7/30/2019 Anemia - Dr. Muncie
1/34
AnemiaA Finding, not yet a diagnosis
Herbert L. Muncie, J r., MD
7/30/2019 Anemia - Dr. Muncie
2/34
zUnder what clinical circumstances
would you order a CBC for anoutpatient?
7/30/2019 Anemia - Dr. Muncie
3/34
When to order a CBC
z Order if suspect patient could be anemic
or infected based upon:z History
z
Symptomsz Signs or physical findings
7/30/2019 Anemia - Dr. Muncie
4/34
When to order a CBC
z Do not order CBC as a screening test
z Baseline values are not necessary todiagnosis anemia
z Variations in Hgb/Hctwithin the normalrange have not been associated withincreased morbidity or mortality
7/30/2019 Anemia - Dr. Muncie
5/34
Case FindingCase Finding -- physical examphysical exam
z
Absence of pallor does not rule outanemia
z Pallor of conjunctivae, face & palms - if
all 3 present helps confirm anemiaz Pallor of nail beds/skin creases - of no
value in assessing presence or absenceof anemia
7/30/2019 Anemia - Dr. Muncie
6/34
zWhat laboratory values are used to
define anemia?
7/30/2019 Anemia - Dr. Muncie
7/34
What Defines Anemia
z Look at hemoglobin & hematocrit
z Anemia is diagnosed if Hgb & Hct arebelow normal
z NormalHgb and Hct ranges change:z throughout childhood
z during pregnancy
z higher for men than women
7/30/2019 Anemia - Dr. Muncie
8/34
What Defines Anemia
z Normal H & H should be adjusted for
smoking, altitudez smokers have higher values due to carbon
monoxide in smoke
z > 3,000 feet - lower oxygen tensions, highervalues
7/30/2019 Anemia - Dr. Muncie
9/34
zOn the CBC results, what value on
the report assists you in decidingthe type of anemia?
7/30/2019 Anemia - Dr. Muncie
10/34
1st Diagnostic Step
Look at MCV -
Microcytic - < 80flNormocytic 80 100 fl
Macrocytic - > 100 fl
7/30/2019 Anemia - Dr. Muncie
11/34
Differential Diagnosis based on
MCVMicrocytic Normocytic Macrocytic
Iron deficiency Chronic disease Folate defic.
Thalassemia B12 defic.
Lead poisoning Liver disease
Hypothyroid
7/30/2019 Anemia - Dr. Muncie
12/34
Tests for Fe Deficiency
MCV - changes occur late
z < 70 probably iron deficiencyz MCH, MCHC - no useful info
RDW - reflects anisocytosis
z helps to differentiate from thalassemia
7/30/2019 Anemia - Dr. Muncie
13/34
zYou suspect iron deficiency anemia in
your next patient.z What test(s) will you order to make that
diagnosis?
7/30/2019 Anemia - Dr. Muncie
14/34
Tests for Fe Deficiency
Serum iron - level alone of little valuez
low in anemia of chronic disease
Iron binding capacity - high in Fe deficiencyz usually low in anemia of chronic disease
7/30/2019 Anemia - Dr. Muncie
15/34
Tests - Ferritin
z Best single test rule in or out Fe
deficiencyz levels < 15 uG/L - diagnostic
z levels > 100 uG/L - Fe deficiency veryunlikely
z Acute phase reactant
z may be elevated in inflammatory,malignant or liver disease
7/30/2019 Anemia - Dr. Muncie
16/34
Iron Deficiency
Causes:
children, teens - inadequate diet
young women menorrhagia &
inadequate dietolder women -
Neoplasm
GI blood loss
Angiodysplasia
7/30/2019 Anemia - Dr. Muncie
17/34
Iron Deficiency - therapy
zTreat with ferrous salts
z Sulfatez Gluconate
z
Start qd, increase to t.i.d. with mealsz Frequent GI distress
7/30/2019 Anemia - Dr. Muncie
18/34
MicrocyticMicrocytic AnemiaAnemia ThalassemiaThalassemia
Definition:
z
hereditary microcytic anemiaz carrier state: thalassemia minor
z Anemia with low MCV & normal RDW
7/30/2019 Anemia - Dr. Muncie
19/34
ThalassemiaThalassemia MinorMinor -- treatmenttreatment
z No disease specific treatment available
z Adjunctive treatment not needed formost cases
z Diagnosis has genetic ramificationsz May suggest prenatal screening
7/30/2019 Anemia - Dr. Muncie
20/34
z What is anemia of chronic disease?
z What causes anemia of chronic disease?
