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Acquired Anaemia Flashcards

1
Q

What are the general features of anaemia due to reduced O2 delivery

A 
Asymptomatic if Hb falls slowly 
Fatigue 
Pallor - mucous membrane / creases
SOB on exertion / rest 
Headache
Chest pain 
Palpitations 
Dizzy due to hypoperfusion of brain 
Hair loss

If severe
Tachycardia
Systolic flow murmur
HF

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2
Q

What are features of anaemia due to underlying cause - ASK

A

Bleeding - menorrhagia / GI Sx / NSAID use
Malabsorption - diarrhoea / weight loss / poor diet
Jaundice if haemolysing
Splenomegaly
Lymphadenopathy
Fatigue
Weight loss / fever / night sweats
PMH anaemia / chronic disease / renal failure

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3
Q

What are the red cell indices

A

MCV - mean cell volume

MCH - mean cell Hb

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4
Q

What are the morphological description of cells

A

Hypochromic microcytic
Normochromic normocytic
Macrocytic

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5
Q

What are hypochromic microcytic

A

MCV low

MCH low

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6
Q

What are normochromic normocytci

A

Normal MCV / MCH

Just less cells

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7
Q

What are macrocytic

A

MCV high

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8
Q

What are the initial investigations of anaemia

A

FBC
Red cell indices
Blood film
U+E, LFT useful

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9
Q

What causes hypochromic

A 
Iron deficiency
Thalassaemia
Secondary anaemia (30%)
Lead poisoning 
Sideroblastic = very rare
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10
Q

What is the next step investigation for hypochromic anaemia

A

Serum ferritin
Ferritin low in iron deficiency
Ferritin high in sideroblastic / thalassaemia (TIBC low)

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11
Q

What causes normochromic normocytic

A

Acute blood loss - high ret
Haemolytic anaemia - high reitucocyte e.g. congenital

Normal or low reticulocyte 
Secodary anaemia
Bone marrow hypoplasia - suspect if WCC / platelet down
- Leukaemia / lymphoma / MM 
- Myelofibrosis / dysplasia / MGUS 
Aplastic anaemia
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12
Q

What causes macrocytis (not always anaemic)

A

Metagloblastic on film
Low B12 / folate -

Non-megaloblastic
Alcohol 
Myelodysplasia
Marrow infiltration 
Abnormal liver 
HYpothyroid
Pregnancy 
Non-megaloblastic - haemolytic (no issue with bone marrow)
Drugs 
- Quinine
- Hydroxychloroquine 
Congenital
- Haemoglobinopathy
- HS
- G6PD 
Autoimmune
Malaria 
Microangiopathy haemolytic anaemia
- HUS
- TTP
- DIC
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13
Q

What is next strep for investigating macrocytic

A

B12/ folate assay

Bone marrow

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14
Q

What is most common cause of anaemia

A

Iron deficiency

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15
Q

Exam Q of normal Hb but microcytosis

A

If no risk of thalassaemia
Polycythaemia ruba vera
- Iron deficiency 2 to bleeding but increased red cells so Hb normal

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16
Q

What happens to absorbed iron

A

Absorbed in duodenum and jejunum
Stored in liver as ferritin
Transferred by transferrin in plasma

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17
Q

What is role of Hepcidin

A

Synthesied in liver in response to inflammation / renal failure / increased iron
Blocks ferroportin so reduced absorption of iron in inflammation / chronic disease

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18
Q

What can cause iron deficiency anaemia

A 
Bleeding = most common in adults 
- GI CANCER / ulcer
- Menorrhagia 
Poor diet = most common in children 
Malabsorption
- Gastrectomy
- Coeliac 
Increased requirement 
- Pregnancy / children
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19
Q

What are specific signs of deficiency

A 
Classic anaemia
Koilonychia
Atrophic glossitis
Angular stomatitis
Post cricoid webs if Plummer Vinson 
Abdo and rectal exam
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20
Q

How do you investigate iron deficiency anaemia

A

Hx about causes
FBC +film
- Microcytic hypo chromic
- Target cell
Serum ferritin - low (beware as raised in inflammation etc)
Transferrin sats - low
TIBC - high
Endoscopy / coeliac serology or stool microscopy if travel Hx to rule out malignancy
2 week cancer if elderly with microcytic anaemia

