1. Anemia Iron Deficiency Megaloblastic
By Dr. Zahoor

2. Anemia
What is Anemia?
Anemia is present when there is decrease in hemoglobin (Hb) in the blood below the reference level for the age and sex

3. Normal Values for Peripheral Blood

4. Classification of Anemia
Classification of Anemia based on
MCV (Mean Cell Volume). There are 3 major
types:
Microcytic Hypochromic Anemia with low MCV
Normocytic Normochromic anemia with normal MCV
Macrocytic anemia with high MCV

5. CLINICAL FEATURES Symptoms (these are non specific)
Fatigue, headache, faintness
Breathlessness
Palpitation
Angina
Intermittent claudication
Signs
Pallor
Tachycardia
Systolic flow murmer
Cardiac Failure

6. Anemia Specific signs are seen in different type of Anemia
Koilonychia – spoon shaped nails seen in long standing iron deficiency anemia
Jaundice – found in hemolytic anemia
Leg ulcers – seen in sickle cell disease
Bone deformities – seen in thalassaemia major

7. INVESTIGATION
When hemoglobin is low, then always evaluate with red cell indices (MCV, MCH, MCHC)
WBC count
Platelet count
Reticulocyte count (it indicates bone marrow activity)
Blood film to see red cell morphology e.g. microcytic, macrocytic

8. INVESTIGATION Bone marrow – To see the cellularity of marrow
– Type of erythropoiesis e.g. normoblastic or megloblastic
– Any infiltration e.g. presence of cancer cells
– Iron stores
– Special test for further diagnosis e.g. immunological, cytogenetic, microbiological culture

9. Classification of Anemia Based On MCV (Mean Corpuscular Volume)
Microcytic Anemia
Red cell appearance – small cell (microcyte)
Indices – low MCV < 80fL
Diagnosis – Iron deficiency
– Thalassaemia
– Anemia of Chronic Disease
– Sideroblastic anemia

10. Classification of Anemia Based On MCV (Mean Corpuscular Volume)
Macrocytic Anemia
Red cell appearance – large cells (macrocyte)
Indices – high MCV > 96 fL
1. Appearance of bone marrow – megloblastic
Diagnosis – vitamin B12 or Folate deficiency
2. If appearance of bone marrow – normoblastic but macrocytosis in the peripheral blood
Diagnosis – Alcohol
– Increased reticulocyte e.g. haemolysis
– Liver disease
– Hypothyroidism
– Drug therapy e.g. Azathioprine

11. Classification of Anemia Based On MCV (Mean Corpuscular Volume)
Normal size RBC
Red cell appearance – normal cells
Indices – normal MCV
Diagnosis – Acute blood loss
– Haemolytic anemia
– Anemia of chronic disease
– Chronic kidney disease
– Auto immune rheumatic disease
– Endocrine disease

12. We will discuss Microcytic Hypochromic (Iron Deficiency) Anemia

13. MICROCYTIC HYPOCHROMIC ANEMIA IRON DEFICIENCY
Iron Deficiency is the most common cause of anemia in the World, affecting 30% of World’s population
Iron is absorbed in upper small intestine in Fe2+ form
Why microcytic (iron deficiency anemia) is common?
Because of limited ability to absorb iron, and loss of iron due to hemorrhage

14. IRON We will discuss important points regarding Iron: Dietary intake
The average daily diet contains 15-20mg of iron, normally only 10% of this is absorbed
Iron is absorbed in proximal intestine, specially duodenum
Iron is present in ferric form in the diet, it is reduced to ferrous form by brush border (small intestine)

15. IRON
Iron Transport
Iron is transported in the plasma bound to transferrin (beta globulin that is synthesized in the liver)
Most of the iron bound to transferrin comes from macrophages in the Recticulo -Endothelial system and not from Iron absorbed by the intestine

16. IRON
Iron Stores
About two third of total body iron is in the circulation as hemoglobin
Iron is stored in recticuloendothelial cells, Hepatocyte and skeletal muscle cells
About two third of iron is stored as ferritin and one third as haemosiderin
Ferritin is water soluble and easily mobilized
Haemosiderin is insoluble, found in macrophages in the bone marrow, liver and spleen

17. IRON Requirements Daily requirement is 1mg
Each day 0.5-1mg of iron is lost in the faeces, urine and sweat
Menstruating women lose 30-40ml of blood per month, an average of mg of iron per day
Blood loss through menstruation in excess of 100ml will usually result in iron deficiency
Demand of iron also increases during growth and pregnancy

18. IRON DEFICIENCY ANEMIA
Iron deficiency anemia occurs, when there is less iron available for Hb synthesis
The causes are
- Blood loss
- Increased demand such as growth and
pregnancy
- Decreased absorption e.g. post gastrectomy
- Poor intake – Diet which contains vegetable
predominantly

