Presentation on theme: "Anemia 101- Case Studies Peter A. Kouides MD"— Presentation transcript:
1Anemia 101- Case Studies Peter A. Kouides MD Associate Professor of Medicine,University of Rochester School of Medicine Attending Physician,The Rochester General Hospital
2Anemia classification based on the mechanism Kinetic Classification (based on retic count)Decreased productionMorpholgical classification (based on MCV)MicrocyticNormocyticMacrocyticIncreased destructionImmunological classification (based on Coomb’s test)Immune-mediatedNon-immune mediated
3The Medical Student’s Approach to Anemia Check the reticulocyte count to determine if the anemia is from decreased production (“hypoproliferative”, “reticulocytopenic”) or increased destruction (“hemolytic”)/acute blood loss (“reticulocytosis”)2. If decreased production, narrow down the causes in terms of the MCV-If the MCV is low, then do iron studies then Hb electropheresisIf the MCV is normal, check the serum creatinine and TSH, if they are WNL then consider bone marrow examIf the MCV is high check a folate and vitamin B12 level3. If the the reticulocyte count is increased-Check a direct Coomb’s test4. Look at the peripheral blood smear to confirm/support the diagnosis
4Anemia Algorithm Patient with anemia and decreased reticulocyte count- What is the MCV ??MicrocyticNormocyticMacrocytic:Vitamin-relatedB12, FolateNon-vitamin:MDSEtOH/Liver DiseaseHypothyroidismFedef.Systemic DiseasesThalDiseases in Bone MarrowMDSSolid TumorMyelomaAplastic anemiaRenal vs. Liver vs. Endocrine vs Anemia of InflammationOther: sideroblastic anemia (meds,PB,Zn excess,Cu def)
5Anemia Algorithm, continued Patient with anemia and increased reticulocyte count= HEMOLYTIC ANEMIA
6Anemia Algorithm, continued Patient with anemia and increased reticulocyte count-What is the result of a Coomb’s test ??NegativePositive (autoimmune hemolytic anemia)Intrinsic red cell defectExtrinsic red cell defect“Warm”“Cold”MembraneCytoplasmVesselValveHemoglobinToxin
7The Attending’s Approach to Anemia 1. Stool guiacs x 32. If the MCV is low, then prescribe iron3. If the MCV is high, then check a folate level and vitamin B12 levelif folate level returns low or “indeterminate”, then begin folic acid 1 mg po qdif B12 level returns low or “indeterminate”, then begin IM vitamin B12
9Case #1-A 67-year-old man is referred for evaluation of dyspnea Case #1-A 67-year-old man is referred for evaluation of dyspnea. The hematocrit is 28%, white blood cell count 4500/mm3, platelet count 550,000/mm3, and reticulocyte count 4%. The MCV is 78 and the blood smear reveals basophilic stippling and a small population of hypochromic microcytic red cells. Serum Fe 225, TIBC 260, Ferritin 490
10Case #2-Patient H.M.A 57-year-old woman presents to the clinic for evaluation of ataxia, weakness, and parathesias. The patient has been taking a multivitamin preparation.Hematocrit is 38%white blood cell count 4,000; platelet count 100,000What tests would you order next ?
11Case #3- A 65-year-old man with a Hematocrit of 33% and a reticulocyte count of 7% is admitted to the hospital with right upper quadrant abdominal pain. Peripheral blood smear reveals occasional spherocytes.
12Case #4- Patient R.B.A 26-year-old woman presents to the hospital with pleuritic chest pain. She gives a history of episodic arthralgias for a number of months, plus one episode of frank arthritis involving the small joints of both hands occurring 2 months prior to admission. The patient has a hematocrit of 29%, a white blood cell count of 4000, and a reticulocyte count of 12%. The smear reveals normocytic, normochromic red blood cells with polychromatophilia, and occasional spherocytes, occaisonal NRBC.
13Case #5- Patient F.D.A 60-year-old woman is hospitalized because of severe fatigue and dyspnea of 2 weeks' duration. Five years ago, the patient had a total hysterectomy and bilateral salpingo-oophorectomy for ovarian adenocarcinoma. She received a course of oral melphalan as adjuvant chemotherapy.
14Patient F.D. continuedThree years ago a restaging laparotomy reveals no evidence of tumor, and blood counts were normal.Now, except for a temperature of 38.4°C (101.1°F) and pallor, she has normal findings.Laboratory studies: Hematocrit 17%, MCV 108 fL. , WBC 4,500, platelet count 50,000, reticulocyte count 0.8%
15MDS vs. Folate/B12 Deficiency Think of MDS when the anemic patient is elderly and the MCV is increasedin one study of the elderly, MDS was the fourth most common cause of anemia after:acute blood loss/Fe Deficiencyanemia of chronic diseaseanemia of renal insufficiencythe B12 level can be borderline low in elderly patients but it is not true B12 deficiency if-a serum total homocysteine level is normala urine methylmalonic acid level is normal
16Case #6- Patient G.D.A 28 year-old black man plans a trip to India and is advised to take prophylaxis for malaria. Three days after beginning treatment, he develops dark urine, pallor, fatigue, and jaundiceHematocrit is 26% (it had been 43%), MCV 100; WBC 3.4, Platelets 199,000
17Patient G.D. continued Reticulocyte count 13% What test should be diagnostic?And, why do I say “should” instead of “is diagnostic”?
18Drugs Causing Anemia LESS COMMON- MORE COMMON- Decreased Production: Anti-Tb drugs= Sideroblastic AnemiaChloramphenicol, Valproic acid= Pure Red Cell AplasiaAZT, Dilantin= Macrocytic AnemiaMORE COMMON-Increased Destruction (Hemolytic):Qunidine, PCN, Aldomet= Auto-immune Hemolytic AnemiaPrimaquine,Nitrofurantoin, Dapsone, Pyridium= G6PD Deficiency
19Case # 7A 21-year-old woman with sickle cell anemia has had a fever and severe pain in the right shin for 3 weeks. The painful area is hot, swollen, tender and indurated.
20Case #8A 66-year-old-man presents with increased fatigue and anemia. Hypothyroidism was detected 3 years ago and thyroid hormone therapy was administered. Anemia was diagnosed 2 years ago, but findings on bone marrow examination were normal, and there was no response to oral therapy with iron. Sexual function has diminished during the last 2 years. He has a blood pressure of 90 Hg systolic and 60 mm Hg diastolic, pallor, absence of axillary hair, and sparse pubic hair. There is no gynecomastia, but the testicles are soft, and the prostate gland is small. The result of an examination of the stool for occult blood is negative. Laboratory studies: hematocrit 36%, leukocyte count 5800/µL, platelet count 255,000/µL, peripheral blood film - normochromic normocytic erythrocytes with anisocytosis or poikilocytosis, MCV: 86 fl, serum creatinine - normal.