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Y3 Conditions > Anaemia > Flashcards

Anaemia Flashcards

1
Q

Anaemia

How is anaemia classified (bloods)?

A

Hb:
< 12g/dL in females
<13.5g/dL in males

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2
Q

Anaemia

What is the most common cause of anaemia?

A

iron deficiency anaemia

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3
Q

Anaemia

List the types of microcytic anaemia.

(4)

A
  • iron deficiency
  • thalassemias
  • sideroblastic
  • anaemia of chronic disease
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4
Q

Anaemia

Macrocytic anaemias can be megaloblastic and non-megaloblastic.

Name some causes of megaloblastic anaemia.

(2)

A
  • Vit B12 deficiency
  • folate deficiency
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5
Q

Anaemia

Macrocytic anaemias can be megaloblastic and non-megaloblastic.

Name some causes of non-megaloblastic anaemia.

A

rare

  • Chronic alcoholism
  • Liver disease
  • Hypothyroidism
  • Drugs e.g. anti-retroviral for HIV or hydroxyurea
  • Myelodysplastic syndrome
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6
Q

Anaemia

List the causes of normocytic anaemia.

(4)

A
  • Increased loss or breakdown of red blood cells (increased reticulocytes)
  • Decreased production of red blood cells (normal or decreased reticulocytes)
  • Increased plasma volume (normal or decreased reticulocytes)
  • Coeliac disease
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7
Q

Anaemia

What circumstances might cause increased a loss or breakdown of red blood cells (increased reticulocytes) causing anaemia?

(2)

A

Haemolysis
or
Haemorrhage

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8
Q

Anaemia

What are some causes of haemolysis?

grouped into 2 sets

A

Acquired
- infections (malaria)
- autoimmune disorders
- physical damage (from an artificial heart valve)
- drugs

Hereditary
- G6PD deficiency (X – linked recessive and more common in African/Mediterranean backgrounds)
- sickle – cell anaemia
- hereditary spherocytosis
- paroxysmal nocturnal haemoglobinuria

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9
Q

Anaemia

What circumstances might cause decreased production of red blood cells (normal or decreased reticulocytes) causing anaemia?

(3)

A
  • CKD or EPO deficiency
  • Bone marrow suppression* (due to infection/drugs/malignancy)*
  • Anaemia of chronic disease
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10
Q

Anaemia

What circumstance might cause **Increased plasma volume ** (normal or decreased reticulocytes) causing anaemia?

(1)

A

Pregnancy

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11
Q

Anaemia

Why might coeliac disease cause normocytic anaemia?

A

mixed deficiencies of folate (macrocytic anaemia) and iron (microcytic anaemia) can occur cancelling each other out and causing normocytic anaemia.

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12
Q

Anaemia

Name some symptoms of anaemia.

4

A
  • fatigue / weakenss
  • SOB
  • pallor
  • palpitations
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13
Q

Anaemia

Name some Symptoms of vitamin B12 deficiency.

A
  • Paraesthesia
  • Ataxia/reduced sense of vibration/positive Romberg’s test due to degeneration of the posterior column
  • Pale skin
  • Petechiae
  • Glossitis
  • Angular cheilitis
  • Cognitive impairment

+ Usual symptoms of anaemia

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14
Q

Anaemia

Name some symptoms of folate deficiency.

A
  • Headache
  • Weight loss

+ Usual symptoms of anaemia

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15
Q

Anaemia

Name some symptoms of haemolytic anaemia.

A
  • Jaundice
  • Splenomegaly may occur with hereditary spherocytosis or non – Hodgkin’s lymphoma
  • Hereditary spherocytosis can cause gallstones – right upper quadrant pain
  • Dark urine will be seen in intravascular haemolysis e.g. G6PD deficiency or paroxysmal nocturnal haemoglobinuria

+ Typical signs of anaemia

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16
Q

Anaemia

What parameters of MCV classify:
- micro
- macro
- normo
anaemia

A
  • Microcytic anaemia = MCV <80fL
  • Macrocytic anaemia = MCV **>100fL **
  • Normocytic anaemia = MCV 80-100fL
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17
Q

