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FULL BLOOD COUNT PRESENTATION Clinical Practice A GROUP C
Iron Deficiency Anaemia Caused by a lack of adequate iron to synthesize haemoglobin and meet body demands in such as during periods of rapid growth and pregnancy Usually due to a diet insufficient in iron or from blood loss Diagnosis includes - Often, the platelet count is elevated (>450,000X10 9 /L) - WBC is usually within reference ranges
Iron Deficiency blood loss: o uterine e.g. menorrhagia o gastrointestinal o malignancy increased demands: o pregnancy o prematurity o growth others: o malabsorption e.g. gastrectomy, coeliac disease o dietary iron deficiency
Investigation and Diagnosis Biochemistry: decreased serum ferritin - best biochemical marker increased total iron binding capacity (TIBC) decreased TIBC saturation - less than 30%; often the best parameter with which to monitor treatment decreased serum iron
Investigation and Diagnosis Haematology: microcytic, hypochromic anaemia blood film shows occasional target cells and pencil- shaped poikilocytes platelet count may be at or above the upper limit of normal if there is persistent bleeding The best proof of iron deficiency anaemia is that the anaemia is cured by administration of iron.
Microcytosis Defined as a reduced mean cell volume – average volume of a single red cell - of less than 80 femtolitres in adults (norm range fl) Characterized by the presence of microcytes (abnormally small red blood cells) in the blood.
Causes iron deficiency anaemia - the commonest cause Vit A, C, copper deficiency sideroblastic anaemia thalassaemias anaemia of chronic disease lead poisoning
Clinical Features Possible symptoms: pallor fatigue dyspnoea anorexia headache bowel disturbance
Investigation to investigate microcytic anaemia, patient has a blood film, then serum iron levels are measured. blood film - iron deficiency anaemia has a microcytic, hypochromic blood film showing anisocytosis and poikilocytosis serum iron, ferritin and total iron binding capacity: - iron deficiency anaemia - low serum iron, low serum ferritin, raised TIBC - other causes are iron loading conditions characterised by raised serum iron, raised ferritin, low total iron binding capacity
Patient Investigation FBC Hb65 g/L MCV74 fL Platelets500 X 10 9 /L X 10 9 /L Serum ferritin5ug/L Serum B12220pmol/L Serum folate2.0nmol/L7-45 Red cell folate100nmol/L
Case History 25 year old female Suspected iron deficiency anaemia Never been pregnant, no change in menstrual flow Normal diet/No medications No GIT problems Low MCV High platelets Normal Serum B12 Low Serum Folate Low Red Cell Folate Low haemoglobin
Is the MCV result consistent with a diagnosis of iron deficiency? Yes in iron deficiency anaemia, MCV is low, however microcytosis is not always caused by iron deficiency anaemia WHY?
Because… In the majority of cases, microcytosis is the result of impaired hemoglobin synthesis. Disorders of iron metabolism and of porphyrin and heme synthesis, as well as impaired globin synthesis, lead to defective hemoglobin production and to the generation of microcytosis.
Could this patient also have associated B12 or folate deficiency? Serum folate, RBC folate and Vitamin B12 levels differentiate between folate and B12 deficiency The patient: Low haemaglobin: anaemia Serum B12: Normal Serum folate and RBC folate: LOW Thus there is a folate deficiency
Folate Deficiency Low folate levels can cause macrocytic anaemia – indicated by high MCV The patient has a low MCV - indicates microcytic anaemia due to iron deficiency
Anisocytosis However, blood film showed anisocytosis: RBC are of unequal size (large and small) Patient can have both iron deficiency anaemia: small size RBC folate deficiency anaemia: large size RBC
Main causes of folate deficiency Dietary – inadequate intake (Common) Blood loss Increase physiological requirements eg infant growth or pregnancy Malabsorption due to GIT problems eg Coeliac disease, Crohns disease Other: Drugs eg Phenytoin, Trimethoprim, Methotrexate, Oral Contraceptives Patient doesnt display any of these factors
Is the data typical for patients with iron deficiency anaemia? Data is normal as in iron deficiency anaemia, patients display low MCV and low serum ferritin levels Folate levels are not normally low in iron deficiency anaemia. Thus the levels must be investigated for other possible causes.
Anisocytosis RBC show abnormal size variation Normal RBC diameter = 6-8 µm. Grades 1 4 depending on % of abnormality Normal RDW (Red cell Distribution Width) is Increased RDW suggest anisocytosis Significance: Sign of many anaemias - Iron deficiency, Vit B12 deficiency
Target Cells Target cells AKA Codocytes Characterised by thin bulls- eye shape and an increase in the surface membrane area to volume ratio due to a decrease in Hb Significance: A sign of Iron Deficiency Anaemia, Vit B12 deficiency Anaemia and other disorders eg Liver Disorders, Thalassemia,
Pencil Cells Oval to elongated, ellipsoid shape with central area of pallor and hemoglobin at both ends of cell Significance: Iron deficiency anaemia (Elongated cells), Vitamin B12 deficiency anaemia (Oval Cells), can also be Inherited, where by >25% elliptocytes are oval.
Howell-Jolly Bodies Smooth, round nuclear fragments made up of DNA Observed when erythropoiesis is active >3% is significant and indicates Megaloblastic Anaemia
Hypersegmented Neutrophils Neutrophils with five or more lobes Significance: an important clue to the presence of deficiency of vitamin B12 or folic acid
Conclusion Patient FBC and Blood film suggest: Iron Deficiency Anaemia AND Folate Deficiency Anaemia As evidenced by Low MCV and Low Folate combined with the presence of Hypochromic, Microcytic Cells, Marked Anisocytosis, Howell-Jolly Bodies, Hypersegmented Neutrophils