A Practical Approach to Anemia Dr.R.V.S.N.Sarma., M.D., M.Sc., (Canada) Consultant Physician & Chest Specialist Visit us at : How to efficiently and accurately work up an anemic patient ?

What is Anemia ? Important to remember Anemia is a clinical sign of disease It is not a single disease by itself Need to look for the underlying cause ! Will we ignore a fever with out investigation ? Its diagnosis is not that simple !! We’ll make it Its very common and imp. in our practice Drug Rx. depends on the cause

Definition of Anemia Decrease in the quantum of circulating red blood cell mass and there by ↓ O 2 carrying capacity Most common hematological disorder by far Almost always a secondary disorder As such, critical for all practitioners to know how to evaluate / determine its cause / treat

Normal Red Cells No nucleus, enzyme packets Biconcave discs – Haem + Gl Center 1/3 pallor Pink cytoplasm (Hb filled) Cell size 7- 8 µ - capill. 2 µ EM pathway, HMP Negative charge – no phago Na less, K more inside days life span

The Factory – Bone Marrow Sternum, pelvis, vertebrae, long bones, skull bones, Tibia (paed) From stem cells (pleuripotent) 75% of marrow for WBC 25% of BM for Red cells Erythrod / Granulocyte Ratio 1:3 E:G ratio increases in Anemia Large white areas are marrow fat

Hemoglobin (Hb)

1 History and Clinical Examination Thorough exam for any bleeding - 2 Hb%, then RCC and Hematocrit Derive MCV, MCH, MCHC 3 Reticulocyte count – Reticulocyte Production Index (RPI) 4 Microcytosis, Macrocytosis, Hypochromia Red cell distribution width (RDW)

5 Peripheral Smear Examination Microcytic hypochromic Anemias 6 Serum Ferritin, TIBC, Bone Marrow Fe IDA, Other Microcytic Anemias 7 Macrocytic Megaloblastic – B12 & Folate Macrocytic Normoblastic – Non MBA 8 Normocytic Normochromic – Chr Disease Hemolytic Anemia – Further work up

First Question The onset of Anemia Acute versus chronic Clues –Hemodynamic stability –Previous CBC –Overt blood loss

Screening Tests – Anemia Clinical Signs and symptoms of Anemia Look for bleeding – all possible sites Look for the causes for anemia Routine Hemoglobin examination Cut off marks for Hb – –US < 13.5 g WHO < 12.5 g –India (ICMR)Less than 12 g%

Clinical Signs to be looked for Skin / mucosal pallor, Skin dryness, palmar creases Bald tongue, Glossitis Mouth ulcers, Rectal exam Jaundice, Purpura Lymph adenopathy Hepato-splenomegaly Breathlessness Tachycardia, CHF Bleeding, Occult Blood

PCV or Hematocrit 57% Plasma 1% Buffy coat – WBC 42% Hct (PCV)

The Three Primary Measures MeasurementNormalRange A.RBC count (RCC) 5 million 4 to 5.7 B.Hemoglobin15 g%12 to 17 C.Hematocrit (PCV)45 38 to 50 A x 3 = B x 3 = C - This is the rule of thumb Check whether this holds good in a given result If not -indicates micro or macrocytosis or hypochro.

The Three Derived Indicies MeasurementNormalRange A.RCC 5 million 4 to 5.7 B.Hemoglobin15 g%12 to 17 C.Hematocrit 45 % 38 to 50 MCV C ÷ A x 10=90 fl MCHB ÷ A x 10=30 pg MCHC(%)B ÷ C x 100=33%

Types of Anemia Hemopoetic A Hemolytic B Hemorrhagic C

Causes of Anemia 1.Decreased production of Red Cells - Hypo proliferative, marrow failure 2.Increased destruction of Red Cells - Hemolysis (decreased survival of RBC) 3.Loss of Red Cells due to bleeding - Acute / chronic blood loss (hemorrhagic) M = P x S ( L)

