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A Practical Approach To Anemia Minal Barve, MD September 28, 2006.

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Presentation on theme: "A Practical Approach To Anemia Minal Barve, MD September 28, 2006."— Presentation transcript:

1 A Practical Approach To Anemia Minal Barve, MD September 28, 2006

2 Objective  Recognition  Diagnosis: do not overlook the primary problem Hematological data Peripheral smear  Treatment

3 Hematological  CBC: Hb, Hct, RBC, WBC and diff, plts, retic count  MCV: useful 100  MCH: not useful  MCHC g/dl if high suggests hereditary spherocytosis  RDW: helpful in ddx of iron deficiency vs thalassemia minor

4 Peripheral Smear  RBC: Size and shape Hb content Polychromatophilia Inclusions: Howell-Jolly bodies, basophilic stippling, malaria Rouleau  WBC  Platelets

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

6 Urinalysis  Protein: light chains are not detected by dipstick  RBC  Hemoglobin

7 Mechanism of anemia  Blood loss  Decreased production  Increased destruction

8 Most common anemias  Iron deficiency  Alpha- thalassemia  Beta-thalassemia  Anemia of chronic disease

9 Other anemias  Sickle cell disorders  Autoimmune hemolytic anemias  Folate and B12 deficiency  Refractory anemia/MDS  Aplastic anemia  Red cell membrane or enzyme defects

10 Classification of anemias  Microcytic  Normocytic  Macrocytic

11 DDX of Microcytosis Iron deficiency anemiaFamilial telangiectasia (OWR) idiopathic pulmonary hemosiderosis, PNH  - thalassemia No simple test, trial of iron therapy  - thalassemia Thal minor - elevated Hb A 2 if not iron deficient Anemia of chronic diseaseMCV 75-82; inadequate erythropoietin response Hb CCAfrican-American, splenomegaly, mild anemia MCV 65, many target cells Hb EESoutheast Asian, no anemia or minimal anemia. MCV 65 many target cells

12 Copyright ©2002 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2002;2002: Figure 1. Note the profound central pallor of the hypochromic and microcytic RBC

13 Copyright ©2002 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2002;2002: Figure 2. Stages of iron deficiency

14 Copyright ©2001 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001: Figure 2. Peripheral smear

15 Lab Test for DDx of Common Microcytic Hypochromic Anemias Iron Deficiency Thalassemia Minor Chronic Disease Scrum Iron N or  TIBC N or  % Iron Saturation  (< 10%)N or  Serum Feritin  FEP  N 

16 Important points in iron therapy  Determine the underlying cause  Ferrous sulfate orally, parenteral iron IV or IM rarely  Start with one tablet (300 mg-60mg Fe) daily then bid until Hgb normalizes  Then reduce to one tablet daily for a year to replete iron stores  Grey/black iron stools vs tarry stools  Avoid tea with iron, encourage citrus fruits

17 Normocytic anemia with a normal or reduced retic count  Anemia of chronic disease (reutilization defect)  Megaloblastic anemia with thalassemia or iron deficiency  Hypoendocrine states  Chronic renal failure  AIDS  Bone marrow infiltration  Myelodysplastic syndromes

18 Normocytic normochromic anemia with increased reticulocyte count  Blood loss anemia  Hemolytic anemia

19 Investigation of Hemolytic Anemia

20 Copyright ©2002 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2002;2002: Figure 4. Low-power view showing dense micro-spherocytes without central pallor

21 Copyright ©2002 American Society of Hematology. Copyright restrictions may apply. Maslak, P. ASH Image Bank 2002;2002: Figure 2. Peripheral smear from a splenectomized patient with recurrent autoimmune hemolytic anemia

22 Hemolytic anemias  Coomb’s test direct negative, indirect positive = delayed transfusion reaction  Hereditary spherocytosis Osmotic fragility test: fresh and incubated Autosomal dominant, spectrin decreased, splenectomy  Sickle cells Sickledex- solubility screening test for hgb S Cellulose acetate electrophoresis necessary to define AS, SS, SC, S-thal etc  Elliptocytes Most are not anemic or have compensated hemolytic process 10-15% have chronic hemolytic anemia

23 Copyright ©2001 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001: Figure 1. Note the dense microspherocytes and the macrocytes with polychromasia

24 Copyright ©2002 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2002;2002: Figure 5. This patient has hereditary elliptocytosis

25 Copyright ©2001 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001: No Caption Found

26 Hemolytic anemias  Acanthocytes Spurr cells- end stage liver disease- fatal prognosis  Burr cells Uremia, PK deficiency  Target cells High degree (30-100%) Hg CC, Hb EE, Hb SC, S-β-thal