7/30/2019 Anemia - Dr. Muncie
21/34
Normocytic -Anemia of Chronic
diseasez Misnomer - can see in acute illness
z
Another name anemia of chronic inflammationz Occurs in infection/ inflammation/ neoplasia
and unknown other conditions
z Anemia can be first clue to diseasez Without known disease pursue further
evaluation
7/30/2019 Anemia - Dr. Muncie
22/34
Anemia of Chronic disease
Pathogenesis:
z Impaired release of Fe from RE cells
z Increased Fe stores
z Results in
z Low serum iron
z Low TIBC
z Low transferrin saturation
7/30/2019 Anemia - Dr. Muncie
23/34
Anemia of Chronic disease
Diagnosis:
z Ferritin level helpful - increased
zTransferrin receptor levelz raised in Fe deficiency, highly sensitive & specific
z
normal in anemia of chronic diseasez Normo/normo anemia then is either:
z Anemia of chronic disease
z Acute blood lossz Fluid overload (eg. Pregnancy)
7/30/2019 Anemia - Dr. Muncie
24/34
z What are the most common etiologies of
macrocytic anemia?
7/30/2019 Anemia - Dr. Muncie
25/34
Macrocytic anemia
z Etiology
z B12 (cobalamin Cbl)
z Folate deficiency
zTypically presents as MCV > 110 fL
z MCV 100-110 common, often unexplainedwith no specific diagnosis found
7/30/2019 Anemia - Dr. Muncie
26/34
Cbl Deficiency
z Level < 100 pg/ml confirm deficiency
z With levels > 100 & < 400 pg/mlz Measure MMA & homocysteine levels
z
Either will be elevated with deficiencyz Levels > 400 pg/ml rule out deficiency
7/30/2019 Anemia - Dr. Muncie
27/34
B12 Deficiency
z Etiologies of B12 deficiency
z Nutritional intake deficiency
z Unless strict vegetarian, Cbl deficiency impliesreduced absorption
z
Reduced absorptionz Loss of intrinsic factor; achlorhydria -
Pernicious anemia
z Drugs, blind loop, gastrectomy etczTakes 2-5 years to develop deficiency
even with severe malabsorption
7/30/2019 Anemia - Dr. Muncie
28/34
Folate Deficiency
z Etiologyof folate deficiency
z Usually nutritional
z Nutritional deficiency can occur quickly
z In 2-3 weeks with very poor diet
7/30/2019 Anemia - Dr. Muncie
29/34
z What is the treatment of B12 deficiency?
z What is the treatment of folate
deficiency?
7/30/2019 Anemia - Dr. Muncie
30/34
Treatment of B12 Deficiency
z Vitamin B12 IM or oral (preferred)
z Oral 1000 - 2000 uG qd equally effective [Kuzminski
1998] four randomized trialsz Minimum dosage 600 ug daily [Eussen 2005]
z 1000 uG IM q month
7/30/2019 Anemia - Dr. Muncie
31/34
Treatment of Folate Deficiency
z Folate oral supplements
z 1 mg qd
z CAUTION - folate may correct anemia of B12deficiency but not the neurologic sequelae
z before initiating folate therapy verify normal B12level
7/30/2019 Anemia - Dr. Muncie
32/34
7/30/2019 Anemia - Dr. Muncie
33/34
Who reads which paper?
1. The Wall Street Journal is read by the people whorun the country.
2. The New York Times is read by people who thinkthey run the country.
3. The Washington Post is read by people who think
they ought to run the country.4. USA Today is read by people who think they ought
to run the country but don't understand the
Washington Post.5. The Los Angeles Times is read by people who
wouldn't mind running the country, if they could spare
the time.
7/30/2019 Anemia - Dr. Muncie
34/34
Who reads which paper?
6. The Boston Globe is read by people whose parentsused to run the country.
7. The New York Daily News is read by people whoaren't too sure who's running the country.
8. The New York Post is read by people who don't care
who's running the country, as long as they dosomething scandalous.
9. The San Francisco Chronicle is read by people who
aren't sure there is a country, or that anyone isrunning it.
10. The Miami Herald is read by people who are
running another country.
Top Related