Basic approach to a case of anemia. Investigations to do and to arrive at the diagnosis. (Management not discussed). Peripheral smear findings with pictures are included.

1. APPROACH TO
ANEMIA

2. Dr. Sumanth K
1st year post graduate
Department of general medicine

4. TOPICS
 RBC Life cycle
 Definition of Anemia
 Clinical Features of Anemia
 History taking and physical examination
 Basic Lab investigations for evaluation of anemia
 Peripheral Smear findings
 Anemia Evaluation – Where to start?
 Evaluation of Macrocytic Anemia
 Evaluation of Microcytic Anemias
 Evaluation of Normocytic Anemias
 Evaluation of Anemias with Bone Marrow Failure
 Evaluation of Hemolytic Anemia

5. RBC LIFE CYCLE

7. ERYTHROPOIETIN
Glycoprotein hormone
Produced by peritubular capillary lining of cells in kidney
Small amount in liver
EPO gene regulation is by Hypoxia inducible factor 1α
Normal levels 10 – 25 U/l
T1/2 – 6-9 hrs

8. Sites of Hematopoiesis

9. Parameters that can define Anemia
1.Haemoglobin
2.Hematocrit (Packed Cell Volume)
3.RBC Count

10. Adult male
<13
Adult Female
<12
Pregnant Female
<11
Newborn
<14
Let’s
Define

12. Clinical Features

13. Depends on the magnitude and rate of reduction in
oxygen carrying capacity of the blood

14. Cardio Vascular and Pulmonary features:
Exertional Fatigue,
Dizziness, Faintness,
Palpitations
Severe Anemia can lead to CCF, Angina pectoris and
Intermittent Claudication
On Examination- systolic flow murmurs can be heard

15. Skin And Mucosal Changes:
Pallor- Where to examine – Palpebral conjunctiva
Tongue
Mucous membrane of mouth and pharynx
Nail Bed
Skin and Creases of the palms
Nails may become Brittle and early graying of hair
Associated Jaundice – Can be suggestive of Hemolytic anemias, some malignancies

16. Associated Petechiae - May suggest Bone marrow failure
or Anemia due to bleeding disorder
Spoon shaped nails – May suggest Iron deficiency Anemia
Chronic Leg Ulcers – Sickle cell anemias and Hereditary spherocytosis
Glossitis – Pernicious anemia
Knuckle Hyperpigmentation – Megaloblastic anemia

17. NeuroMuscular Features:
Headache, vertigo, tinnitus, scotoma, Lack of concentration
muscular weakness
Ophthalmologic findings:
Flame shaped hemorhages, Cotton wool spots, And in severe cases
Papilledema
Gastro Intestinal Changes:
Dysphagia can be seen in Iron deficiency anemia
Occult GI blood loss can cause Iron deficiency anemia
Painful ulcerative lesions in mouth and pharynx can be seen as a part of
associated neutropenia

18.  Family History of Hemoglobinopathies, Bleeding Disorders
 History of Jaundice, Gallstones, Splenectomy and Bleeding
 Travel History
 Drug History
 Dietary History
 History of any major surgeries
 History of any worm in stool and dark tarry stools
 History of Fever – can be seen in Infections, Malignancies and Connective tissue disorders
 Menstrual History (Defined as excessive flow – Duration exceeds 7 days
More than 12 pads used
Clots after 1st day of menstruation)

19.  Scleral icterus
 Lymphadenopathy
 Sternal Tenderness
 Palpation of Liver and Spleen
 Fundus Examination
 Thorough examination of other systems

20.  Haemoglobin
 Hematocrit
 RBC count
 Reticulocyte count
 MCV
 MCHC
 MCH
 RDW
 TC and DC
 Platelets
 Peripheral Smear

21. PERIPHERAL SMEAR
FINDINGS

24. Hb H Cabot ring

25. RPI<2.5% RPI>2.5%

27. RPI<2.5% RPI>2.5%

28. RPI <2.5 PERCENT – GO FOR MCV
•Microcytic Anemia<80
•Normocytic
Anemia80-100
•Macrocytic Anemia>100

29. EVALUATION OF MACROCYTIC
ANEMIA
MCV 110-130 MCV 100-110

31. Hypersegmented Neutrophil
Ovalocytes

32. DRUGS CAUSING
MEGALOBLASTIC ANEMIA
 Folate antagonists (e.g., methotrexate)
 Purine antagonists (e.g., 6-mercaptopurine)
 Pyrimidine antagonists (e.g., cytosine arabinoside)
 Alkylating agents (e.g., cyclophosphamide)
 Zidovudine (AZT, Retrovir)
 Trimethoprim
 Oral contraceptives
 Nitrous oxide
 Arsenic