27 Copyright ©2002 American Society of Hematology. Copyright restrictions may apply. Lazarchick, J. ASH Image Bank 2002;2002: Figure 1. Peripheral smear from a patient with liver disease and hemolytic anemia

28 Hemolytic anemias  RBC enzyme defects G6PD deficiency-X linked, NSHA, Favism, Spot test Pyruvate kinase and other enzyme defects Autosomal recessive, for most Chronic hemolytic anemia Specific enzyme assays  Intravascular hemolysis Serum haptoglobin Urine hemosiderin-useful 1-3 weeks after episode of intravascular hemolysis

29 Copyright ©2001 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001: Figure 1. Note the "bite cells" and the cells with "blisters" and dense cross-bonded hemoglobin

30 Hemolytic anemias  Causes of chronic intravascular hemolysis Cardiac abnormalities, usually prosthetic valve PNH  PNH- paroxysmal nocturnal hemoglobinuria Sucrose hemolysis test Acid serum hemolysis test (Ham’s test) Flow cytometry for CD55, CD59

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32 Macrocytic-normochromic anemia  MCV  Chronic liver disease  Hypothyroidism  Drugs- hydrea, methotrexate etc  Primary bone marrow disorder- aplastic anemia, MDS, leukemia, myeloma, etc  BM infiltrative disease-miliary TB, metastatic ca,

33 Copyright ©2001 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001: No Caption Found

34 Copyright ©2001 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001: Figure 2. Note the hypersegmented neutrophil (7-8 lobes)

35 MCV > 115 fl DDX Folate or B12 Deficiency Folic Acid Deficiency B 12 Deficiency Peripheral smear & BM morphology Same Dietary CauseCommon, in 3- 4 months Rare, except pure vegans, 3-4 yrs Drugs interfering with absorbtion Dilantin, oral contraceptives Omeprazole (Prilosec) Neurologic findingsNoMay be present Methylmalonic acid levelNormalElevated Schilling testUseful for etiology Obtain after Rx

36 Important Points About Anemia Retic peak occurs 1 week after Rx Fe, B 12, folate Hb/Hct increases to normal in 6- 8 weeks If not, complications 1% reticulocytosis increases MCV 1fl (Chronic reticulocytosis) High LDH suggests megaloblastic anemia ( U/ml) High MCHC suggests hereditary spherocytosis (or acquired spherocytosis) Bilirubin not over 4mg/dl with hemolysis Higher values = complications

37 Case 1  27 yo female with a history of lupus presents with a one week history of worsening dyspnea on exertion  Reports dark urine  Labs: hgb 8, mcv 101, rdw 19, total bili 1.9

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42 Case 2  62 yo white male presents with worsening fatigue for 3 months.  He reported anginal pain to his PCP and was referred to cardiology and had an abnormal stress test  Underwent cardiac cath which was unremarkable  Labs done post- cath showed a hgb of 6, hct 20, MCV 62, RDW 20, platelets 500K

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44 Case 3  84 yo female living in an assisted living facility admitted for “failure to thrive”  Admission labs: WBC 3.2 with normal diff, hgb 8.7, mcv 112, platelets 92K, LDH 1800

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46 Case 4  68 yo white female with a 10 year history of poorly controlled type II DM, HTN, CAD presents for routine follow-up.  CBC: wbc 7.2 with normal diff, hgb 9.8, hct 28, mcv 82, rdw 11, platelets 252K  BMP: creatinine 3.4

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51 Case 5  28 yo AAM with a h/o HIV brought to the ER for altered mental status  Found to have a temp of  Labs: wbc 2.2, ANC 1200, hgb 7.2, mcv 80, rdw 18, platelets 52K, creatinine 3.2, LDH 4200, bili 2.2

52 Copyright ©2001 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001: Figure 1. Note the fragmented schistocytes, burr cells, and helmet cells

53 Case 6  55 yo female with metastatic breast cancer reports worsening fatigue for a few weeks  CBC: wbc 6.8 with 1% blasts, hgb 9.1,mcv 102, platelets 86K

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55 Case 7  72 yo female with no significant PMH is brought for a routine physical by her daughter  She has not seen a doctor in 20 years  Daughter notes that mom is increasingly tired and has abdominal distension  On exam, patient is pale and has marked splenomegaly  CBC: wbc 4.2, hgb 7, hct 20, mcv 94, platelets 72K

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