19. IRON DEFICIENCY ANEMIA
Clinical Features
Symptoms
- Fatigue, headache, faintness
- Palpitation
- Breathlessness
- Angina
- Intermittent claudication

20. IRON DEFICIENCY ANEMIA
Clinical Features
In long standing iron deficiency anemia, well known clinical features are
- Brittle nails
- Spoon shaped nails (Koilonychia)
- Atrophy of papillae of the tongue
- Angular stomatitis
- Brittle hair
IMPORTANT
– Plummer-Vinson or Paterson-Brown-Kelly Syndrome
It is presence of Iron deficiency anemia, Dysphagia and glossitis

21. IRON DEFICIENCY ANEMIA
Investigations
Blood film shows RBC – microcytic MCV < 80fL and hypochromic MCH < 27 pg
There are poikilocytosis (variation in shape) and anisocytosis (variation in size). Target cells are seen
Microcytic hypochromic cells, Poikilocytosis and Anisocytosis is seen

22. IRON DEFICIENCY ANEMIA
Investigations (cont)
Serum iron and iron binding capacity
Serum iron is low and total iron binding capacity (TIBC) is increased
Serum ferritin
Serum ferritin is low (serum ferritin level tells us about the amount of stored iron)
Serum soluble transferrin receptors
Number of transferrin receptors increases in iron deficiency anemia
It is done by immunoassay

23. DIFFERENTIAL DIAGNOSIS
Differential Diagnosis of Microcytic
Hypochromic Anemia
Iron Deficiency Anemia – iron stores (ferritin) is low
Thalassaemia – iron stores are normal
Sideroblastic Anemia – iron stores are raised
Anemia of Chronic Disease – iron stores are normal or raised

24. Microcytic Anemia: the differential diagnosis

25. TREATMENT
Find and treat the underlying cause e.g. diet, blood loss due to peptic ulcer, hemorrhoids
Oral iron
– ferrous sulphate 200mg three times daily (it provides 180mg ferrous iron), it is best absorbed when patient is fasting
– Oral iron is given for 6 months to correct hemoglobin level and replenish the iron stores
Parenteral iron
– Given by slow IV infusion of low molecular weight iron dextrin (test dose is required)
– It is given when patient is intolerant to oral preparation e.g. severe malabsorption

26. ANEMIA OF CHRONIC DISEASE
In hospital patients, common type of Anemia is the anemia of chronic disease, occurs in patient with TB, inflammatory bowel disease, rheumatoid arthritis, SLE, Malignant disease
Cause
- Decrease release of iron from bone marrow to developing erthythroblast
- Decreased response to erythropoietin
- Decrease RBC survival
Investigation
- Decreased serum iron, decreased TIBC
- Serum ferritin is normal or raised
- Patient do not respond to iron therapy and treatment is for
underlying cause

27. SIDEROBLASTIC ANEMIA It maybe inherited or acquired
It may be transmitted as X-linked disease by female
It is characterized by microcytic hypochromic cells in peripheral blood and excess iron and ring sideroblast in bone marrow
Presence of ring sideroblast in bone marrow is diagnostic feature of Sideroblastic anemia, ring is due to accumulation of iron in the mitochondria of erythroblast. They can be seen with Perl's stain
Causes Myeloid leukaemia, lead toxicity, alcohol abuse

28. Bone marrow showing sideroblast stained with Perl’s Prussian blue
Sideroblastic Anemia
Bone marrow showing sideroblast stained with Perl’s Prussian blue

29. NORMOCYTIC ANEMIA Normocytic Normochromic anemia is seen in
Anemia of chronic disease
Endocrine disorders e.g. Hypopituitarism, hypothyroidism, Hypoadrenalism
Some hematological disorders e.g. Aplastic anemia and some hemolytic anemia
In acute blood loss

30. MACROCYTIC ANEMIA
They are divided into two types based on bone marrow findings:
Megaloblastic
Non Megaloblastic
Megaloblastic Anemia:
It is characterized by erythroblast, present in the bone marrow (Erythroblast are premature RBC, they occur due to defective DNA synthesis)
Megaloblast are large cell and have large immature nuclei

31. Megaloblasts in Bone Marrow:

32. MACROCYTIC ANEMIA Megaloblastic Anemia:
What is the cause of megaloblastic anemia?
Vitamin B12 deficiency or abnormal Vit. B12 metabolism
Folic acid deficiency or abnormal folate metabolism
Drugs interfering with DNA synthesis eg. Hydroxyurea, azathioprine, Zidovudin (AZT),
Myelodysplasia

33. MACROCYTIC ANEMIA Megaloblastic Anemia: Hematological findings:
Anemia is present MCV > 96fl
Peripheral blood film shows oval macrocytes with hypersegmented polymorph with six or more lobes in nucleus
If severe there may be leukopenia and thrombocytopenia

