Presentation on theme: "Differential diagnosis of Anemia:"— Presentation transcript:
1 Differential diagnosis of Anemia: 1. A complete blood count, CBCRBC countHematocrit (Hct) or packed cell volumeHemoglobin determinationRBC indices calculationReticulocyte count2. Blood smear examination to evaluate:Poikilocytosis.Leukocytes or Platelets abnormalities.
2 3. A bone marrow smear and biopsy to observe: Maturation of RBC and WBC seriesPresence of megakaryocytesRatio of myeloid to erythroid series.Presence or absence of granulomas or tumor cellsHemoglobin electrophoresisAntiglobulin test:(Coomb’s test).Osmotic fragility test
3 Red blood cell indices RBCs Indices: They are part of the complete blood count (CBC) test that provide information about the hemoglobin content and size of red blood. They are used in diagnosis of anemia and it’s causes.The indices include:Mean corpuscular volume (MCV): is the average size of a red blood cell and is calculated by dividing the hematocrit (Hct) by the red blood cell count.MCV = Hct / RBCNormal range: (78-98) fL (femto- is 10-15)
4 Red blood cell indicesMean corpuscular hemoglobin (MCH): is the average amount of hemoglobin (Hb) per red blood cell and is calculated by dividing the hemoglobin by the red blood cell count.MCH = Hb / RBCNormal range: pg/cell (pico- is 10-12)Mean corpuscular hemoglobin concentration (MCHC): is the average concentration of hemoglobin per Packed red blood cells and is calculated by dividing the hemoglobin by the hematocrit.MCHC = Hb / HctNormal range: g/dL (deci is 10-1)
5 Morphological Classification of Anemia Based on RBC morphologyAnemia is divided into three groups mainly on the basis of the MCV, and MCH (RBC indices):Normocytic Normochromic anemia:(normal red cell indices)Blood loss anemia (Acute bleeding)Hemolytic anemia (except thalassaemia)Aplastic anemiaPure red cell aplasia.
6 3. Macrocytic Normochromic Microcytic hypochromic anemia:( low red cell indices)Iron deficiency anemiaSideroblastic anemiaThalassemiaChronic diseases3. Macrocytic Normochromic( high MCV and MCH, normal MCHC)Megaloblastic anemia (Vit. B12 deficiency & Folic acid deficiency).Liver diseasePost splenectomy
10 A- Iron Deficiency Anemia (IDA) : Is a condition in which the total body iron content is decreased below a normal levelThis results in a reduced red blood cell and hemoglobin productionMore than half of all anemia are due to iron deficiency.Clinical Picture:Symptoms: fatigue, dizziness, headacheSigns eg.PallorTongue atrophy/ glossitis - raw and soreAngular cheilosis (Stomatitis)Spoon‑shaped nails (koilonychia), brittle nails and hair.
12 Lab. Investigations of IDA: a) CBC:Lab findingsLow RBC, Hb, HctLow MCV, MCH, MCHCNormal WBC and PLTRBC morphologyHypochromiaMicrocytosisAnisocytosisPoikilocytosisPencil cells.Target cells
13 b) Bone marrow iron (Tissue iron): - Erythroid hyperplasia. Tissue biopsy of bone marrowPrussian blue stainType of iron is hemosiderinAbsence of iron stores in BM.c) Plasma Iron parameters:Low serum iron,Low serum ferritinIron deficiency
14 B- Thalassemia:Inherited decrease in alpha or beta globin chain synthesis associated with Hb A quantitative defectAll have microcytic/hypochromic RBCs and target cellsGenetic mutations classified by:↓ beta chains = beta thalassemia…Greek/Italian↓ alpha chains = alpha thalassemia…Asian
16 Classification of Thalassemia: These genetic disorders can be classified according to the severity.Severity ranges from lethal, to severe transfusion-dependency, to moderate, to no clinical abnormalities.Severity depends on the number and type of abnormal globin genes inherited.Clinically, Thalassemia are divided into:Major severe anemia; no α (or β) chains are produced, so cannot make normal hemoglobin.Intermedia moderate anemia with splenomegaly & iron overload.Minor/trait mild anemia; slight decrease in normal hemoglobin types made.
17 Beta Thalassemia Major (Homozygous) Both beta genes are abnormal:(Chr. 11)Marked decrease/absence of beta chains leads to Hb F production ( α2γ2) …… Hb A will not be produced.Rigid RBCs with Heinz bodies destroyed in bone marrow and blood (ineffective erythropoiesis).
