A Practical Approach to Anemia

How to efficiently and accurately work up an anemic patient ?

Dr Kishore Kumar DM (Clinical Haematology) Institute Of Haematology & Transfusion Medicine Kolkata, India

M.B.B.S

M.D

D.M

Anemia is a clinical sign of disease

It is not a single disease by itself

Need to look for the underlying cause !

Will we ignore a fever with out investigation ?

Its diagnosis is not that simple !! Well make it Its very common and imp. in our practice Drug Rx. depends on the cause

The onset of Anaemia Acute versus chronic Clues

Hemodynamic stability
Previous CBC Overt blood loss

RETICULOCYTE COUNT %

RBC to be or Apprentice RBC Fragments of nuclear material RNA strands which stain blue

Normal Less than 2%

R.Index<2.5 Rbc Morphology N/N Micro Or Macro

Hypoproliferative Marrow Damage Infiltration/Fibrosis Aplasia Maturation Disorder Cyoplasmic Defects Iron Deficiency Thalessemia

Stimulation

Renal Disease

Sideroblastic Anemia Nuclear Defects

Vit B12/Folate Deficiency Drug Toxicity

Metabolic Defects Inflammation Mild Iron Deficiency

 Hemolysis/Haemorrhage

Blood

Loss

CBC: Hb, Hct, RBC, WBC and diff, plts, retic count MCV: useful <80, 80-100, >100 MCH: not useful

MCHC g/dl if high suggests hereditary spherocytosis

RDW: helpful in ddx of iron deficiency vs

thalassemia minor

RBC:
Size and shape Hb content Polychromatophilia Inclusions: Howell-Jolly bodies, basophilic stippling, malaria Rouleaux

WBC Platelets

BUN, creatinine Bilirubin, icterus = 2.5mg/dl (direct and indirect) LDH, haptoglobin Proteins, polyclonal/monoclonal Iron/TIBC Ferritin Folic acid Vitamin B12

Measurement Normal
A. B. C.

Range
4 to 6 12 to 17 38 to 50

RBC count Hemoglobin Hematocrit

5 million 15 g% 45

A x 3 = B x 3 = C - This is the rule of thumb Check whether this holds good in given results If not -indicates micro or macrocytosis or hypochro.

Hb PCV RBC

6.6 20.7

TLC Neutro

7200 Platelets 78% 4,80,000 19% Retic 0.4%

2.3mil Lympho

MCV
MCH MCHC

74.6
24.8 28.2

Mono
Eosino Baso

2%
1% nil

RBC morph: Aniso++ Poikilo++ hypochrom++

RDW-cv

22.4

Abnormal cells

nil

Iron deficiency has latent phase

Cells normal in size during this..

Overt deficiency low Hb in rbcs so small sized

BUT THE OLDER ONES ALSO SURVIVE FOR 120 DAYS

Hence both sizes INCREASED RDW..

But ratios maintained..

Hb PCV RBC

10.2 28.7

TLC Neutro

7200 Platelets 88% 2,40,000 10% Retic 1.4%

5.2mil Lympho

MCV
MCH MCHC

74.6
24.8 28.2

Mono
Eosino Baso

1%
1% nil

RBC morph: hypochrom++ Target cells+

RDW-cv

13.4

Abnormal cells

nil

In Thal the problem lies in globin chain formation .. So all cells have low Hb in them resulting in a uniform microcytosis.. low RDW..

In view of hypoxia EPO increases production of

Rbcs

So more cells less Hb resulting in disproportion..

Hb PCV RBC

8.6 26.7 3 mil 31.8 33.2

TLC Neutro Lympho Eosino Baso

3200 Platelets 68% 40,000 30% Retic 6.4%

MCV
MCH MCHC

104.6 Mono

1%
1% nil

RDW-cv

16.4

Abnormal cells

nil

RBC morph: Macroovalocyt es++ Polychromasia ..

Why not aplastic anemia..

Hb PCV RBC

8.6 26.7

TLC Neutro

9200 Platelets 68% 2,40,000 30% Retic 0.4%

2.9mil Lympho

MCV
MCH MCHC

72.6
27.8 28.2

Mono
Eosino Baso

1%
1% nil

RBC morph: Microcytes++ Hypochromia+ +

RDW-cv

24.4

Abnormal cells

nil

S. Ferritin 320ng/ml.

Hb PCV RBC

6.6 20.7

TLC Neutro

6200 Platelets 62% 2,40,000 30% Retic 22.4%

2.8mil Lympho

MCV
MCH

114
27.8

Mono
Eosino Baso

6%
2% nil

RBC morph: Mod aniso++ Spherocytes on PBS..

RDW-cv

16.4

Abnormal cells

nil

If negative think of other causes..

Hb PCV RBC

6.6 20.7

TLC Neutro

6200 Platelets 62% 10,000 30% Retic 22.4%

2.8mil Lympho

MCV
MCH

114
27.8

Mono
Eosino Baso

6%
2% nil

RBC morph: Mod aniso++ Spherocytes on PBS..

RDW-cv

16.4

Abnormal cells

nil

If the same hemogram report with DCT Negativity and presence of schistocytes in PBS is reported from critically ill patients..

Hb PCV RBC

6.6 20.7

TLC Neutro

2200 Platelets 62% 1,10,000 30% Retic 8.6%

2.8mil Lympho

MCV
MCH

104
27.8

Mono
Eosino Baso

6%
2% nil

RBC morph: Mod aniso++

RDW-cv

16.4

Abnormal cells

nil

???

If a young boy had a similar picture after Rx for malaria

Hb PCV RBC

6.6 20.7

TLC Neutro

5200 62% 30%

Platelets 62,000

2.9mil Lympho

MCV
MCH

92
27.8

Myelo

RDW-cv

17.4

RBC morph: Mod aniso++ Metamyelo 2% Tear drop 10/100 Nrbcs cells seen.. Abnormal nil Leukoerythro cells blastic picture+

6%

PMF

Hb PCV RBC

7.6 23.7

TLC Neutro

9200 Platelets 58% 2,40,000 40% Retic 1.4%

2.8mil Lympho

MCV
MCH ESR

86.6
27.8

Mono
Eosino

1%
1% nil

82/hr Baso

RBC morph: N/N Rouleaux noted on PBS

RDW-cv

16.4

Abnormal cells

nil

Next investigations to advice..

Hb PCV RBC MCV MCH

6.6 20.7 104 27.8

TLC Neutro Mono Eosino Baso

2200 Platelets 62% 1,10,000 30% Retic 1.6% 6% 2% nil RBC morph: Mod aniso++

2.8mil Lympho

RDW-cv

16.4

Abnormal cells

nil

Retic index not appropriately increased

No evidence of iron/B-12/folate deficiency, renal failure,

endocrinopathy, inflammation or other low EPO state

Poor response to EPO, iron or vitamin replacement WBC/plts/diff abnormal, monoclonal gammopathy, or other peripheral blood evidence of marrow disorder

Would you treat leukemia/MDS or other neoplastic

disorder if you found it?

If Hb% is low Do not start on Iron straight away

Order for Reticulocyte count Is RPI < 2 % or > 2%

Is it hypo-proliferative or hemolytic or hemorrhagic

anaemia

If hypo proliferative Microcytic or Macrocytic? (MCV, RDW)

If microcytic IDA or others Spl. Iron tests, BM Iron

If macrocytic Megaloblastic (B12, FA) or

Normoblastic BM

If normocytic Anaemia of chr. Disease Liver, , Ca

If retic. count is - HA work up; Hb EP, spl. tests

Thanks for your attention