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Haematology > Acquired Anaemia > Flashcards

Acquired Anaemia Flashcards

1
Q

Define anaemia

A

Hb below normal for age and sex

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2
Q

How is normal Hb level worked out?

A

It is +/- 2 SDs from the mean (this includes 95% of the population)

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3
Q

What factors influence normal Hb levels?

A 
Age 
Sex (higher in men due to testosterone) 
Time sample taken (e.g. if fasting sample Hb will be higher, than if diluted) 
Time to analyse
Ethnicity
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4
Q

What is the normal Hb level for woman?

A

12-70: 120-160

>70: 108-143

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5
Q

What is the normal Hb level for men?

A

12-70: 140-180

>70: 116-156

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6
Q

What are some general features of anaemia/

A 
Due to reduced O2 delivery to tissues:
Tiredness
Pallor
Dizziness (reduced O2 to brain) 
Breathlessness
Chest pain (myocardial ischaemia) 
Swelling of ankles
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7
Q

What clues in history may help you identify a cause for anaemia?

A 
Menorrhagia
Dyspepsia, PR bleeding
Malabsorption (diarrhoea, weight loss) 
Jaundice (haemolysing --> increased bilirubin) 
Splenomegaly/lymphadenopathy
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8
Q

What are the main red cell indices to be aware of?

A 
MCV = mean cell volume (size) 
MCH = mean cell haemoglobin (pigmentation)
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9
Q

How are the red cell indices measured?

A

Automatic machine that uses a laser

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10
Q

What are the three main types of acquired anaemia?

A 
Hypochromic microcytic (small, pale cells) 
Normochromic normocytic (normal looking cells, reduced in number) 
Macrocytic (large cells)
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11
Q

What further tests should you do if you find hypochromic microcytic cells?

A

Serum ferritin

Most common reason for HM cells = Fe deficient anaemia

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12
Q

What further tests should you do if you find normochromic normocytic cells?

A

Reticulocyte count

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13
Q

What further tests should you do if you find macrocytic cells?

A

B12/Folate
Bone marrow

Commonest cause of macrocytic cells = B12/folate deficiency

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14
Q

Hypochromic microcytic cells + low serum ferritin =?

A

Fe deficient anosmia

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15
Q

Hypochromic microcytic cells + normal/high serum ferritin =?

A

Thalassaemia
Secondary anaemia (although more commonly get normocytic normochromic cells with this)
A lot more rarely: sideroblastic anaemia

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16
Q

How much iron is in the body?

A

4g

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17
Q

What is the pathway to get rid of excess iron?

A

No pathway for this exists

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18
Q

What are the two things that can happen to iron in the gut?

A

Bound to mucosal ferritin and sloughed off

Transported across basement membrane by ferroportin then bound to transferrin in plasma

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19
Q

Which Fe ion is absorbed more readily in the gut?

A

Fe2+ (from animals haem form) > Fe3+ (non-haem form)

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20
Q

What form is iron stored as in the body?

A

Ferritin

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21
Q

What is the role of hepcidin in controlling iron levels in the body?

A

Hepcidin synthesised by hepatocytes in response to too much iron, liver failure, inflammatory markers (esp. IL6)

Hepcidin blocks ferroportin –> reduced Fe absorption in the gut

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22
Q

What must you do after you get a diagnosis of iron deficient anaemia?

A

Find a cause

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23
Q

What must you check for in the history?

A 
Dyspepsia, GI bleeding
Menorrhagia 
Diet (e.g. vegan?)
Increased requirements? - e.g. pregnant 
Malabsorption - gastrectomy, coeliac disease, diarrhoea
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24
Q

What are signs of Fe deficient anaemia?

A

Sore, atrophic tongue
Kolionychia
Angular cheilitis

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25
Q

Management of Fe deficiency

A

Correct cause (diet, ulcer therapy, gynae interventions, surgery)

Oral iron (IV if intolerant)

26
Q

Normochromic normocytic anaemia + increased reticulocyte count = ?

A

Haemolysis
Acute blood loss

(bone marrow working and compensating for loss of blood cells)

27
Q

Normochromic normocytic anaemia + decreased/normal reticulocyte count = ?

A

Secondary anaemia
Hypoplasia
Marrow infiltration

28
Q

what is haemolytic anaemia?

A

Accelerated RBC destruction –> decreased Hb

With compensation of bone marrow (hence increased retic count)

29
Q

What are the two types of haemolysis?

A

Intravascular - RBC destruction in circulation

Extravascular - RBC breakdown in spleen etc.

30
Q

Where are RBCs normally broken down?

