An Approach to Anemia

Question 1

Definition of anemia

Answer 1

Decrease in blood Hb concentration

Can be due to either decreased total red blood cells or an increase in plasma volume

Question 2

Normal Hb range for

1. Women
2. Men

Answer 2

1. 120 to 160

2. 140 to 170

Question 3

3 factors that can help identify the severity and urgency for work up and management

Answer 3

Time course (rapid vs chronic)
Current clinical context (symptoms)
Hb level

Question 4

What does anemia look like that gives slight concern?

Answer 4

Chronic/stable anemia
Asymptomatic
Isolated anemia
Hb > 110
Just do basic investigations and follow over time

Question 5

What does anemia look like that gives moderate concern?

Answer 5

Slowly progressive
Co-existing abnormalities in white cells or platelets (increased likelihood of marrow disorder)
Worrisome symptoms/signs
Asymptomatic
Hb < 110
More extensive investigation +/1 referral to hematologist

Question 6

What does anemia look like that gives major concern?

Answer 6

Rapidly progressive
Symptomatic (usually < 80/90 - rarely above 100)
Active bleeding
Concerning morphologic abnormalities (blasts, spherocytes, fragments/schistocytes sickle cells)
Investigate and refer - may also need transfusion/treatment

Question 7

Pathogenesis approach

Answer 7

Look at the reticulocyte count
Low or normal: decreased production
High: blood loss, increased destruction

Question 8

MCV approach

Answer 8

Look at the MCV
Can be microcytic (under 80)
Normocytic (80-100)
Macrocytic (> 100)

Question 9

What are the normal values for

1. WBC count
2. Platelet

Answer 9

1. 4 or higher

2. 150-400

Question 10

Microcytic anemia

Answer 10

Under 80
Can be thought of as red cell underfilling
Due to abnormalities in iron availability, heme or globin production

Question 11

5 main causes of microcytic anemia (and what is most common)

Answer 11

TAILS!
T: thalassemia trait
A: anemia of chronic disease
I: iron deficiency
L: lead poisoning
S: sideroblastic anemia
T and I are the most common, L and S are rare

Question 12

What is the best test for iron deficiency?

Answer 12

Ferritin!

Question 13

3 iron studies that are not ferritin

Answer 13

TIBC: indicates the maximum amount of iron needed to saturate plasma or serum transferrin
Serum iron level
Transferrin saturation (serum iron/TIBC x 10)

Question 14

Serum ferritin levels in

1. Iron deficiency
2. Chronic inflammation or malignancy
3. Thalassaemia

Answer 14

1. Reduced
2. Normal or raised
3. Normal

Question 15

Serum iron levels in

1. Iron deficiency
2. Chronic inflammation or malignancy
3. Thalassaemia

Answer 15

1. Reduced
2. Reduced
3. Normal

Question 16

TIBC levels in

1. Iron deficiency
2. Chronic inflammation or malignancy
3. Thalassaemia

Answer 16

1. Raised
2. Reduced
3. Normal

Question 17

Causes of iron deficiency resulting in microcytic anemia

Answer 17

Increased iron (blood) loss: GI, gynae, intravascular hemolysis, blood donation
Decreased iron absorption/intake: GI (celiac, resection, h pylori, PPI), dietary deficiency

Question 18

Top cause of Fe deficiency in NA

Answer 18

Bleeding

Always this until proven otherwise!!

Question 19

2 types of macrocytic anemia

Answer 19

Megaloblastic

Non-megaloblastic

Question 20

5 causes of non-megaloblastic anemia

Answer 20

Liver disease
Alcohol consumption
Hypothyroidism
Multiple myeloma
COPD
Liver disease and alcohol work by causing abnormal membrane lipids

Question 21

3 causes of megaloblastic anemia

Answer 21

B12/folate deficiency
Drugs (chemo)
Myelodysplasia
Its from nuclear-cytoplasmic asynchrony due to impaired DNA metabolism

Question 22

What is the cause of macrocytic anemia with a high MCV and high retics?

Answer 22

Hemolysis

Question 23

What do the neutrophils look like in macrocytic anemia (MDS)?

Answer 23

Pelgeroid neutrophils
Only have 2 lobes
Sign of dysplasia

Question 24

Myelodysplastic syndrome (MDS)

Answer 24

Rare type of bone marrow cancer
Results in marrow failure where the early cells in the marrow do not mature into healthy blood cells
Can see the pelgeroid neutrophils on smear

Question 25

Normocytic anemia with increased retics can be from…

Answer 25

1. Increased RBC loss (bleeding or hemolysis)

2. Premature release from the bone marrow (marrow stress, marrow disruption)

Question 26

Normocytic anemia with low or “inappropriately normal” retics can be from…

Answer 26

1. Extrinsic marrow limitation (nutrient deficiency (iron, B12, folate), trophic factor deficiency (EPO, test), suppression (inflammation))
2. Intrinsic marrow disorder (abnormal development (myelodysplastic, acute leukemia, aplastic anemia, red cell aplasia), marrow replacement (malignancy infection))

Question 27

Schistocytes

Answer 27

Ruptured/sheared off RBCs

Question 28

Aplastic anemia

Answer 28

Normal MCV
Bone marrow biopsy will show only fat
Autoimmune condition
Needs to be admitted to hospital, transfused, and started on treatment immediately

Question 29

Symptoms of iron deficiency specific to children

Answer 29

All ages: inattention, poor school performance, irritability/depression, growth retardation, unexplained cognitive and intellectual impairment, breath holding spells
Infants: poor feeding, lethargy, failure to thrive, cardiomegaly, tachypnea
Adolescents: similar to adults