Hypoproliferative Anemias Failure of cell maturation Nuclear breakdown Cytoplasmic breakdown Megaloblastic Anemia Defective DNA synthesis Folate or B 12 deficiency Haem defect Globin defect Thalassemia Sickle cell A FePhorph IDA, SA

Anemia – Second Test RETICULOCYTE COUNT % Normal Less than 2% ‘RBC to be’ or Apprentice RBC Fragments of nuclear material RNA strands which stain blue

Reticulocyte No definite nucleus Reticulum of RNA Deep blue staining Light blue cytoplasm Cell size about 10 µ

Reticulocytes Leishman’sSupravital

Reticulocyte Production Index For example, the RPI is calculated as follows Reticulocyte count9% Hb content7.5 g% 1.Correction for Anemia = 9 x (7.5 ÷ 15) = 9 x 0.5 = 4.5 % 2.Correction for life span 4.5 ÷ 2 = 2.25 % 3.Thus, the RPI is 2.25

Anemia Hypoproliferative Hemolytic RPI < 2RPI > 2 Hb% < 12, Hct < 38%

Workup – Third Test The next step is ‘What is the size of RBC’ ? MCV indicates the Red cell volume (size) Both the MCH & MCHC tell Hb content of RBC If the RPI is 2 or less We are dealing with either –Hypoproliferative Anemia (lack of raw material) –Maturation defect with less production –Bone marrow suppression (primary/ secondary)

Red Cell Size

Mean Cell Volume (MCV) RBC size is measured indirectly by The Mean Cell Volume (MCV) and RDW Microcytic < 80 fl MCV NormocyticMacrocytic fl> 100 fl < 6.5 µ µ> 9 µ

Anemia Workup - MCV Microcytic MCV NormocyticMacrocytic Iron Deficiency (IDA) Chronic Infections Thalassemias Hemoglobinopathies Sideroblastic Anemia Chronic diseases, CKD Early IDA Hemoglobinopathies Primary marrow disorders Combined deficiencies Increased destruction Megaloblastic anemias Liver disease/alcohol Hemoglobinopathies Metabolic disorders Marrow disorders Increased destruction

Anemia Workup – 4 th Test Red cell Distribution Width – RDW RDW < 13 Mean 90 fl RDW is 13 MCV 90 fl

Red cell Distribution Width - RDW Microcytic Left MCV NormocyticMacrocytic Mean 90Right

Anemia Workup - 5 th Test Peripheral Smear Study Are all RBC of the same size ? Are all RBC of the same normal discoid shape ? How is the colour (Hb content) saturation ? Are all the RBC of same colour/ multi coloured ? Are there any RBC inclusions ? Are there any hemo-parasites in the RBC ? Are leucocytes normal in number and D.C ? Is platelet distribution adequate ?

IDA -CBC

Severe Hypochromia

Microcytic Hypochromic - IDA

Microcytic Hypochromic Anemia Serum Ferritin < 33 pmol / l pmol / l > 270pmol / l Not IDA, Other Mi A TIBC ( ) HIGH N or ↓ BM Fe + - Iron Deficiency Anemia IDA

IDA Summary MicrocyticMCV < 80 fl, RBC < 6 µ RDWWidened and shifted to left HypochromicMCH < 27 pg, MCHC < 30% RPI < 2 Retic. countMay be > 2 % Serum ferritinVery low < 33 (p mols/L) TIBCIncreased > 340 (µg/dL) BM Iron stainIron is Absent Response to Fe Rx.Excellent

IDA- Some Nuggets Look for occult blood loss – 2 days non veg. free Pica and Pagophagia – Ice sucking Absorption of Haem Iron > Fe ++ > Fe +++ Food, Phytates, Ca, Phosphate, antacids ↓ absorption Ascorbic acid ↑ absorption Oral iron Rx. always is the best, ? Carbonyl Fe FeSO 4 is the best. Reserve parenteral Rx. Packed cell transfusion in emergency Continue Fe Rx at least 2 months after normal Hb 1 gram ↑ in Hb every week can be expected Always supplement protein for the Globin component

