ANEMIA I.

Definition/General Considerations * Anemia definition - Males: Hgb < 13 g/dL or Hct < 39 % - Females: Hgb <12 g/L or Hct < 3 % * !"#es of anemia A$ %& < 2 1$ Microc"tic '< ()$ * +"to#lasmic defects a$ Lac, of Fe - Fe deficienc" anemia: Lo- Fe. Hig/ !&0+. Lo- Ferritin - 11 anemia in -orld /oo,-orms 11 ca2se - &n elderl". colon +A 2ntil #ro3en ot/er-ise - Anemia of c/ronic inflammation: Lo- Fe. Lo- !&0+. 4ormal Ferritin - Fe tra##ed in macro#/ages - 567 %A. 8L5. c/ronic osteo b$ Lac, of al#/a or beta globin !/alassemia macro#/ages - Al#/a t/alassemia 'Asians$ - 9 alleles affected /"dro#s fetalis: fetal demise. anasarca. 0arts beta-9 - 3 alleles affected Hgb H disease: :reci#itate beta-c/ain tetramers. intra%0+ incl2sions - 2 alleles affected al#/a t/al minor: mild microc"tic - 1 allele affected not/ing - 0eta t/alassemia 'Mediterranean and African-Americans$ - Ma;or: Lo- HgA. Hig/ HgA2. Hig/ HgF - 8mear: :oi,iloc"tosis. target cells. microc"tic. /"#oc/romic. baso#/ilic sti##ling - Minor: Lo- HgA. Hig/ HgA2. 4ormal HgF - H"#oc/romia. microc"tic. target cells c$ Lac, of #roto#or#/"rin - Hereditar" sideroblastic anemia: Hig/ Fe. Hig/ !&0+. Hig/ Ferritin - <2e to ineffecti3e er"t/ro#oiesis - +a2ses: +/ronic 5t=H. &4H. genetic - <6: %inged sideroblasts on 0M as#irate - Lead #oisoning 2$ Macroc"tic '> 9?$ * 42clear defect a$ Alco/ol/Li3er disease d2e to c/anges in :L : c/olesterol ratio b$ Megalosblastic: +ell di3ides slo-l" -/ile Hgb acc2m2lates normall" - 0M: H"#er#lasia - 8mear: Macroc"tes. /"#ersegmented ne2tro#/ils - 012 deficienc" - <2e to :A. ac/lor"dia in older #eo#le. neom"cin and colc/icines. malabsor#tion from gastric resection. resectionof ile2m. ta#e-orm - Folate deficienc" - <2e to lac, of green foliage and citr2s. #roblems -it/ absor#tion '80 resection. #/enobarbital. #/en"toin. and increased demand '#regnant. #soriasis. c/emo. HA$ - Ha3e 3 mont/ s2##l" - 8ee in alco/olic - +"toto6ic dr2gs - M<8 c$ %etic2loc"tosis: %eleased earl" from cell in res#onse to 5:= big b/c not eno2g/ time to di3ide "et d$ H"#ot/"roidism/M"6edema 3$ 4ormoc"tic '()-9?$ a$ &ncreased destr2ction * /emol"sis//emorr/age - 0lood loss

