Anemia

Symptoms

  • Lassitude
  • Fatigue
  • SOBOE
  • Palpitations
  • Throbbing in head and ears
  • Dizziness
  • Tinnitus
  • Headache
  • Dimness of vision
  • Insomnia
  • Paresthesias
  • Angina

Signs

  • Tachycardia
  • Pallor (skin, MM, conjunctiva, palms)
  • Cardiac dilatation
  • Systolic flow murmurs
  • Edema
  1. Is the anemia microcytic, macrocytic, or normocytic?
  2. Is pancytopenia present?
  3. Is the marrow response appropriate for the anemia as determined by the reticulocyte count?



 

Microcytic (MCV <80fL)

  • Fe deficiency
  • Globin: Thalassemia
  • Prophyrin:
    • Pb poisoning
    • Sideroblastic
  • Anemia of chronic disease

Reticulocyte count:

  • High: bleeding, hemolysis
  • Normal or low:
    • Look at the blood film
      • Hypochromia
      • Target cells – Thalassemias (β – ↑HbA2)
      • Basophilic stipping – Pb poisoning
      • Dimorphic – Sideroblastic
    • Look at the sFe, ferritin and TIBC
      • Fe deficiency: ↓Fe, ↓ferritin and ↑TIBC
      • Thalassemia: normal Fe
      • Sideroblastic: ↑Fe, ↑ferritin
      • ACD: ↓Fe, N/↑ ferritin, ↓TIBC

* Investigate for occult blood loss – i.e. FOB

Normocytic (MCV 80-100fL)

  • Bleeding
  • Nutritional
  • Renal insufficiency
  • Hemolysis
  • Bone marrow
  • Anemia of chronic disease

Reticulocyte count

  • Low (underproduction) – look at platelet counts
    • Low (BM: replacement or failure) – Are blasts present?
      • Yes: Leukemia, Metastatic tumor
      • No: Aplastic or hypoplastic anemia, Lipid storage
    • High/Normal: Renal disease, Infection, Chronic disease, Inflammation, Hypothyroidism, Blackfan-Diamond anemia, Transient erythroblastopenia, Congenital dyserythropoietic anemia, Protein malnutrition
  • High
    • Blood loss
    • Hemolytic anemia
      • Look at the smear
        • Schizocyte: Intravascular hemolysis
        • Spherocyte: Extravascular hemolysis
        • Sickled cells or Heinz bodies: glucose-6-phosphate-dehydrogenase deficiency
      • Coombs’ test (Ab against Ab on RBC – agglutination)
        • Positive: Isoimmune/Rh/ABO, Incompatible transfusion, Autoimmune hemolytic anemia
        • Negative: Toxic, Infection, Metabolic, Microangiopathic (HUS, DIC), Liver disease

Macrocytic (MCV >100fL)

  • Megaloblastic: B12/folate/pernicious
  • Alcohol (liver disease)
  • Aplastic or hypoplastic anemia
  • Hypothyroidism
  • Fanconi’s anemia
  • Drugs (hydroxyurea, zidovudine)
  • Myelodysplasia
  • Reticulocytosis

Peripheral smear:

  • Large oval red cells (macroovalocytes) and hypersegmented polymorphoneutrophils – Megaloblastosis
  • Target cells: Liver disease

LDH: 4-50x normal in Megaloblastic anemia, elevated 2-4x normal in Hemolytic anemia
B12: ↓ in B12 deficiency anemia, normal in Folate deficiency anemia
Folate: ↓ in Folate deficiency anemia, N/↑ in B12 deficiency anemia
Red cell folate: ↓ in Folate deficiency anemia, ↑ in B12 deficiency anemia

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