Anemia: Classification,general
features and approach
Definition of anemia
Anemia is functionally defined as an
insufficient RBC mass to adequately
deliver oxygen to peripheral tissues.
Indicators: Hemoglobin level,
hematocrit, RBC number
Adult Reference Ranges for Red Cells
Measurement (units) Men
Hemoglobin (gm/dL) 13.617.2
Hematocrit (%)
3949
Red cell count ( 106/L) 4.35.9
Reticulocyte count (%) 0.51.5
Mean cell volume (fL)
8296
MCH(pg)
2733
MCHC(gm/dL)
3337
RDW
11.514.5
Women
12.015.0
3343
3.55.0
Limitations in this concept
Hb and HCT may reflect altered plasma
volume not a change in RBC mass
Hb and HCT changes may reflect underlying
physiological conditions with different oxygen
needs
Classification
Etiological
Blood loss
Increased red cell destruction
Decreased red cell production (Hypo-proliferative
or maturation disorder)
Morphological
Clinical features
Symptoms depend on duration of the disease
Weakness
Fatigue
Palpitation
Shortness of breath
Tachycardia
Headache,vertigo,tinitus,parasthesias
Patient History
Dietary habits
Bowel habits
Medications
Exposure to chemicals and toxins
History of fever
Menstrual bleeding
Bruises,ecchymoses
Family history
Physical examination
Skin pallor/Pale conjunctiva
Jaundice
Smooth tongue
Sternal tenderness
Spleno/Hepatomegaly/lymphadenopathy
Purpura
Neurological dysfunction
Angular Stomatitis
Glossitis
Koilonychia
Laboratory Examination
First Line Studies
- CBC:Hb, Hcrit, Rbc indices, Cell count,
Reti count
- PB morphology examination
- Chemistry
-Urine examination
Second Line Studies
- Iron/TIBC/Ferritin
- BM study
-HPLC
- others
Useful RBC indices
Mean cell volume: the average volume of a red
cell expressed in femtoliters (fL)
Mean cell hemoglobin: the average content
(mass) of hemoglobin per red cell, expressed in
picograms
Mean cell hemoglobin concentration: the
average concentration of hemoglobin in a given
volume of packed red cells, expressed in grams
per deciliter
Red cell distribution width: the coefficient of
variation of red cell volume
Reticulocyte count
Corrected Reti(%)
(Reticulocyte Index, RI)
Correction of dilutional factor
= Reti(%) x Patients Hcrit / 45
Normal
Anemia
Red Cell Production Index(RPI)
Correction of shift factor
= Corrected Reti / Shift factor
BM normoblasts &
reticulocytes(days)
Hcrit
PB
reticulocytes(days)
45
3.5
1.0
35
3.0
1.5
25
2.5
1.5
2.0
15
2.5
Shift correction factor
Normal marrow response to anemia
Hematocrit
Production index
Marrow M/E ratio
45
3:1
35
2-3
2:1-1:1
25
3-5
1:1-1:2
15
3-5
1:1-1:2
Anemia alone or Not ?
Anemia alone
Bicytopenia or Pancytopenia
- Aplastic anemia/PNH
- MDS
- Acute leukemia
- Hypersplenism/Autoimmune disorders
- Megaloblastic anemia(not always)
- Myelophthisic anemia
Is there an appropriate reticulocyte
response to anemia
If reticulocytosis is present look for evidence
of hemolysis.
Hyperbilirubinemia
Increased LDH
Increased excretion hemoglobin (low
haptoglobin,hemoglobinemia,hemoglobinuria,he
mosiderinuria)
Anemia associated with low
reticulocyte count
Reflects impairment of normal hematopoeisis
Impaired erythropoeisis may be because of
Reduction in red cell precursors (hypogenerative)
Ineffective erythropoeisis
Macro-, Normo-, or Microcytic ?
Microcytic (MCV < 80 fL)
- IDA, Thalassemia, ACD
Macrocytic (MCV > 100 fL)
- Megaloblastic anemia, Reticulocytosis
Liver disease, Aplastic anemia
Normocytic
Anemia of renal failure, MDS, Leukemia, Aplastic
anemia, ACD, Others
R.INDEX<2.5
RBC MORPHOLOGY
N/N
MICRO OR MACRO
HYPOPROLIFERATIVE
MATURATION DISORDER
MARROW DAMAGE
CYOPLASMIC DEFECTS
INFILTRATION/FIBROSIS
IRON DEFICIENCY
APLASIA
THALESSEMIA
STIMULATION
RENAL DISEASE
METABOLIC DEFECTS
INFLAMMATION
MILD IRON DEFICIENCY
SIDEROBLASTIC ANEMIA
NUCLEAR DEFECTS
VIT B12/FOLATE DEFICIENCY
DRUG TOXICITY
REFRACTORY ANEMIA
R INDEX>2.5
HEMOLYSIS/HAEMORRHAGE
BLOOD LOSS
INTRAVASCULAR HEMOLYSIS
MEMBRANE ABNORMALITY
HEMOGLOBINOPATHY
AUTOIMMUNE DEFECT
FRAGMENTATION HEMOLYSIS
METABOLIC DEFECT
Is anemia associated with red cell populations
of different sizes?
Is the anemia associated with abnormalities
on peripheral smear?
Is a bone-marrow examination required for
clarifying the cause of anemia?
Peripheral Blood Smear
Size
Central pallour
Shape
Distribution
Inclusions
Abnormal cells
PBS Shape (cont)
Spherocyte,Sickle cell,schistocytes
Target cell increased ratio RBC
surface/volume
CLD, thalassemia
Teardrop
myelofibrosis
Acanthocyte (spur cells)
severe liver disease
Burr cell uremia, artifact
Microcytic hypochromic picture
Macrocytic picture
Megaloblasts in bone-marrow
Leuco-erythroblastic reaction
Normocytic picture with rouleaux
Spherocyte
http://www.wadsworth.org/chemheme/heme/microscope/spherocyte.htm
Sickle Cell
http://www.wadsworth.org/chemheme/heme/microscope/sicklecell.htm
Schistocyte
http://www.wadsworth.org/chemheme/heme/microscope/schistocyte.htm
Target Cell
http://www.wadsworth.org/chemheme/heme/microscope/targetcells.htm
Burr cell
http://www.wadsworth.org/chemheme/heme/microscope/echinocytes.htm
Tear drop cell (dacrocyte)
Rouleaux formation
http://www.wadsworth.org/chemheme/heme/microscope/rouleaux.htm
PBS - Inclusions
Nucleated RBC immature RBCs
Extramedullary hematopoiesis, hypoxia, hemolysis
Heinz bodies denatured and precipitated
hemoglobin
G6PD deficiency
Howell-Jolly bodies small nuclear remnant with the
colour of a pyknotic nucleus
s/p splenectomy, hyposplenism
Basophilic stippling deep blue granulations,
pathologic aggregation of ribosomes
Lead intoxication, thalassemia
Howell Jolly Bodies
http://www.wadsworth.org/chemheme/heme/microscope/howelljolly.htm
Basophilic stippling
http://www.wadsworth.org/chemheme/heme/microscope/basostip.htm
Bite cells and Heinz Bodies
When is bone-marrow required?
Refractory anemias
Parasites
Presence of abnormal cells on peripheral
smear
Rule out infiltration of marrow
Hypocellular bone marrow in aplastic
anemia
Contrast with erythroid hyperplasia
LD bodies in bone-marrow
Bone-marrow granuloma
Thank You..
