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
- Is the anemia microcytic, macrocytic, or normocytic?
- Is pancytopenia present?
- 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
- Look at the blood film
* 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
- Low (BM: replacement or failure) – Are blasts present?
- 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
- Look at the smear
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