigue for a month. Dyspnea on exertion. No fever No orthopnea or PND No bone pain No passing bloody stool No passing dark urine

• PH: • Never be hospitalized before.

• Social history:• Social drinker• No smoking

• FH: • Grand children has ‘blood disease’ that need to receive blood

every 2 months• His wife died last month from multiple organ failure

Physical exam

• An old man with alert and oriented• VS BP 103/80 PR 97/min• HEENT : mild pale conjunctivae, no icteric sclerae• Heart : regular, SEM gr II all valvular area• Lungs : clear , equal breath sound• Abd : No hepatospleenomegaly• Ext : No pitting edema• PR : No melena

• Corrected RC = 6.62 X (18.3 /45) = 2.68

TS = SI/TIBC = 16.5%

Hb-typing 1 day after the patient received PRC 2 u

Which mechanism is the major contributor for anemia in this patient

•A. Low iron intake •B. Occult blood lost•C. Bone marrow failure•D. Extravascular hemolysis•E. Inflammatory reactant-Hepcidin

PBS• Hypochromic microcytic. Anisopoikilocyte 2+ ,No nRBC • Increased polychromasia Imp: Thallasemia trait with occult blood lost

Further work up for occult blood loss

•Stool occult blood positive•EGD & Colonoscopy •Mild gastritis• Internal hemorrhoid

Hb < 12 for femaleHb < 13 for male

MCV, RC

Low MCV <80

High RC

Low RC

Normal MCV 80-100

High RC

Low RC

High MCV >100

High RC

Low RC

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Adapted from Norasettada L et al. 2013

! !

Hemolysis ?- LDH - Bilirubin w Indirect bilirubin - Haptoglobin (likely intravas)

SI/TIBC high• Lead poisoning• Sideroblastic

Hb typing normal• PNH• IDA w Iron

suppl

Bi/pancytopenia• Aplastic • MDS• BM infiltrate

Coomb’s positive• AIHA (E)

Megaloblastic : hypersegmented neutrophil• B12 def• Folic def

SI/TIBC low <20• Iron def

anemia• ACD• Thal trait

Hb typing abn• Thalasemia

major

Occult bleeding ?

Pure anemia• Endocrine Thyroid, AI• BM defect

MM, PRCA

Non megaloblastic• Liver disease/Alcohol• Hypothyroid• BM defect

Coomb’s negative• MAHA (I )• G-6-PD (I )• Malaria (I)• Spherocytosis(E)

!

Challenge of anemia in OPD

When PBS (usually the must) is not available•Hemoglobin problem? -> MCV•RBC production -> RC, Abs reti•Hemolysis -> LDH, DB, Haptoglobin• Iron status -> SI/TIBC, Ferritin •Anisocytosis -> RDW• Thailand -- Thalassemia land

MCV < 80

Corrected reticulocyte count= %RC x Hb pt / 45• < 1%= poor RBC production• > 3%= increase RBC production• 1-3% Need correlate with degree of anemia

Absolute reticulocyte count

= corrected RC X RBC

• < 25,000 /mm3 (25x10^9/L) = poor RBC production

• > 100,000 /mm3 (100x10^9/L) = increase RBC production

• 25,000 -50,000 need correlate with degree of anemia ie abs reti 30,000 (1.2 times) in Hb drop from 12 -> 6 (2 times) = poor RBC production

Hemolysis

• LDH increase• Increase dominant indirect bilirubin (> 1/3 of TB)•Haptoglobin decrease or absent -> likely

intravascular hemolysis

Free Hb bind to

Haptoglobin

Accumulate PTP intermediate = Porphyrias (Greek – Purple) Acute intermittent porphyria Porphyria cutanea tada

Lack of Protoporphyrin lead to excess iron

= Sideroblastic anemia (Greek – iron) B6 deficiency

Lead poisoning

Fe

PTP

• Feritin is the best indicator for Iron storage status

cut point 100 sens = 70 % spec = 95 %

• TIBC is Transferin ‘seeking for Fe’ Lower Fe -> Higher TIBC

(SI/TIBC)

350 ug/dl

100 ug/dl

50 ug/dl 300 ug/dl

Note : Iron deficiency concert

•SI decreaseand•TIBC increase and•Feritin decrease

RDW = Level of varies in size (anisocytosis)

Normal range of RDW-CV < 16-18 %

Why divide by MCV ?= To fair with higher upper limit of RBC population

Thallasemia minor/ trait

• Hb normal or mildly reduced • MCV reduced• Hb electrophoresis • HbA2: <5 % (<3.5 = alpha , > 3.5 = beta)• Hb F: < 5 %• HbCS 1-2%

• Not cause of significant hemolytic anemia• PBS- milder anisopoikilocytosis. No nRBC

Exercise case A 25 year old waiter with recurrent pulmonary TB and long term Isoniazid treatment

• Hb = 3.8 • MCV = 72• RC corrected = 1.7• RDW = 22• SI = 246 (50-150) TIBC = 254 (250-450) Feritin = 446 (27-224)• TB/DB = 1.0/0.2

What is the most likely diagnosisA. Iron def anemiaB. ThallasemiaC. Anemia of chronic diseaseD. Sideroblastic anemiaE. Lead poisoning