- &ntra3asc2lar /emol"is: &n 0@ - Abnormalities of %0+ interior: 5nA"me defects 'BC:<H def > :D deficienc"$. /emoglobino#at/ies. sic,le cell. t/alassemi - %0+ membrane abnormalities: H8 'osmotic fragilit" test$. :4H. 8#2r cell anemia 'cirr/osis. A4$ - Mec/anical: Mec/anical /eart 3al3e and <&+ - 8mear: 8c/istoc"tes - 56tra3asc2lar /emol"sis: &n s#leen - 567 H"#ers#lenism. A&HA '-arm f/l"m#/oma/le2,emia/8L5 and cold f/m"co#lasma$. M&HA. infections. to6ins - :ositi3e <irect +oombs - 8mear: 8#/eroc"tes b$ <ecreased #rod2ction * H"#o#roliferati3e - Marro- damage - &nfiltration/fibrosis - A#lasia - <ecreased stim2lation - Anemia of c/ronic inflammation - %enal disease decreased 5:= - Metabolic defect 0$ %& > 2 Eill be a normoc"tic #rocess 1$ &ndirect bilir2bin increased. L<H increased. /a#toglobin decreased a$ 8c/istoc"tes &@ /emol"sis b$ 8#/eroc"tes 5@ /emol"sis 2$ &ndirect bilir2bin not increased. L<H not increased. /a#toglobin not decreased a$ B& bleed b$ Menses c$ =t/er bleed * Beneral considerations - Hgb and Hct meas2re #lasma 3ol2me - Falsel" ele3ated in de/"dration - Falsel" decreased in cirr/osis and +HF - Most common ca2se is d2e to blood loss 'B& bleed 37 menses$ > /emol"tic II. Clinical Findings (Signs/Symptoms) A$ Beneral 1$ Fatig2e 2$ :allor 3$ 8=0/Lig/t/eadedness 9$ !ac/"cardia ?$ <iAA" 0$ 012 deficienc" 1$ 0eef" red tong2e 2$ <ecreased #osition and 3ibrator" sensation +$ 8igns of end-stage li3er disease <$ Fe deficienc" 1$ Hea3" menses 2$ 0lac, or blood" stool 3$ :ica 9$ :/ago#/agia: :ica for ice ?$ Doilon"c/ia s#oon nails C$ Atro#/ic glossitis smoot/ red tong2e 5$ 4ormoc/romic 1$ 8igns of malignanc": Anore6ia. -eig/t loss. nig/t s-eats 2$ Marro- fibrosis: 8mear s/o-s teardro#s F$ Lead #oisoning 1$ Lead lines '02rtonFs lines$. ence#/alo#at/". er"t/roc"te baso#/ilic sti##ling sideroblastic anemia. -rist/foot dro#. dimerca#rol and/or 5<!A

B$ !/alassemia 1$ 0eta ma;or: Anemia G C mo. s#lenomegal". frontal bossing. Fe o3erload from transf2sion 2$ 0eta minor: As"m#tomatic III. Work-up A$ Histor" 1$ 4ormal Hct before &f "es. not congenital 'e6ce#t for BC:<H def$ 2$ 8o2rce of bleed #resent 3$ <r2gs - +/emot/era#". anticon32lsants. and !M: all ca2se megaloblastic - +olc/icines. c/loroH2ine. and some Ab6 9$ :re3io2s s2rger" on stomac/. d2oden2m 'Fe$. ;e;2n2m 'folate$. and ile2m '012$ ?$ Inderl"ing diseases li,e renal fail2re. +A. or inflammator" '%A$ 0$ :5 1$ 8,in - :latelets: :etec/iae and #2r#2ric s,in lesions and/or bleeding from m2cosal s2rfaces - +oag2lation factors: 5cc/"moses. /ematomas. and /emart/roses 2$ 4odes. /e#atos#lenomegal": L"m#/oma 3$ %ectal: 8tool g2aiacs +$ Labs 1$ Hct/Hgb 2$ E0+. diff. and #latelets 3$ M+@ 9$ Fe st2dies: Fe. !&0+. and ferritin ?$ %etic co2nt C$ :eri#/eral smear $ 0M as#irate and bio#s" c"togenetics and c"tolog" I . !a"oratory findings * 8ee abo3e . Differential Diagnosis * 8ee abo3e I. #reatment A$ Fe deficienc" anemia - +orrect 2nderl"ing #roblem - Ferro2s s2lfate 32? mg := J<. t/en mo3e 2# to 0&< 0$ 8ideroblastic anemia - =ccasionall". 0C -or,s +$ Folate deficienc" - Folic acid 1 mg := J< ? mg J< for #atients -it/ malabso#rtion <$ @itamin 012 - :arenteral 012 1)) mcg &M Hd for da"s. t/en 1))-1))) mcg &M #er mont/ - 2 mg oral cr"stalline 3itamin 012 #er da" 5$ Anemia of c/ronic inflammation - !6 2nderl"ing d6 - Ise 5:= ?)-?)) I/,g 36/-ee, if 2remia #resent F$ 8ic,le cell - H"dro6"2ra 1)-3) g/,g/da" := - !6 infection earl". s2##lement folic acid. gi3e /"dration. =2. and analgesics if /a3e crises - :ne2mococcal 3accine B$ !/al ma;or - !ransf2se to ,ee# Hgb > 9. defero6amine. folic acid - 8#lenectom" 37 allogeneic 0M trans#lant H$ AA - Antit/"moc"te glob2lin K/- c"clos#orine. 0M trans#lant

&$ A&HA - B+ or &8