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Haematology > Acquired Anaemia > Flashcards

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
Q

How do you differentiate iron vs chronic disease

A

Iron

  • TIBC high
  • Ferritin low

AOCD

  • TIBC low
  • Ferritin high as inflammation
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26
Q

When is reticulocyte increased in normochromic

A

Acute blood loss

Haemolytic anaemia

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27
Q

When is reticulocyte normal or low

A

Secondary anaemia / chronic disease - CKD
Bone marrow infiltration
Aplastic anaemia

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28
Q

What can haemolytic be

A

Extravascular
- Warm
Intravascular
Both

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29
Q

What happens in intravascular

A

Red cells burst in circulation so tend to be much sicker

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30
Q

What are acquired extravascular causes

A

Auto-immune - can be
- Warm AB mediated
- Cold Ab mediated
Alloimmune

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31
Q

What drugs cause extra-vascular haemolytic

A

Methydopa

Penicillin

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32
Q

What are acquired intravascular causes

A 
Non-immune 
Mechanical valve 
Severe infection / DIC 
Micro-angiopathic - PET / HUS / TTP / malignancy / drugs 
Malaria
Paroxysmal haemoglobinruia
33
Q

How do you Dx autoimmune

A

DAT - direct antiglobuin test +ve

34
Q

What causes warm Ab

A 
Idiopathic 
Auto-immune - SLE 
Drugs - methyldopa / penicillin
CLL / lymphoma
Rhd - IgG
35
Q

What causes cold Ab - occur at cold temp

A 
More commonly 2 to other diseases 
CHAD
Infection - mycoplasma / EBV / CMV 
Lymhpoma
Leukaemia 
SLE 
ABO - IgM
36
Q

What causes allo-Ab

A

Transfusion reaction

Haemolytic disease new born

37
Q

Where do warm Ab tend to occur

A

Extravascular

38
Q

Where do cold Ab tend to occur

A

Intravascular

39
Q

How do you Dx haemolytic / what are the symptoms

A

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
Q

What is serum haptoglobin

A

Low in intravascular

41
Q

How do you manage haemolytic anaemia

A 
Folic acid
Correct cause
Immunosuppression 
Steroid 
Ritixumiab 
Splenectomy to remove site
Consider transfusion
ITU as high clotting risk
42
Q

How does chronic disease cause anaemia

A

Increased hepcidin which blocks absorption of iron

  • Autoimmune
  • Rheumatological
  • Malignancy
  • Chronic infection
43
Q

What is aplastic anaemia characterised by and how is it Dx

A 
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
Q

What causes

A 
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
Q

What causes megaloblastic macrocytic anaemia

A

B12 / folate ONLY

Film = hypersegmented neutrophils

46
Q

What causes non-megaloblastic

A

Myelodysplasia
Marrow infiltration
Cytotoxic drugs

47
Q

What must you do if non-megaloblastic

A

Bone marrow

48
Q

How does B12 / folate deificny present

A

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
Q

What causes B12 deficiency

A

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
Q

How is B12 absorbed

A

Binds to intrsinc factor secreted by gastric pariteal cells

Attaches to ileum and absorbed

51
Q

What causes folate deficiency

A

Dietary
Increased requirement
GI pathology

52
Q

How do you Dx B12 deficiency

A

Anti-intrinsic factor Ab = diagnostic and most important
Anti-patietal AB = specific
If present confirms pernicious
Film = hyperhsegmented neutrophils

53
Q

How do you treat

A

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
Q

What must you do before treating folate

A

Ensure B12 normal as can worsen neuropathy / cause SCAD

55
Q

How do you give B12

A

6 injections over 2 weeks

then 3 monthly

56
Q

What are causes of macrocytosis

A 
Alcohol
Methotrexate / ARV / hydroxycarbamide 
Phenytoin due to altered folate metabolism 
Liver disease
Pregnancy
Hypothyroid
Myelodysplasia
57
Q

If patient presents to AMIA with acute low Hb what do you want to know

A 
Is patient stable - ABCDE
Is patient bleeding
Has patient bled
Does patient need transfusion
What is the cause
58
Q

When do you consider sideroblastic anaemia

A

If microcytic anaemia not responding to iron

59
Q

What causes

A 
Congenital X-linked = rare
Myeloproliferative 
Lead poison
Alcohol 
Chemo
Anti-TB
RT
60
Q

What tests

A

Increased ferritin
Microcytic anaemia
Sideroblasts in marrow with
Papneheimer bodys (iron pooled in mitochondria)

61
Q

Rx

A

Remove cause

62
Q

What happens in sideroblast

A

Body has iron but can’t incorporate into Hb so deposited around mitochondria

63
Q

What are the microangiopathic haemolytic anaemia’s (MAHA)

A

HUS
TTP
DIC
Due to endothelial layer of small blood vessel = disrupted leading to fragmentation of red cells and consumption of platelet

64
Q

What do they all have in common

A

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
Q

What causes HUS

A

E.coli0157

Malignancy

66
Q

What is typical picture

A 
Bloody diarrhoea a few weeks before
Anaemia
Jaundice
Bruising
Oedema
Hypertension
67
Q

What will investigation show

A 
Haemolytic anaemia 
Thrombocytopenia
Renal failure 
Normal PT / APTT
Film = schistocytes
68
Q

How do you Rx

A

IV fluid
SUpportive
NO AX

69
Q

What causes TTP

A 
Coagulation problem (ADAMTS13 definceicy)
Malignancy
70
Q

What is typical picture

A

Same as HUS but also
FEVER
CNS - weakness / visual / seizure / LOC

71
Q

How do you investigate

A

Same as HUS

Clinical differentiation

72
Q

How do you Rx

A

Plasmapharesis and FFP
Specialist
Very very sick as red blood cells are bursting

73
Q

What causes DIC

A

Sepsis
HELLP in pregnancy
Malignancy

74
Q

How do you Ix

A

Thrombocytopenia
Raised PT / APTT
Low fibrinogen
Schistocyte on film

75
Q

How does it present

A 
Same as above
Anaemia
Jaundice
Brusiing
Oedema
HYPOTENSION / SHCOK
Decreased consciousness
76
Q

What ar path-pneumonia for MAHA - microangiopathic

A

Schisocytes on film

77
Q

What is Fanconi Anaemia

A

AR aplastic anaemia

78
Q

What are features

A

Anaemia
Neuro Sx
Short stature
Cafe au lait

79
Q

What are you at increased risk of

A

AML

Haematology (13 decks)

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