Anaemia

How might iron studies come back for:
Iron deficiency anaemia

A
  • low serum iron
  • low ferritin
  • increased total iron-binding capacity
  • transferrin <16%
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18
Q

How might iron studies come back for:
Thalassemia

A

normal

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19
Q

How might iron studies come back for:
Sideroblastic anaemia

A
  • high serum iron
  • high ferritin
  • low total iron-binding capacity
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20
Q

How might iron studies come back for:
Anaemia of chronic disease

A
  • low serum iron
  • high ferritin
  • low total iron-binding capacity
  • transferrin 5-15%
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21
Q

Anaemia

What might cause Vit B12 deficiency?

A
  • vegan diet
  • Crohn’s disease
  • gastric bypass
  • pernicious anaemia
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22
Q

What might cause folate deficiency?

A

pregnancy or diet

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23
Q

Anaemia

What might cause iron deficiency anaemia?

A
  • Blood loss
  • diet
  • Poor iron absorption e.g. coeliac disease, IBD, H. Pylori, GI surgery or TMRPSS6 gene mutation
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24
Q

Anaemia

How do pts with beta-thalassemia trait present?

A

usually asymptomatic with little anaemia, but marked microcytosis

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25
Q

Anaemia

What is sideroblastic anaemia?

Why might be the cause of this happening? (3)

A

iron accumulation in red blood cell’s mitochondria prevents the ability to use iron to produce haemoglobin
- Inherited (X – linked recessive, ALAS2 gene)
- Acquired e.g. alcoholism, myelodysplastic syndrome, copper deficiency, B6 deficiency
- Idiopathic

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26
Q

Anaemia

What chronic diseases might cause anaemia of chronic disease?

A

Autoimmune disease
Cancer

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27
Q

Anaemia

What might reticulocyte count be like in normocytic anaemia?

A

Hyperproliferative (reticulocyte count >2%) due to haemmorhage/haemolysis and therefore increased erythropoeisis
Hypoproliferative (reticulocyte count <2%) due to disease of decreased erythropoeisis originally

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28
Q

Anaemia

Why might creatinine be raised in a pt with normocytic anaemia?

A

CKD

29
Q

Anaemia

What investigation (beyond bloods) might you do for iron deficiency anaemia?

A
  • Test for H. Pylori infection
  • Consider faecal occult blood test and endoscopy or colonoscopy in patients with suspected GI bleeding
  • Coeliac serology to rule out coeliac disease
30
Q

Anaemia

What investigation is required to diagnose sideroblastic anaemia?

What will a positive test show?

A

Bone marrow biopsy and staining of red blood cells

  • ringed sideroblasts in mitochondria seen.
31
Q

Anaemia

What investigation (beyond iron studies) might you do for megaloblastic anaemia?

A
  • Blood smear
  • Test vitamin B12 and folate levels
  • Plasma homocysteine
  • Plasma or serum methylmalonic acid
  • Test for anti–Intrinsic factor antibodies
  • Endoscopy for patients with suspected Crohn’s disease
32
Q

Anaemia

How would a blood smear help is to differentiate between megaloblastic and non-megaloblastic anaemia?

A

Macrocytosis and hypersegmented neutrophils seen on a blood smear for megaloblastic

33
Q

Anaemia

How do plasma homocysteine and plasma/serum methylmalonic appear in B12 and folate deficiency?

A

Plasma homocysteine
- increased in B12 deficiency
- increased in folate deficiency

Plasma/serum methylmalonic acid
- increased in B12 deficiency
- normal in folate deficiency

34
Q

Anaemia

What investigation (beyond bloods) might you do for non-megaloblastic anaemia?

