4. Anemia

Question 1

Describe : Anemia (2)

Answer 1

• Usually defined as low hemoglobin or hematocrit
• (Approximately Hb <135 for men <120 for women)

Question 2

Describe transfusion in anemia (3)

Answer 2

• Restrict transfusions if stable, consider maintain Hb>70-80 (if underlying cardiovascular disease, planned surgery)
• Consider transfusions in symptomatic, unstable, ongoing losses
• If transfused, may repeat post-transfusion hemoglobin levels even after 15 minutes (1pRBC usually raises Hb by 10g/L)

Question 3

Name causes MICROCYTIC anemia

Answer 3

TAILS
* Thalassemia (alpha, beta)
* Anemia of chronic disease
* Iron deficiency
* Rare

Question 4

Describe : Thalassemia (3)

Answer 4

• Alpha, beta
• Africa, Mediterranean, Southeast Asia
• Mild Splenomegaly

Question 5

Name iron deficiency causes (2)

Answer 5

• Nutrition
• Chronic blood loss (GI, celiac, menstruation)

Question 6

Name rare causes of microcytic anemia

Answer 6

• Lead poisoning
• B6 deficiency
• Cuivre or Zinc deficiency
• Sideroblastic (iron metabolism defect)

Question 7

Name NORMOCYTIC causes of anemia (4)

Answer 7

ABCD
* Acute blood loss
* Bone marrow failure (Insuffisance médullaire)
* Chronic disease
* Destruction (Hemolysis) : Inherited, Acquired

Question 8

Name DDX of INHERITED destruction (hemolysis) anemia (3)

Answer 8

• Hemoglobinopathy: Sickle cell, Thalassemia, Unstable Hb
• Membrane: Spherocytic
• Metabolic: HMP shunt, glycolytic

Question 9

Name DDX of ACQUIRED destruction (hemolysis) anemia (4)

Answer 9

• Immune
• Infection
• MAHA
• Oxidative

Question 10

Name DDX of MACROCYTIC anemia (6)

Answer 10

• Folate / Fetus (pregnancy)
• Alcoholism / Liver disease
• Thyroid (hypo) / Endocrine
• Reticulocytosis
• B12 deficiency
• Cytotoxic Drugs / Dysplasia

Question 11

Name causes of DECREASED RBC PRODUCTION (4)

Answer 11

• Nutrients (B12, iron)
• Bone marrow disorder/suppression
• Low trophic hormones (EPO, thyroid hormone, androgens)
• Note: Inflammation reduces available iron, EPO, and RBC lifespan

Question 12

Name causes of INCREASED RBC DESTRUCTION (6)

Answer 12

Extravascular (spleen/liver)
* Inherited (spherocytosis, sickle, thalassemia)
* Acquired (autoimmune, thrombotic thrombocytopenic purpura, malaria, paroxysmal nocturnal hemoglobinuria)
* Hypersplenism
Intravascular
* MAHA
* Paroxysmal nocturnal hemoglobinuria
* Cold agglutinin

Question 13

Consider iron profile when ? ()

Answer 13

consider if
* blood loss
* or low VGM
* low hémoglobine corpusculaire moyenne
* high RDW

Question 14

Describe : Hemolysis work-up ()

Answer 14

• LDH
• Bilirubin (indirect)
• Haptoglobin (reduced in hemolysis)
• Consider Coombs’ test
• Consider urinary hemoglobin and hemosiderin for intravascular hemolysis in paroxysmal nocturnal hemoglobinuria

Question 15

Bone marrow biopsy indicated when? (2)

Answer 15

Usually indicated in pancytopenia or blast cells (rule out malignancy)

Question 16

Describe history of anemia in children (12)

Answer 16

• Lethargy, tachycardia, pallor
• Signs of hemolysis (urine color, scleral icterus, jaundice)
• Failure to thrive
• Bleeding history
• PMH (birth, jaundice, anemia, medical conditions)
• Family History : Bleeding disorder, hemoglobinopathy, IBD
• Poverty
• Non-iron-fortified formula
• Ethnicity
• Whole cow’s milk diet
• Exclusive breastfeed after 6 months of age
• Poorly controlled maternal diabetes

Question 17

What type of anemia in black/hispanic people ?

Answer 17

Hb S and C

Question 18

What type of anemia in Mediterranean/Southeast Asian people ?

Answer 18

Thalassemia

Question 19

Name DDX of anemia in 0-3 months (6)

Answer 19

Newborns
* Blood loss
* hemolysis (Rh or ABO incompatibility)
* congenital infection
* twin-twin transfusion
* congenital hemolytic anemia (spherocytosis, G6PD deficiency)
* Physiologic anemia (nadir of 110 at 6-9w of age due to decrease in EPO)

Question 20

What type of anemia in Jews/Filipinos/Greeks/Sardinians/Kurds/black people ?

Answer 20

G6PD

Question 21

Name DDX of anemia in 3-6 months (2)

Answer 21

Hemoglobinopathy (thalassemia, sickle cell)

Question 22

Name DDX of anemia in 9-12 months (2)

Answer 22

• Acquired (iron deficiency anemia)
• WHO recommends screening in all children 9-12 months : Consider targeted screening if risk factors (poverty, poor weight gain, excessive milk intake + low iron-rich foods [malnutrition], malabsorption, GI blood loss, obesity)