Microcytic Anemias MCV < 80 flSerum FerritinTIBCBM Perls stain Iron Def. Anemia ↓↓↑↑ 0 Chronic Infection ↓↓ + Thalassemia ↑↑ N+ + Hemoglobinopathy NN + Lead poisoning NN + Sideroblastic ↑↑ N+ +

Ringed Sideroblasts in BM Prussian Blue Stain

Macrocytic Anemias A. Megaloblastic Macrocytic – B 12 and Folate ↓ B. Non Megaloblastic Macrocytic Anemias 1.Liver disease/alcohol 2.Hemoglobinopathies 3.Metabolic disorders, Hypothyroidism 4.Myelodystrophy, BM infiltration 5.Accelerated Erythropoesis - ↑ destruction 6.Drugs (cytotoxics, immuno suppressants, AZT, anticonvulsants)

Anemia - Macrocytic (MCV > 100) Premature gray hair – consider MBA Macrocytic anemias may be asymptomatic until the Hb is as low as 6 grams MCV fl must look for other causes of macrocytosis MCV > 110 fl almost always folate or B 12 deficiency

Macrocytosis of Alcoholism 25-96% of alcoholics MCV elevation usually slight ( fl) Minimal or no anemia Macrocytes round (not oval) Neutrophil hyper segmentation absent Folate stores normal Smoking increases the Red Cell Mass

Megaloblastic Hematopoiesis Marrow failure due to Disrupted DNA synth. & ineffective erythropoesis Giant precursors (Megaloblasts) Nuclear : Cytoplasmic dyssynchrony in marrow Neutrophil hyper segmentation & macro ovalocytes Anemia (and often leukopenia & thrombocytopenia) Almost always due to B 12 or folate deficiency

MBA

Macrocytosis -MBA

Anisocytosis - Macrocytic Anemia

HSN - MBA

Basophilic Stippling - MBA BS occurs in Lead poisoning also

Megalocyte in PS

MBA - BM

MBA - BM

Megaloblast – FA deficiency

Pernicious Anemia - Tongue Bald, smooth, lemon yellowish red tongue

Normocytic Anemias 1.Chronic diseases, CKD 2.Early IDA 3.Hemoglobinopathies 4.Primary marrow disorders 5.Combined deficiencies 6.Increased destruction 7.Anemia of investigations -ICU

Anemia of Chronic Disease Thyroid diseases Malignancy Collagen Vascular Disease –Rheumatoid Arthritis –SLE –Polymyositis –Polyarteritis Nodosa IBD – Ulcerative Colitis – Crohn’s Disease Chronic Infections – HIV, Osteomyelitis – Tuberculosis CKD, Renal Failure

‘Dimorphic’ Anemia Folate & Fe deficiency (pregnancy, alcoholism) B 12 & Fe deficiency (PA with atrophic gastritis) Thalassemia minor & B 12 or folate deficiency Fe deficiency & hemolysis (prosthetic valve) Folate deficiency & hemolysis (Hb SS disease) Peripheral smear exam is critical to assess these RDW is increased very much

Anemia Suspected Thorough Clin, Bleed Hb%, RCC, Hct Decreased RPI, Retic count <2 RPI, Retic count >2 Hemolytic Anemia Coombs DAT, IDAT Hb electrophoresis Osmotic fragility MCV, MCH, MCHC, PSE Microcytic hypochromicMacrocytic hypo/normo MegaloblasticNormoblasticIron Def. Anemia Ferritin, TIBC, BM Fe Thalassemia, Hb pathy Sederoblastic Anaem. Chr. Infection, Lead Folate defici. B12 def., PA Ca, Leukemia, Ulcer Identify the cause ALD, CLD, Drug Chr. Renal dis. Hypothyroid BM infiltration Acid hemolysis Cold agglutinins Coagulopathy, DIC Algorithm for Diagnosis of Anemia