18 Beta Thalassemia Minor (Heterozygous) One abnormal beta gene allele:(Both Hb A and Hb F will be produced).Slight decreased rate of beta chain productionBlood picture can look similar to iron deficiency
19 Alpha Thal Major (Homozygous) Deletion of all 4 alpha genes (Ch. 16) results in complete absence of alpha chain production.No normal hemoglobin;Bart’s Hb formation (four γ chains Hb); Barts Hydrops Fetalis.Die of hypoxia…. Bart’s Hb has a High affinity for oxygen.
20 Alpha Thalassemia Intermedia = Hb H Disease: Three alpha genes deletedModerate decrease in alpha chains leads to beta chain excess… unstable Hb H (Excess 4 β ).Moderate anemia. – Formation of Bart’s Hb (4 γ).Hepatosplenomegaly and H. bodies.Target cells
21 Alpha Thalassaemia Minor (Heterozygous) One or two alpha genes deleted (group)Slight decrease in alpha chain productionMild or no anemia, few target cellsEssentially normal electrophoresis; may undiagnosed
22 Lab. Investigations of Thalassemia: Laboratory findings:Hb ↓, MCV ↓, MCH ↓, MCHC ↓RBCs :Hypochromic, Microcytic RBCs. Target cells, nucleated red cellsAnisocytosisPoikilocytosis Basophilic stipplingRBC inclusionsPlatelets: NormalWBCs: NormalPlasma: - ↑ iron- Normal or ↑ ferritin.
23 2. Macrocytic Normocytic Anemia: A. Megaloblastic anemia:Vitamin B12 deficiencyFolate deficiencyAbnormal metabolism of folate and Vit. B12B. Non- Megaloblastic anemia:Liver diseaseAlcoholismNeonatal macrocytosisStress erythropoiesis.
24 Lab Findings of Megaloblastic Anemia Mild to severe anemia,Increased MCV & MCH, normal MCHCLow RBC, Hb, WBC and PLT counts (fragile cells) due to ineffective hematopoiesis.Macrocytic ovalocytes and teardrops;Neutrophils show ↑ nuclear lobulations (hypersegmentations > 6 nuclei)Giant platelets & megakaryocytes fragments
26 3. Normocytic Normochromic Anemia Is a condition in which the size & Hb content of RBCs is normal but the number of RBCs is decreased.It includes:Aplastic anemia due to BM failureBlood loss anemiaHemolytic anemiaAplastic AnemiaCondition of blood pancytopenia caused by bone marrow failure…decreased production of all cell lines and replacement of marrow with fat.Due to damaged stem cells, damaged bone marrow environment or suppression.
27 Lab diagnosis of Aplastic Anemia: 1- Peripheral blood:Normochromic –Normocytic RBCs (normal MCV & MCH)PancytopeniaNo abnormal cells2- Bone marrow:Hypocellular BM with increased:Fat spaces.Lymph cellsPlasma cellsMacrophagesMast cells
28 B. Hemolytic anemia (H.A): Result from an increase in the rate of pre mature red cell destruction.It leads toErythropoietic hyperplasiaBM produces red cells 6 to 8 times the normal rate.Marked reticulocytosis.Two main mechanisms for RBC destruction in HAIntravascular hemolysis: in the circulationExtravascular hemolysis: in RE system (Reticuloendothelial system).
29 Lab features of extravascular haemolysis: Increased RBC break downSerum bilirubin increaseStool stercobilinogen increaseUrine urobilinogen increaseLab features of intravascular haemolysis:Hemoglobinemia and hemoglobinuriaHemosiderinuriaReduced/absentSerum haptoglobin.
36 Hb Electrophoresis:Pattern of hemoglobin electrophoresis from several different individuals. Lanes 1 and 5 are hemoglobin standards. Lane 2 is a normal adult. Lane 3 is a normal neonate. Lane 4 is a homozygous HbS individual. Lanes 6 and 8 are heterozygous sickle individuals. Lane 7 is a SC disease individual.
37 2. Acquired hemolytic anemia: A variety of acquired conditions result in: shortened survival of previously normal red cells.Result of extrinsic causes:1-Immune Hemolytic anemia IHA; Warm IHA, Cold IHA(detected by Coomb’s test; Antiglobulin test).2-Drug-induced HA.3-Infection associated: Malaria.