1. Anemias

2. Actuality of theme: Anemia is very often met in 20% women of the developed countries and in 50% women of the non- developed countries; More than 50% patients with chronic diseases and tumors; Considerably worsens quality of life and capacity.

3. Definition of anemia Anemia is the decreasing of hemoglobin and red blood cells level in the unit of blood volume Reduction in one or more of the major red blood cell (RBC) measurements: Hemoglobin Hematocrit RBC count From data of WHO: a hematocrit less than 40 in men and 37 in women, or hemoglobin less than 130 g/l in men and less than 120 g/l in women.

4. Signs and symptoms  Weakness and fatigue are the most common symptoms of anemia.  Decreased energy  Shortness of breath on exertion (dyspnea)  Palpitations (feeling of the heart racing or beating irregularly)  Cold hands or feet  Headache  Lightheadedness or dizziness  Dizziness and passing out, especially upon standing  Ringing in the ears (tinnitus)  Irritability and other mood disturbances  Mental confusion  Lethargy

5. Signs and symptoms  Chest pain (angina or heart attack)  Intermittent claudication  Loss of sexual drive  Abdominal pain  Weight loss

6. Physical Examination  The skin and mucous membranes are pale (however, healthy-looking skin color does not rule out anemia if a patient has risk factors and other symptoms of anemia)  Rapid heartbeat - tachycardia,  Heart murmur - systolic flow murmur,  heart failure  tachypnea  Low blood pressure (hypotension)

7. Reticulocyte count Retic count = % immature RBC Normal 0.5-1.5% (for non-anemic) <1% Inadequate production >=1% Increased production (? adequacy)

8. Classification according to mechanism Blood loss acute and chronic Excessive destruction of rbcs Impaired production of rbcs

9. Decreased Production NUTRITIONAL DEFICIENCY Iron B12 Folate

11. - Usually hypochromic as well  Iron-deficiency anemia  Anemia of chronic diseases(rare)  Sideroblastosis  Hereditary anemia (thalassemia)  Lead poisoning  Deficit of copper, poisoning by zinc Microcytic anemia (MCV less than 80)

12. Microcytic Anemia MCV <80 Reduced iron availability Reduced heme synthesis Reduced globin production

13. Microcytic Anemia REDUCED HEME SYNTHESIS Lead poisoning Acquired or congenital sideroblastic anemia Characteristic smear finding: Basophylic stippling

14. Microcytic Anemia REDUCED GLOBIN PRODUCTION Thalassemias Smear Characteristics ◦Hypochromia ◦Microcytosis ◦Target Cells ◦Tear Drops

15. Thalassemia Normal to inc. RPI Normal RDW Target cells Mentzer index <13 =MCV/RBC Youden’s index - using RDW & Mentzer index - sensitivity = 82% - specificity = 80% confirm w/ Hgb electrophoresis

19. koilonychia

21. Lab tests of iron deficiency of increased severity NORMAL Fe deficiency Without anemia Fe deficiency With mild anemia Fe deficiency With severe anemia Serum Iron 60-15060-150<60<40 Iron Binding Capacity 300-360300-390350-400>410 Saturation20-5030<15<10 HemoglobinNormalNormal9-126-7 Serum Ferritin 40-200<20<100-10

22. Makrocytic anemia (MCV more than 100 fl) - Megaloblastic anemia (vitamin В12 or folic acid deficiency ) - Toxic effect of chemotherapeutic agents (methotrexate) or other medications (zidovudine (AZT), phenytoin) - Pathology of bone marrow - Chronic abuse by alcohol (toxic effect) - Liver disease

23. Megaloblastic Anemia Folate Inadequate intake Synthesized by plants and micro-organism Green leafy vege’s Fruits Absorbed in jejunum B12 Inadequate absorption Synthesized by bacteria Meat, fish, dairy (strict vegans) Absorbed as B12-IF complex in ileum (gastrectomy) Ca++ and pH dependant (PPI)

24. Megaloblastic Anemia Smear Macro-ovalocytic Polychromasia Hypersegmented neutrophil

25. Normocytic Anemia (MCV 80-100 fl) Type of anemia Blood filmFerritinFeTIBCMarrow Fe stores Chronic disease* Normochromic, normocytic Nl or ↑↓ ↓Nl or ↑, clumped Early Fe deficien cy Mild anisocytosis hypochromia Nl or ↓↓↑absent *including anemia due to renal disease and AIDS

26. Aplastic Anemia Fanconi anemia – congenital Fanconi anemia Direct stem cell destruction – external radiation Direct stem cell destruction Drugs - chloramphenicol, gold, sulfonamides, felbamate Drugs Other Toxins - Solvents, degreasing agents, pesticides Viral infection - parvovirus B19, HIV, other Viral infection Idiopathic

27. Hemolytic Anemia Coombs’ (DAT) Positive Immune Hemolysis Drug related Hemolysis Transfusion, Infection, Cancer Negative Hemoglobinopathy, G6PD, PK, Spherocytosis, Eliptocytosis, PNH, TTP, DIC

29. Hemolytic Anemia Coombs’ (DAT) Positive Immune Hemolysis Drug related Hemolysis Transfusion, Infection, Cancer Negative Hemoglobinopathy, G6PD, PK, Spherocytosis, Eliptocytosis, PNH, TTP, DIC

30. TTP-HUS / DIC

31. Spherocytes. One arrow points to a spherocyte; the other, to a normal RBC with a central pallor.

32. Schistocytes (thrombotic thrombocytopenic purpura).

33. Peripheral blood smear with sickled cells

34. Clinical Presentation: Signs and Symptoms General anemiapallor, fatigue, SOB on exertion Acute chest syndromecough, dyspnea, chest pain, fever Infectionmalaise, cough and chest pain, diarrhea and/or vomiting Painful crisespersistent pain in skeleton, chest, and/or abdomen Hand-foot syndromeswollen and painful hands and feet (by 2 years of age: 50% of Jamaican and 25% of American children with sickle cell anemia have experienced at least one episode of dactylitis) Stroke(affects 10% of patients; 6-17% of children and young adults), sudden neurologic deficits including motor, difficulty with language, writing, and/or reading; seizures; sensory deficits; altered consciousness Priapismpenile erection not related to arousal Delayed growth and puberty Patient more slender or small in size. JaundiceYellowing of skin and eyes OtherSome people remain asymptomatic into late childhood and are only incidentally diagnosed http://www.ornl.gov/sci/techresources/Human_Genome/posters/chromosome/sca.shtml

35. A prolonged environment of low oxygen leads to aggregation and polymerization of hemoglobins into long chains of rod-like fibers, causing the RBC to form the shape of a crescent or sickle. http://www.humanillnesses.com/original/images/hdc_0001_0003_0_img0235.jpg Donut-shaped Soft and malleable Able to pass through small spaces Lifespan ~120 days Sickle-shaped Hard and rod-like Gets stuck in narrow spaces Lifespan ~20 days

36. Sickling of red blood cells leads to: 1. Vaso-occlusive complications 2. Severe anemia 3. Chronic hyperbilirubine mia

37. Vaso-occlusive complications Occur in areas with: Prolonged, low oxygen tension Decreased pH Inflammation Low blood flow Source: Robbins

38. Severe Anemia and Chronic Hyperbilirubinemia Irreversibly sickled cells end up in the spleen. Hemolysis occurs at the splenic cords. Decreased RBCs and increased bilirubin Infarction and fibrosis causes autosplenectomy. Source: Robbins

39. Thank you for attention!