Anaemia Flashcards
What do we mean by the term Haemolysis and Haemolytic anaemia?
Blood cells destroyed faster than they can be made,
when r.b.c number decreases = anaemia
What does this patient have?
- yellow tinge in eyes
- LFT and bloods normal
- bilirubin 30
- unconjugated
- Hb 98
- Spherocytes
- polychromatic macrocytes
- high reticulocytes
- reticulocyte increase = bone marrow compensating for bleeding (or haemolysis)
- jaundice due to bilirubin from haemolysis and not other cause as it is unconjugated
- Low Hb
Haemolytic anaemia
How is haemolytic anaemia treated?
Folic acid - required to make red blood cells due to increased need
Splenectomy - if severe to increase red cell life span
upper right abdo pain and tenderness
Bilirubin 60
Largely conjugated?
18 years old
Anaemia
gallstones at a very young age due to increased breakdown of haemoglobin into bilirubin
Stone has caused obstructive jaundice
Liver is able to conjugate bilirubin but it is not passing from the bile ducts and gall bladder into duodenum
What type of gallstones can one get due to anaemia?
Pigmented - due to bilirubin from r.b.c breakdown in haemolytic anaemia
What type of anaemia is the following:
Low Hb high MCV high ferritin normal B12 and folate high bilirubin high creatinine high LDH
Macrocytic anaemia
Bilirubin and LDH shows haemolysis based macrocytic anaemia
What does LDH signify?
Marker of cell breakdown, it is an intracellular enzyme so levels should not be high
What is Auto Immune haemolytic anaemia DAT positive?
Can be seen with other disorders of the immune system and autoimmune disorders
direct antiglobulin test (DAT) shows antibodies bound to RBC
What inherited defects of red blood cells can cause haemolysis?
abnormal membrane
abnormal Hb
Defect in glycolytic pathway
defect in enzymes of pentose shunt
What is an example of abnormal r.b.c membrane?
hereditary spherocytosis
What is an example of abnormal Hb?
sickle cells anaemia
What is an example of defect in glycolytic pathway?
pyruvate kinase deficiency - provides energy for the cell
What is an example of defect in enzyme of pentose shunt?
G6PD Deficiency * key enzyme in pentose shunt which protects from oxidant damage
Blood film with Ghost cells, Heinz Bodies, Hemighosts, irregularly contracted cells
G6PD deficiency
What cells on a blood film show oxidant damage?
Irregularly contracted cells and heinz bodies
The Heinz bodies are precipitated oxidised haemoglobin
What do Ghost cells show?
There has been intravascular haemolysis
What advise is given to patients with G6PD deficiency?
Avoid oxidant drugs
Don’t eat broad beans
avoid nephthalene
- be aware that haemolysis can result from something like infection which can generate oxidants
58 year old presents:
- tired
- lethargy
- breathlessness at rest
- worsens at exertion
- ankle swelling end of day
blood test:
Low Hb Low MCV Low ferritin Low serum Iron High transferrin
Iron deficiency anaemia
But why?
What further questions should be asked if someone has iron deficiency anaemia?
- Are you veggie
- GI symptoms
- Changes in bowel habit
- Menstrual history
- weight loss
- Medication e.g. NSAIDs
What clinical signs are there of iron deficiency anaemia?
Koilonychia
Glossitis
Angular stomatitis
What investigations for an elderly post menopausal women, with anaemia?
FIT test (Faecal Immunochemical Test) to detect faecal occult blood
Imaging
biopsy
colonoscopy
coeliac antibody testing
What can cause increased blood loss for iron deficiency anaemia?
Hookworm
Menstrual
Gastrointestinal
What can cause insufficient iron intake for iron deficiency anaemia?
Dietary - vegetarians
Malabsorption : coeliac disease, H.Pylori gastritis
What can cause increased iron requirements not being fulfilled for iron deficiency anaemia?
Pregnancy
Infancy
Iron deficiency anaemia blood film?
Low MCV
Pale, hypochromia cells
target cells
Pencil cells
45 year old male presents:
Anaemia Hb 85, previous was normal
Has RA
Takes NSAIDS + corticosteroids
Normal reticulocytes Low MCV High ferritin Low transferrin High ESR
Blood film: hypochromic, microcytic, rouleaux
His Anaemia is due to RBC production not destruction * due to normal reticulocytes
ESR shows inflammation
could be iron deficiency and anaemia of chronic disease
Hepcidin increases in inflammatory states so iron absorption is not regulated
Describe the pathophysiology of chronic disease?
Pro inflammatory cytokines IL-1 TNFa IL-6
–> Decreased Erythropoietin production
and
–> Hepcidin increase –> Iron absorption, transport, availability decreases
What are some common causes of anaemia of chronic disease?
Infection:
TB, HIV
RA / autoimmune
Malignancy
62 year old women presents:
Tiredness
Decrease exercise capacity
‘Walking on cotton wool’
Jaundice / depigmentation on face
Low Hb
High MCV
High LDH
High bilirubin
film : poikilocytosis, megloblastic anaemia , neutrophil hypersegmentation
B12 deficiency signs on blood film
B12 needed for DNA synthesis, without is severe anaemia
- megaloblastic changes can also be due to DNA synthesis impairments from drugs, Folate antagonists, BM cancers
Which drugs can cause DNA impairment in megaloblastic anaemia?
Azathioprine cytotoxic chemo
Which folate antagonists can cause DNA impairment in megaloblastic anaemia?
methotrexate
Which cancers can cause DNA impairment in megaloblastic anaemia?
myelodysplastic syndrome
What is folic acid required for?
Homocysteine metabolism
Examples of neurological disorders due to B12 deficiency?
Dementia
SACD - sub acute combined degeneration - of spinal cord
What defects can folic acid deficiency cause?
Developmental neural tube defects during pregnancy
What are the causes of reduced red cell survival?
Hereditary spherocytes
Autoimmune haemolytic anaemia
G6PD
What are the cases of reduced red cell production?
Iron deficiency anaemia
Anaemia of chronic disease
Megaloblastic anaemia / Vit B12 lack
Which rbc are hypochromic?
microcytic
Which rbc are normocytic?
normocytic
macrocytic
What is thalassaemia?
defect in globin synthesis, can be alpha or beta chain defect
causes microcytic anaemia
What can case pooling of red cells in spleen?
hypersplenism e.g. liver cirrhosis, splenic sequestrations in sickle cell
What gastric based issues can cause vit b12 deficiency?
Gastrectomy or autoimmune pernicious anaemia:
Intrinsic factors not available for vit b12 absorption
What does pernicious anaemia do?
Anti gastric parietal cell antibodies - that are supposed to secrete IF
What bowel based issues can cause vitamin B12 deficiency?
Crohns disease
ileal resection