LET US LOOK AT SOME REPORTS OF PATIENTS In order to make a differential diagnosis

Test DoneValueRemarks RBC3.96 million/c mmDecreased Hb%9.7 g%Decreased Hematocrit23.9 %Decreasd MCV60.4 flMicrocytosis MCH24.6 pg/lHypochromia MCHC40.5 %Not relevant RC and RPI4 %, 1.29Not Hemolytic Peripheral SmearMicrocytic hypochromicDD of Microcytic Serum Ferritin46 pmol/lBoarderline TIBC390 µg/dlElevated BM Iron stainAbsentClinches IDA

Test DoneValueRemarks RBC3.86 million/c mmDecreased Hb%10.4 g%Decreased Hematocrit26.9 %Decreasd MCV69.7 flMicrocytosis MCH25.8 pg/lHypochromia MCHC38.66 %Not relevant RC and RPI5 %, 1.73Not Hemolytic Peripheral SmearMicrocytic hypochromicDD of Microcytic Serum Ferritin320 pmol/lHigh TIBC300 µg/dlNormal BM Iron stainRinged sideroblastsClinches SBA

Test DoneValueRemarks RBC2.69 million/c mmDecreased Hb%10.6 g%Decreased Hematocrit31.6 %Decreasd MCV117.5 flMacrocytosis (Severe) MCH39.4 pg/lHyperchromia MCHC33.5 %Normal RC and RPI5 %, 1.76Not Hemolytic Peripheral SmearMacrocytic HyperchromicDD of Macrocytic Serum Ferritin240 pmol/lNormal (Not required) TIBC338 µg/dlNormal (Not required) BM ExamMegaloblastic BMClinches MBA (F, B12)

Test DoneValueRemarks RBC3.09 million/c mmDecreased Hb%10.6 g%Decreased Hematocrit31.6 %Decreasd MCV102.3 flMacrocytosis (Moderate) MCH34.3 pg/lHyperchromia MCHC33.5 %Normal RC and RPI3 %, 1.06Not Hemolytic Peripheral SmearMacrocytic HyperchromicDD of Macrocytic Serum Ferritin240 pmol/lNormal (Not required) TIBC338 µg/dlNormal (Not required) BM ExamNormoblastic BMClinches MCA (Chr D)

Test DoneValueRemarks RBC3.10 million/c mmDecreased Hb%9.3 g%Decreased Hematocrit27.9 %Decreasd MCV90 flNormocytosis MCH30.0 pg/lNormochromia MCHC33.3 %Normal RC and RPI1.5 %, 0.47Not Hemolytic Peripheral SmearNormocytic NormochromicDD of Normocytic A Serum Ferritin240 pmol/lNormal (Not required) TIBC338 µg/dlNormal (Not required) BM ExamNormoblastic BMCLD, ALD, CKD, Drugs

Test DoneValueRemarks RBC3.81 million/c mmDecreased Hb%11.1 g%Decreased Hematocrit33.3 %Decreasd MCV87.4 flNormocytosis MCH29.2 pg/lNormochromia MCHC33.33 %Normal RC and RPI10 %, 3.70Hemolytic Peripheral SmearPiokilo, Aniso, target cellsDD of Hemolytic Anemia Serum Ferritin240 pmol/lNormal (Not required) TIBC338 µg/dlNormal (Not required) BM ExamE : G Ratio is 2 : 1Hypercellular marrow

