ANEMIA - 2 Dr. Shaikh Mujeeb Ahmed Assistant Professor AlMaarefa College IMS 423 BLOCK

Anemias of Deficient Red Cell Production Deficiency of – Iron – Vitamin B12 – Folic acid Bone marrow failure

Iron-Deficiency Anemia Dietary deficiency Loss of iron through bleeding Increased demands Daily dietary requirement of iron – Male 1 mg – Adolescents 2-3 mg – Female (15 to 45 years) 2-3 mg – Pregnancy 3-4 mg – Infancy 1 mg

Body iron

Factors

Hepcidin - the Iron Regulatory Hormone Hepcidin as the main regulator of systemic iron homeostasis. Hepcidin synthesis is induced by – iron loading and inflammation and suppressed by – erythropoiesis.

Causes of iron deficiency anemia Chronic blood loss – Peptic ulcer – Itestinal polyps – Hemorrhoids – Malignancy Excessive aspirin intake – undetected blood loss Menstruation – 1.5mg iron /day

Characterstics Low hemoglobin Low Hematocrit, Low serum iron and ferritin levels.  RBC count Microcytic and hypochromic Poikilocytosis (irregular shape) Anisocytosis(irregular size)  MCHC and MCV.

General features

Clinical features Smooth tongueAngular Cheilitis

Management Preventaion In infants & children – Iron supplimentation after 4-6 months of age in breastfed infants – Iron fortified formulas & cereals in <1 yr. age – Above 1 yr – iron rich diet + iron fortified vitamins Control chronic blood loss Supplemental iron – ferrous sulphate

Megaloblastic Anemias Impaired DNA synthesis MCV > 100fL Vitamin B12 & Folic acid deficiency Slow progress

Vitamin B 12 –Deficiency Anemia Essential for DNA synthesis and nuclear maturation Found in all foods of animal origin Absorbed by a unique process Daily B 12 requirement Adults μg Pregnancy μg Lactation μg Infants μg Children (1-10 years) μg /kg Children (11-16) μg

Cause pernicious anemia, resulting from an atrophic gastritis immunologically mediated, possibly autoimmune, destruction of the gastric mucosa. Gastrectomy Ileal resection Inflammation or neoplasms in the terminal ileum Malabsorption syndromes

Clinical Features Glossitis Anorexia Diarrhea Demyelination of the dorsal and lateral columns of the spinal cord causes symmetric paresthesias of the feet and fingers, loss of vibratory and position sense, and eventual spastic ataxia.

Atrophic glossitis Megaloblastic anemia

Management Intramuscular injection or high oral dose of vitamin B 12

Folic Acid–Deficiency Anemia Folic acid is also required for DNA synthesis and red cell maturation Increased MCV and normal MCHC Folic acid is readily absorbed from the intestine. It is found in vegetables (particularly the green leafy types),fruits, cereals, and meats.

Dietary requirement for folate (µg/24h) Adult males Adult females Pregnancy Lactation – Children 1-6 years - 50 – 7-12 years – years - 170

Causes of deficiency Pregnancy Malnutrition Alcoholism Total body stores of folic acid amount to 2000 to 5000 µ g, Daily requirement - 50 µ g Malabsorption of folic acid in – Celiac disease – Drugs Phenobarital, phenytoin, primidone Diuretic Methotrexate – anti cancer

Aplastic Anemia Disorder of pluripotential bone marrow stem cells that results in a reduction of all three hematopoietic cell lines—red blood cells, white blood cells, and platelets The cells that remain are of normal size and color Features – weakness, – fatigability, – Pallor – Petechiae (i.e., small, punctate skin hemorrhages) – Ecchymoses (i.e., bruises) often occur on the skin, – and bleeding from the nose, gums, vagina, or gastrointestinal tract due to decreased platelet levels. – increases susceptibility to infection -  neutrophils.

Causes Exposure to – Radiation, – Chemicals – Toxins Complication of infections – Viral hepatitis – Mononucleosis, – other viral illnesses, including acquired immunodeficiency syndrome (AIDS). – In 2/3 rd cases, no known cause as idiopathic aplastic anemia

Management Stem cell replacement by bone marrow or peripheral blood transplantation Immunosuppressive therapy Blood transfusion Corticosteroid therapy

Photomicrographs show hypocellular bone marrow before (a) bone marrow transplantation and regenerating hematopoeisis and normal cellularity after bone marrow transplantation (b). A B

Anemia of Chronic Disease As a complication of – Chronic infections – Inflammation – Cancer – Chronic kidney disease Treatment for the underlying disease Short-term erythropoietin therapy Iron supplementation Blood transfusions

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