LETTERS TO THE EDITOR
Practical Algorithms in Anemia Diagnosis that correspond to each of the 3 categories of anemia. I am
happy to accommodate that request (Figures 1, 2, and 3).
To the Editor: In the October 2003 issue of Mayo Clinic However, I remind readers that such algorithms should serve
Proceedings, I authored a concise review article on a contem- only as guidelines and that an in-depth review of the clinical
porary approach to the evaluation and diagnosis of anemia in and laboratory data is essential before making a specific diag-
adults.1 In that article, I classified anemia into macrocytic, nosis in an individual patient.
normocytic, and microcytic categories based on the mean
corpuscular volume (MCV)—MCV >100 fL, 80-100 fL, and Ayalew Tefferi, MD
<80 fL, respectively. I also provided a stepwise approach to a Mayo Clinic College of Medicine
specific diagnosis in each of these categories. I have since Rochester, Minn
received numerous requests from readers of the Proceedings 1. Tefferi A. Anemia in adults: a contemporary approach to diagnosis. Mayo
to complement the concise review with practical algorithms Clin Proc. 2003;78:1274-1280.
Evaluation of macrocytic anemia
Step 1: Rule out drug causes including
hydroxyurea and AZT use
Step 2: Check serum vitamin B12 and homocysteine
Both normal One or both abnormal
Check serum MMA
Nutritional cause unlikely
Normal Increased
Moderately macrocytic Markedly macrocytic
(MCV, 100-110 fL) (MCV, >110 fL)
Check serum Consider vitamin
folate B12 deficiency
Blood smear shows Blood smear shows Consider:
round macrocytes, oval macrocytes, (1) Myelodysplastic syndrome
target cells, or anisocytosis, or (2) Other marrow disease
reticulocytosis pseudo–Pelger-Huët
nuclear anomaly
Consider:
(1) Hemolysis
(2) Excess alcohol use
(3) Liver disease
FIGURE 1. Evaluation of macrocytic anemia. AZT = zidovudine; MCV = mean corpuscular volume; MMA =
methylmalonic acid.
952
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LETTERS TO THE EDITOR
Evaluation of normocytic anemia
Step 1: Rule out treatable causes
Bleeding Nutritional causes Renal insufficiency Hemolysis
Check serum ferritin Check haptoglobin,
Check history Check serum
and vitamin LDH, bilirubin, and
Perform FOBT creatinine
B12/folate reticulocyte count
Step 2: If all the above are unrevealing, consider:
Anemia of chronic disease or
Primary bone marrow disorder
Step 3: Perform bone marrow biopsy only if:
(1) Information will influence treatment or
(2) Anemia is symptomatic or
(3) Blood smear suggests a primary bone
marrow disease
FIGURE 2. Evaluation of normocytic anemia. FOBT = fecal occult blood test; LDH = lactate dehydrogenase.
Evaluation of microcytic anemia
Step 1: Check serum ferritin
Low = iron-depleted state Normal or elevated
Step 2: Is the microcytosis new?
Yes
No
Consider anemia of Consider
chronic disease thalassemia
Determine whether
Usual causes: Unusual causes:
other family
Rheumatoid arthritis Renal cell carcinoma members are
Temporal arteritis Hodgkin lymphoma affected
Chronic infection Castleman disease Check hemoglobin
Chronic inflammation Myelofibrosis electrophoresis
FIGURE 3. Evaluation of microcytic anemia.
Mayo Clin Proc. • July 2004;79(7):945-956 • www.mayo.edu/proceedings 953
956
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