Anemia - Summary If Hb% is low – Do not start on Iron straight away Ask for RCC, Hematocrit – Derive MCV, MCH, MCHC Order for Reticulocyte count – Is RPI 2% Thoroughly look for blood loss – acute / chronic / occult Is it hypo-proliferative or hemolytic or hemorrhagic Anemia If hypo proliferative – Microcytic or Macrocytic? (MCV, RDW) If microcytic – IDA or others – Sr Ferritin TIBC, BM Iron If macrocytic – Megaloblastic (B12, FA) or Normoblastic BM If normocytic – Anemia of chr. Disease – Liver, CKD, Ca Peripheral smear study for RBC size, shape, colouration etc. If retic. count is ↑- HA work up; Hb EP, spl. tests

RBC Size – Anisocytosis Different sizes of RBC

Poikilocytosis Different Shapes of RBC

Polychromasia - Spherocytosis

Target Cells 1.Liver Disease 2.Thalassemia 3.Hb D Disease 4.Post splenectomy

Tear Drop Cells 1.Myelofibosis 2.Infiltration of BM 3.Tumours of BM 4.Thalassemia

Hair on end - Thalassemia Major

Drepanocytes - SS

Sickle Cell Anemia

Autosplenectomy - SS Normal spleen is 8 to 12 cm

Hemolytic Anemia Anemia of increased RBC destruction – Normochromic, normocytic anemia – Shortened RBC survival – Reticulocytosis – due to ↑ RBC destruction Will not be symptomatic until the RBC life span is reduced to 20 days – BM compensates 6 times

Tests Used to Diagnose Hemolysis 1.Reticulocyte count 2.Combined with serial Hb 3.Hemoglobin electrophotesis 4.Serum LDH 5.Serum bilirubin 6.Haptoglobin 7.Urine hemosiderin 8.Hemoglobinuria

Findings in Hemolytic Anemia Reticulocyte count and RPIIncreased Serum Unconjugated BilirubinIncreased Serum LDH 1: LDH 2Increased Serum HaptoglobinDecreased Urine HemoglobinPresent Urine HemosiderinPresent Urine UrobilinogenIncreased Cr 51 labeled RBC life spanDecreased

Tests to define the cause of hemolysis 1.Hemoglobin electrophoresis 2.Hemoglobin A 2 (βeta-Thalassemia trait) 3.RBC enzymes (G6PD, PK, etc) 4.Direct & indirect antiglobulin tests (immune) 5.Cold agglutinins 6.Osmotic fragility (spherocytosis) 7.Acid hemolysis test (PNH) 8.Clotting profile (DIC)

MAHA Micro Angiopathic Hemolytic Anemia

MAHA Micro Angiopathic Hemolytic Anemia

Hyperactive BM – Skull Hemolytic Anemia

Spherocytosis

Spherocytosis Hereditary Spherocytosis

Spherocytosis

Elliptocytes Hereditary Elliptocytosis, B 12 or Folate↓

Stomatocytes S lit like central pallor in RBC 1.Liver Disease 2.Acute Alcoholism 3.H Stomatocyosis 4.Malignancies

Echinocytes Evenly distributed spicules > 10 1.Uremia 2.Peptic ulcer 3.Gastric Ca 4.PK-D Called Burr Cells

Acanthocytes 5-8 spikes of varying length, irregular intervals Called Spur Cells, Occur in A H A

Shistocytes 1.MAHA 2.Prosthetic valves 3.Uremia 4.Malignant HT Fragmented, Helmet or triangle shaped RBC

Leukoplakia - Aplastic Anemia 1.Chloramphenicol 2.Neomercazole 3.Sulfonamides 4.Analgin 5.Phenytoin 6.Butazolidin group 7.Anti Ca drugs

Normal BM High Power E : G = 1 : 3

Shift in E : G Ratio E : G = 2 : 1

BM - Aplastic Anemia

Myelofibrosis

Post transfusion - CBC

Howell-Jolly Bodies Absence of Splenic function; Nuclear chromatin in RBC

Pelger-Huet Anomaly Inherited condition PMN - Spectacles Heterozygous Homozygous fatal Neutrophil Bands ↑ Normal WCC No e/o infection

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