34. MICROCYTIC ANEMIA

36. Serum Iron – Measures Iron bound to Transferrin – 70 – 200 ug/dl
TIBC- Total Iron binding capacity- a measure of transferrin - 250 – 435ug/dl
TIBC saturation – (Transferrin saturation) – 20% - 45%
Serum Ferritin level – Males 20 – 500 ug/L Females 10 – 200 ug/dl
Bone Marrow Iron Stores Graded 0 to 6
Transferrin receptors
Zinc erythro protoporphyrin
FEP/ZPP – Free erythrocyte protoporphyrin / Zinc protoporphyrin

38. Mentzer Index
MCV/RBC >14 - S/O IRON DEFICIENCY
12-14 - INDETERMINATE
<12 - THALASSEMIA TRAIT
RDW 13.4+/- 1.2 (Normal)
RDW 16.3 +/- 1.8 (IRON DEF)
THALASSEMIAS AND OTHER HAEMOGLOBINOPATHIES
Go for Haemoglobin electrophoresis- Done in Alkaline pH.
To distinguish HbA2 and Hb C also do in Acidic pH
Beta Thalassemias have increased HbF and HbA2
Alpha Thalassemias are not diagnosed in Hb electrophoresis unless 3 genes
are deleted
Alpha Thalassemia trait is diagnosed by exclusion of Beta Thalasemia and
Iron deficiency Anemia

41. SIDEROBLASTIC ANEMIA
Hereditary
X-linked - ALA synthetase deficiency
Autosomal – Disorder in Glycine transport to Mitochondria
Acquired
Primary sideroblastic anemia (refractory)
Secondary sideroblastic anemias caused by drugs and bone marrow
Toxins
Pyridoxine deficiency and Zinc excess
• Isoniazid
• Chloramphenicol
• Alcohol
• Lead
• Chemotherapeutic agents

42. NORMOCYTIC ANEMIA

43. Anemia associated with appropriately increased erythrocyte production
Posthemorrhagic anemia
Hemolytic anemia
Decreased erythropoietin secretion
Renal: anemia of renal insufficiency
Hepatic: anemia of liver disease
Anemia of endocrine deficiency
Protein-calorie malnutrition
Anemia of chronic disorders
Anemia with impaired marrow response
Red blood cell aplasia
Acquired pure red cell aplasia in adults
Transient aplastic crises associated with hemolysis
Aplastic anemia (pancytopenia)
Bone marrow infiltrative disorders
Leukemia
Myeloma
Myelodysplastic anemias
Congenital dyserythropoietic anemia ([CDA] type II)

44. ANEMIA OF CHRONIC
DISEASE

45. Chronic Infections
Pulmonary infections: abscesses, TB, pneumonia
Subacute bacterial endocarditis
Pelvic inflammatory disease
Osteomyelitis
Chronic urinary tract infections
Chronic fungal disease
Meningitis
Human immunodeficiency virus
Chronic, Noninfectious Inflammations
Rheumatoid arthritis
Rheumatic fever
Systemic lupus erythematosus
Severe trauma
Thermal injury
Vasculitis
Malignant Diseases
Carcinoma
Hodgkin disease
Non-Hodgkin lymphoma
Leukemia
Multiple myeloma
Miscellaneous
Alcoholic liver disease
Congestive heart failure
Thrombophlebitis
Ischemic heart disease
Idiopathic

46. ANEMIA DUE TO IMPAIRED BONE
MARROW RESPONSE
 Red blood cell aplasia
 Aplastic anemia
 Myelodysplasia
 Leukemias
 Myelophthisic anemia
 Marrow infiltration
 Myeloma
 Congenital Dyserythropoietic Anemias

47. When to do Bone marrow cytology or biopsy in a case of anemia?
reticulocytopenic
anemias, particularly
when there is more than
one hematopoietic
cell line affected.
Bone marrow was done to
detect Iron stores. Not
done these days

50. HEMOLYTIC ANEMIAS

51. Marrow compensation occurs in Hemolytic Anemia
Anemia manifests if Mean RBC Life span falls to 15 to 20 days
In congenital Hemolytic Anemias expansion of erythroid bone marrow occurs
featuring as tower shaped skull , frontal bossing, maxillary and dental abnormalities
Pigmented gallstones, splenomegaly may also be present in congenital haemolytic anemias
Acquired haemolytic anemias have associated icterus , fever and aching pains of
back, abdomen and limbs

52. Laboratory signs of Hemolysis
 Increased Indirect Bilirubin
 Increased serum LDH
 Decreased Serum Haptoglobin
 Increased Carbon Monoxide
Production
 Intravascular Hemolysis
 Haemoglobinemia
 Haemoglobinuria
 Methaemalbuminaemia
 Reticulocytosis
 Peripheral smear
 Polychromatophilia
 Basophilic stippling
 Erythroblastosis
 Schistocytes

53. RBC LIFE CYCLE

54. Laboratory signs of Hemolysis
 Increased Indirect Bilirubin
 Increased serum LDH
 Decreased Serum Haptoglobin
 Increased Carbon Monoxide
Production
 Intravascular Hemolysis
 Haemoglobinemia
 Haemoglobinuria
 Methaemalbuminaemia
 Reticulocytosis
 Peripheral smear
 Polychromatophilia
 Basophilic stippling
 Erythroblastosis
 Schistocytes