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21
Q

What is important in HX

A 
Weight loss 
Change in bowel
Diet
Medication - NSAID 
Menstrual
PMH chronic disease
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22
Q

When can ferritin be high

A

Inflammation / CKD / malignancy / liver disease
Iron overload - haemochormatosis / transfusion
So do sats

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23
Q

How do you treat iron deficiency

A

Oral iron ‘ferrous sulphate’
Continue for 3 months once Hb back - want it to rise by 10 per week
IV iron if intolerant / or if cardiac signs e.g. SOB ON REST
Blood transfusion = very rare
Correct cause
Refer to GI

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24
Q

SE of iron

A 
Nausea
Abdo pain
Constipation
Diarrhoea
Dark stool
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25
How do you differentiate iron vs chronic disease
Iron - TIBC high - Ferritin low AOCD - TIBC low - Ferritin high as inflammation
26
When is reticulocyte increased in normochromic
Acute blood loss | Haemolytic anaemia
27
When is reticulocyte normal or low
Secondary anaemia / chronic disease - CKD Bone marrow infiltration Aplastic anaemia
28
What can haemolytic be
Extravascular - Warm Intravascular Both
29
What happens in intravascular
Red cells burst in circulation so tend to be much sicker
30
What are acquired extravascular causes
Auto-immune - can be - Warm AB mediated - Cold Ab mediated Alloimmune
31
What drugs cause extra-vascular haemolytic
Methydopa | Penicillin
32
What are acquired intravascular causes
``` Non-immune Mechanical valve Severe infection / DIC Micro-angiopathic - PET / HUS / TTP / malignancy / drugs Malaria Paroxysmal haemoglobinruia ```
33
How do you Dx autoimmune
DAT - direct antiglobuin test +ve
34
What causes warm Ab
``` Idiopathic Auto-immune - SLE Drugs - methyldopa / penicillin CLL / lymphoma Rhd - IgG ```
35
What causes cold Ab - occur at cold temp
``` More commonly 2 to other diseases CHAD Infection - mycoplasma / EBV / CMV Lymhpoma Leukaemia SLE ABO - IgM ```
36
What causes allo-Ab
Transfusion reaction | Haemolytic disease new born
37
Where do warm Ab tend to occur
Extravascular
38
Where do cold Ab tend to occur
Intravascular
39
How do you Dx haemolytic / what are the symptoms
Symptoms - anaemia, jaundice - isolated hyperbilurbin, splenomegaly ``` History - FH, race, jaundice, drugs, travel Examination - jaundice, gall stones, HSM +Ve DAT FBC - normocytic Reticulocyte - high Film - spherocytes Serum bilirubin - high High LDH Serum haptoglobin Malaria screened if hx of travel ```
40
What is serum haptoglobin
Low in intravascular
41
How do you manage haemolytic anaemia
``` Folic acid Correct cause Immunosuppression Steroid Ritixumiab Splenectomy to remove site Consider transfusion ITU as high clotting risk ```
42
How does chronic disease cause anaemia
Increased hepcidin which blocks absorption of iron - Autoimmune - Rheumatological - Malignancy - Chronic infection
43
What is aplastic anaemia characterised by and how is it Dx
``` Sudden failure of bone marrow (hypo plastic) Get aplastic crisis if no RBC produced Normochromic anaemia Low reticulocyte Pancytopenia - lymphocyte spare - Thrombocytopenia ``` Dx on bone marrow trephine or aspirate showing reduced cells
44
What causes
``` Parovirus = classic cause - Exacerpates sickle causing crisis Congenital ALL / AML Drugs - Anti-malaria - AED - carbamazepine - Cytotoxic - Chloramphenicol - Sulphonamide - Phenytoin - Anti-thyroid Infection - parovirus / hepatiis / HIV / EBV Radiation ```
45
What causes megaloblastic macrocytic anaemia
B12 / folate ONLY | Film = hypersegmented neutrophils
46
What causes non-megaloblastic
Myelodysplasia Marrow infiltration Cytotoxic drugs
47
What must you do if non-megaloblastic
Bone marrow
48