A

RES (mostly spleen)

31
Q

What are types of haemolytic anaemia?

A

Congenital - hereditary spherocytosis, enzyme deficiency, haemoglobinopathy (HbSS)

Extravascular - Auto-immune haemolytic anaemia

Intravascular - mechanical (e.g. heart valve), infection/DIC, PET/HUS/TTP

32
Q

What is HUS?

A

Thrombotic microangiopathy in which microthrombi occlude arterioles and capillaries –> thrombocytopenia, haemolytic anaemia, AKI

33
Q

Acquired haemolytic anaemia is broadly split into two categories - what are these?

A

Immune - mostly extravascular

Non-immune - mostly intravascular

34
Q

How do you distinguish between immune and non-immune haemolytic anaemia?

A

DAT (direct coombs test)

Mix red cells with anti-human globulin, agglutination = positive test (presence of autoantibodies on surface of RBCs)

35
Q

Normochromic, normocytic cells, high reticulocyte count, positive DAT test, presence of spherocytes on blood film is most likely to indicate what?

A

Autoimmune haemolytic anaemia

36
Q

Warm autoantibody is most likely to indicate what?

A

Autoimmune
Drugs
CLL

37
Q

Cold autoantibody is most likely to indicate what?

A

CHAD
Infections
Lymphoma

38
Q

Alloautoantibody is most likely to indicate what?

A

Transfusion reactions

39
Q

Why might you see spherocytes on film in an autoimmune haemolytic anaemia?

A

Bits of membrane of RBCs tagged with autoantibodies are broken down leading to spherocytes

40
Q

What kind of cells may you see in intravascular haemolysis?

A

Schistocytes

smashed up cells

41
Q

How can you work out if a patient is haemolysing?

A 
FBC, high retic count, blood film (spherocytes/schistocytes) 
High bilirubin 
Low serum haptoglobin 
DAT 
Urine for haemosiderin/urobilinogen
42
Q

What is haptoglobin?

A

Mops up free Hb (so levels of empty haptoglobin are low in haemolytic anaemia)

43
Q

How do you manage patients with haemolytic anaemia?

A

Folic acid to support marrow
Correct cause - immunosuppression (steroids)
Treat CLL, lymphoma, stop causative meds Splenectomy (removing site of RBC destruction)
Consider transfusion if struggling

44
Q

Normochromic, normocytic anaemia + normal/low reticulocyte count mostly commonly = ?

A

Secondary anaemia

45
Q

What is the pathophysiology behind secondary anaemia?

A

Inflammatory markers/renal failure –> increased hepicidin –> blocks ferroportin so there is defective iron absorption

46
Q

Why do you need to be careful when diagnosing secondary anaemia?

A

May be initial increase in ferritin

47
Q

What may cause a secondary anaemia?

A

Infection, inflammation, malignancy

48
Q

What are the two types macrocytic anaemia?

A

Megaloblastic

Non-megaloblastic

49
Q

What is the cause of megaloblastic anaemia?

A

B12 and folate deficiency

50
Q

Aside from anaemia what else is associated with B12/folate deficiency?

A

Neurological symptoms (due to degeneration of the cord (B12))

51
Q

What are the two causes of B12 deficiency?

A

Pernicious anaemia

Gastric/ileal disease

52
Q

What are the causes of folate deficiency?

A

Dietary
Increased requirements (e.g. pregnancy, haemolysis)
GI pathology, e.g. coeliac

53
Q

Why do you get a lemon yellow tinge in megaloblastic anaemia?

A

Abnormal cells –> increased haemolysis –> increased bilirubin

54
Q

How is B12 absorbed from the gut?

A

Binds intrinsic factor (made by parietal cells)
Absorbed in distal ileum
Bound to transcobalamin II in portal circulation for transport to marrow/other tissues

55
Q

What is the most common cause of B12 deficiency in western world?

A

Pernicious anaemia

56
Q

What is the pathophysiology of pernicious anaemia?

A

Autoantibody against intrinsic factor/parietal cells

57
Q

Why do the signs/symptoms of B12 deficiency take years to come on after development of IF antibody?

A

As stores of B12 are so goog

58
Q

How do you treat megaloblastic anaemia?

A 
B12 replacement (3monthy IM injection) 
Oral folate
59
Q

What are other common causes of macrocytosis?

A 
Alcohol 
Drugs (methotrexate, antiretrovirals, hydroxycarbamide) 
Disordered liver function 
Hypothyroidism
Myelodysplasia
60
Q

Macrocytic anaemia that is non-megaloblastic may indicate what?

A

Myelodysplasia
Marrow infiltration
Drugs

Haematology (14 decks)

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