55. Peripheral
smear
Coombs
test
Osmotic
fragility
tests
Approach in a case of Hemolytic Anemia

56. SICKLE CELL ANEMIA
Clinical complications of sickle cell anemia
Toddlers
 Splenomegaly and sequestration
 Frequent infections
 Dactylitis
Childhood
 Painful crises
 Acute chest syndrome
 Osteonecrosis
Adolescence
 Painful crises
 Stroke
 Priapism
 Psychosocial problems
Adults
 Painful crises
 Pulmonary Hypertension
 Renal insufficiency
 Osteonecrosis
 Retinopathy
 Leg Ulcers

57. In a Hemolytic picture go for Coombs test and Osmotic fragility test

58. Osmotic Fragility Test

60. DISEASES OR CONDITIONS ASSOCIATED WITH WARM
AUTOIMMUNE ANTIBODIES
Autoimmune disorders
Systemic lupus erythematosus
Rheumatoid arthritis
Scleroderma
Ulcerative colitis
Antiphospholipid antibodies
Lymphoproliferative disorders
Chronic lymphocytic leukemia
Acute myelocytic leukemia
Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma
Waldenström macroglobulinemia
Other lymphoproliferative disorders
Multiple myeloma
Other Neoplastic disorders
Thymoma
Teratoma
Kaposi sarcoma
Viral Infections
EBV
KIV
Hepatitis C
Other
DPT Vaccination
Bone Marrow Transplantation
Hypogammaglobulinemia
Pregnancy

61. Disorders associated with Cold autoimmune antibodies
Idiopathic Cold agglutinin disease
Paroxysmal Cold Hemoglobinuria
Neoplasms
Waldenstrom Macroglobulinemia
CLL
Myeloma
Kaposi sarcoma
Infections
Mycoplasma
EBV
Adenovirus
Influenza
Rubella
Mumps
Varicella
HIV
E Coli
Legionnaires disease
Malaria
Trypanasomiasis
Syphilis
Tropical Eosinophilia

63. An 85-year-old slender, frail white woman was hospitalized for diagnosis and treatment of anemia suspected during a
routine examination by her physician. The physician noted that she appeared pale and inquired about fatigue and
tiredness. Although the patient generally felt well, she admitted to feeling slightly tired when climbing stairs. A point-of-
care haemoglobin performed in the physician’s office showed a dangerously low value of 3 g/dL, so the patient was
hospitalized for further evaluation. Her hospital CBC results are as follows:

64. During a holiday visit, the children of a 76-year-old man noticed that he seemed more forgetful than usual and
that he had difficulty walking. Concerned about the possibility of a mild stroke, the children insisted that he
see his physician. The physician diagnosed a peripheral neuropathy affecting the father’s ability to walk. In
addition, the physician noted that he was pale and ordered routine hematologic studies. The results were as
follows
WBC differential: unremarkable with the exception of hypersegmentation of neutrophils RBC morphology:
moderate anisocytosis, moderate poikilocytosis, macrocytes, oval macrocytes, few teardrop cells

65. A 16-year-old female presented to her pediatrician with jaundice. Her pediatrician checked liver enzyme and
bilirubin levels, which were elevated. Hepatitis A, B, and C serologies were all negative. She was referred to a
gastroenterologist, who diagnosed her with autoimmune hepatitis. With immunomodulatory treatment, her
hepatitis improved. However, over the next several months, she noticed increasing fatigue and bruising. She
also developed heavier menses, with menstrual cycles lasting up to 2 weeks in duration. Physical examination
revealed pallor and scattered ecchymoses with petechiae on her chest and shoulders with no other
abnormalities. Complete blood count results were as follows
Serum vitamin B12 and folate levels were within reference intervals. Bone marrow aspirate revealed mild
dyserythropoiesis but normal myelopoiesis and megakaryopoiesis. Iron stain revealed normal stores. A bone
marrow biopsy specimen was moderately hypocellular (15%) with a reduction in all three cell lines. There was
no increase in reticulin or blasts. Cytogenetic testing revealed a normal karyotype, and results of flow
cytometry for paroxysmal nocturnal hemoglobinuria (PNH) cells was negative

66. A 24-year-old male was found to have a hemoglobin level of 10.2 g/dL. He is not having any symptoms.
He got this Haemoglobin value in a routine blood checkup. He was ordered other tests and results were
as followed
Peripheral blood RBCs exhibited moderate microcytosis, slight hypochromia, and slight poikilocytosis with
occasional target cells, and several RBCs had basophilic stippling.
Hb A2 was 4.9% of total hemoglobin by high-performance liquid chromatography (reference interval, 0% to
3.5%).
Serum ferritin level was 320 ng/mL (reference interval, 15 to 400 ng/mL).

67. Harrison’s principles of Internal Medicine
Wintrobe’s Clinical Hematology
Rodak’s Hematology
Manson’s Tropical Diseases