34. Macrocytes and a hyper segmented neutrophil (arrowed) on a peripheral blood film

35. MACROCYTIC ANEMIA Megaloblastic Anemia:
Biochemical basis of megaloblastic anemia:
Biochemical problem is Vit. B12 & Folate deficiency causing block in DNA synthesis
We will talk about Vit. B12 & Folic Acid
Vit. B12:
Daily requirement 2.4 microgram/day
It is found in meat, fish, eggs and milk
It is not found in plants
It is not usually destroyed by cooking
Average daily diet contains 5 – 30 mcg of which 2 – 3 mcg are absorbed
Average adult stores are 2 – 3 mg mainly in the liver therefore it may take 2 years after absorption failure before vit B12 deficiency develops

36. MACROCYTIC ANEMIA Vit. B12: Vit B12 Deficiency:
Absorption and transport:
Vit B12 is bound to Intrinsic factor in the stomach (Intrinsic Factor is secreted by Parietal cells of stomach)
Combination of Vit B12 and Intrinsic factor, it is carried to the ilium, Vit B12 enters the ilial cells and intrinsic factor remains in lumen and is excreted.
After absorption of Vit B12 is transported to bone marrow by glycoprotein Transcobalamine II (TC II)
Vit B12 Deficiency:
Causes :
Low intake – vegetarian diet
Impaired absorption
Stomach –
pernicious anemia, Gastrectomy
Small bowel –
ileal disease or resection, bacterial overgrowth, tropical sprue, fish- tapeworm

37. MACROCYTIC ANEMIA Treatment –Vit B12 deficiency:
Hydroxocobalamine 1000mcg can be given IM to total of 5-6 mg over the course of 3 weeks then 1000mcg every 3 months for rest of life
Alternate oral vit B12, 2 mg per day, as 1 -2% of oral dose is absorbed by diffusion and does not require Intrinsic factor

38. MACROCYTIC ANEMIA Pernicious Anemia (PA):
It is an autoimmune disorder in which there is atrophic gastritis, with loss of parietal cells in the gastric mucosa therefore failure of Intrinsic factor production and vit B12 absorption
Pathogenesis of PA:
Commonly in elderly, age over 60 years,
blood group A
Female > Male
Association with other autoimmune disease e.g thyroid disease, Addison's, Vitiligo
Parietal cell antibodies are present in 90 % and intrinsic factor antibody found in 50% of patients

39. MACROCYTIC ANEMIA Folic acid:
Folic acid monoglutamate is not itself present in nature but occurs as polyglutamate
Folate are present in the food as polyglutamate
Dietary intake:
Minimum daily requirement is 100 mcg
Folate is found in green vegetables, e.g spinach, Brocolli and also in liver and kidney
Cooking causes loss of 60-90% of folate

40. MACROCYTIC ANEMIA Folic acid: Causes of folate deficiency:
Physiological – pregnancy, lactation
Poor intake – poor social condition, starvation, ↑alcohol consumption,
GIT diseases eg. Partial gastrectomy, coeliac disease. Crohn's disease
Antifolate drugs e.g.. Phenytoin (Anticonvulsant), Methotrexate, trimethoprin
Pathological – hemolysis, malignant disease, hemodialysis or peritoneal dialysis
Small bowel diseases causing malabsorption

41. MACROCYTIC ANEMIA Folic acid:
Folate reserves are low about 10 mg therefore diet deficient in folate causes folate deficiency anemia in about 4 months
Folic acid supplementation in mother during first 12 weeks of pregnancy reduces the incidence of neural tube defect
Clinical features:
Patient may be asymptomatic or present with anemia of underlying cause
Glossitis can occur
In folic acid deficiency peripheral neuropathy does not occur (occurs in B12 deficiency)

42. MACROCYTIC ANEMIA Folic acid: Investigations:
Serum and red cell folate are assessed by radioisotope dilution or immunological methods
RBC folate is better measure
Normal serum folate is 4-18 mcg/liter (5-63nmol/lit)
Normal RBC folate mcg/liter

43. MACROCYTIC ANEMIA Treatment -Folic acid deficiency:
Folate 5 mg per day for 4 months to replace body stores
Treat underlying cause
Prophylactic folic acid 400mcg per day is given to all women planning a pregnancy and throughout the pregnancy

44. MACROCYTIC ANEMIA Macrocytosis without Megaloblastic changes:
Raised MCV with macrocytosis but normobalstic bone marrow
Physiological causes – pregnancy, new born,
Pathological causes –
Alcohol excess
Liver disease
Reticulocytosis
Hypothyroidism
Sideroblastic anemia
Drugs – Azathioprine,
Important: In all these conditions normal level of Vit B12 and folic acid are found – then why there is macrocytosis?
May be due to increase lipid deposition in RBC membrane

45. THANK YOU