How does B12 / folate deificny present
Anaemia Neuro-psychiatric - depression / psychosis Neurological - paraesthesia / neuropathy ALWAYS TEST FOR B12 DEFICINECY IF NEUROPATHY SCAD Neuro signs - involved in DNA synthesis Take 1-2 years to develop symptoms as stores good
49
What causes B12 deficiency
Pernicious anaemia = main cause (autoimmune attack on intrinsic factor or gastric parietal cells) Poor diet - alcohol / elderly Increased demand - pregnancy Gastric/ ideal disease Malabsoprition - coeliac / tropical spure Drugs - AED, methotrexate, trimethoprim
50
How is B12 absorbed
Binds to intrsinc factor secreted by gastric pariteal cells | Attaches to ileum and absorbed
51
What causes folate deficiency
Dietary Increased requirement GI pathology
52
How do you Dx B12 deficiency
Anti-intrinsic factor Ab = diagnostic and most important Anti-patietal AB = specific If present confirms pernicious Film = hyperhsegmented neutrophils
53
How do you treat
Replace vitamin - B12 injection (can't give oral if pernicious as can't absorb) Oral B12 if just deficiency e.g. poor diet Oral folate
54
What must you do before treating folate
Ensure B12 normal as can worsen neuropathy / cause SCAD
55
How do you give B12
6 injections over 2 weeks | then 3 monthly
56
What are causes of macrocytosis
``` Alcohol Methotrexate / ARV / hydroxycarbamide Phenytoin due to altered folate metabolism Liver disease Pregnancy Hypothyroid Myelodysplasia ```
57
If patient presents to AMIA with acute low Hb what do you want to know
``` Is patient stable - ABCDE Is patient bleeding Has patient bled Does patient need transfusion What is the cause ```
58
When do you consider sideroblastic anaemia
If microcytic anaemia not responding to iron
59
What causes
``` Congenital X-linked = rare Myeloproliferative Lead poison Alcohol Chemo Anti-TB RT ```
60
What tests
Increased ferritin Microcytic anaemia Sideroblasts in marrow with Papneheimer bodys (iron pooled in mitochondria)
61
Rx
Remove cause
62
What happens in sideroblast
Body has iron but can't incorporate into Hb so deposited around mitochondria
63
What are the microangiopathic haemolytic anaemia's (MAHA)
HUS TTP DIC Due to endothelial layer of small blood vessel = disrupted leading to fragmentation of red cells and consumption of platelet
64
What do they all have in common
Thrombocytopenia - Increased coagulation activation uses up platelet Haemolytic anaemia - Fibrin forms in arterioles and capillaries - RBC get fragmented and sheared - Schistocyte on film = sheared RBC AKI (renal failure) - Due to impact on renal vessel
65
What causes HUS
E.coli0157 | Malignancy
66
What is typical picture
``` Bloody diarrhoea a few weeks before Anaemia Jaundice Bruising Oedema Hypertension ```
67
What will investigation show
``` Haemolytic anaemia Thrombocytopenia Renal failure Normal PT / APTT Film = schistocytes ```
68
How do you Rx
IV fluid SUpportive NO AX
69
What causes TTP
``` Coagulation problem (ADAMTS13 definceicy) Malignancy ```
70
What is typical picture
Same as HUS but also FEVER CNS - weakness / visual / seizure / LOC
71
How do you investigate
Same as HUS | Clinical differentiation
72
How do you Rx
Plasmapharesis and FFP Specialist Very very sick as red blood cells are bursting
73
What causes DIC
Sepsis HELLP in pregnancy Malignancy
74
How do you Ix
Thrombocytopenia Raised PT / APTT Low fibrinogen Schistocyte on film
75
How does it present
``` Same as above Anaemia Jaundice Brusiing Oedema HYPOTENSION / SHCOK Decreased consciousness ```
76
What ar path-pneumonia for MAHA - microangiopathic
Schisocytes on film
77
What is Fanconi Anaemia
AR aplastic anaemia
78
What are features
Anaemia Neuro Sx Short stature Cafe au lait
79
What are you at increased risk of
AML

Haematology (13 decks)

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