Very complicated, just read thru this one

A
  • Imaging to look for suspected haemorrhage.
  • Haemolysis: increased LDH, decreased haptoglobin, increased bilirubin, raised reticulocytes. A peripheral smear will show abnormal red blood cells such as schistocytes, spherocytes, blister cells or tear cells depending on the cause.
  • Hereditary spherocytosis (haemolytic anaemia) can cause gallstones which can be seen on x-ray.
  • Coombs test used to test for or rule out autoimmune haemolytic anaemia, in which case it will be positive.
  • Haemoglobin electrophoresis may be needed to diagnose sickle cell disease.
  • G6PD deficiency: Peripheral blood smear will show Heinz bodies and bite cells. (Note that during an acute attack, G6PD levels will not be low).
  • Flow cytometry is needed for paroxysmal nocturnal haemoglobinuria diagnosis: >1-3% of anchor-deficient granulocytes.
35
Q

Anaemia

How do we treat pts with iron deficiency anaemia? (prescribing)

A

Iron replacement

  • Oral
  • Consider ascorbic acid alongside iron supplementation if oral iron is not well tolerated.
  • IV iron replacement can be used for patients not tolerating oral iron.
  • A blood transfusion may also be required.
36
Q

Anaemia

In what form do pts take oral iron replacement? What is taken alongside it?

A
  • ferrous sulphate
  • ferrous gluconate
  • ferrous fumarate
  • ferric maltol

usually taken alongside vitamin C

37
Q

Anaemia

How do we treat pts with Vit B12 deficiency, asymptomatic/mild deficiency? (prescribing)

A

vegan pts or over 65 years old with an inadequate diet
- oral B12 supplementation
- if no response -> cyanocobalamin or hydroxocobalamin for life.

pts with chronic GI condition/reasons cyanocobalamin or hydroxocobalamin should be used.

38
Q

Anaemia

How do we treat pts with Vit B12 deficiency, symptomatic? (prescribing)

A

**mild/moderate symptoms **
- lifelong cyanocobalamin or hydroxocobalamin

severe symptoms
- parenteral cyanocobalamin or hydroxocobalamin for life is required.
- refer to specialist to a
Some patients may also require a blood transfusion and folic acid supplementation also.

39
Q

Anaemia

Who do we give folate supplementation to? (prescribing)

(2)

A
  • All pregnant women
  • those at risk of deficiency from other conditions
40
Q

Anaemia

How do we treat pts with normocytic anaemia caused by chronic renal disease:? (prescribing)

A

Erythropoiesis stimulating agents
- epoetin alfa can be used

41
Q

Anaemia

How do we manage sickle cell disease? (prescribing / non-prescribing)

A
  • Long term hydroxycarbamide
  • Avoid cold weather, sudden changes in temperature, high altitude or dehydration to prevent a sickle cell crisis.
  • Regular blood transfusions with iron chelation therapy may be required.
42
Q

Anaemia

How do we treat paroxysmal nocturnal haemoglobinuria? (prescribing)

A
  • Eculizumab
  • Blood transfusions
43
Q

Anaemia

How do we treat siderolastic anaemia?

A
  • Treat underlying cause
  • Vitamin B6 therapy
  • Desferrioxamine subcutaneously or intramuscular used to remove excess iron
44
Q

Anaemia

How do we manage G6PD deficiency?

A
  • Avoid broad beans or drugs that can cause an attack such as primaquine, aspirin, dapsone or sulphonamides.
  • Blood transfusions and folic acid supplementation.
  • Splenectomy may be required
45
Q

Anaemia

What should pt with G6PD deficiency avoid?

A

broad beans

drugs that can cause an attack:
- primaquine
- aspirin
- dapsone
- sulphonamides

46
Q

Anaemia

How would these values be in IDA?

____ Hb and haematocrit
____ MCV and ____ MCH
Peripheral blood smear showing ____ and ____
____ Reticulocyte count
____ Serum Iron
____ Total iron-binding capacity (TIBC)
____ Transferrin Saturation
____ Serum Ferritin

A

< Hb and haematocrit
< MCV and <MCH
Peripheral blood smear showing microcytic, hypochromic cells.
< Reticulocyte count
< Serum Iron
> Total iron-binding capacity (TIBC)
< Transferrin Saturation
< Serum Ferritin

47
Q

Anaemia

Name some classical signs and symptoms of IDA

10

A
  • Fatigue
  • Headaches
  • Exercise intolerance
  • Weakness
  • Pica
  • Restless Leg Syndrome
  • Exertional Dyspnoea
  • Koilonychia
  • Cheilosis/Angular Cheilitis
  • Atrophic Glossitis
48
Q

Anaemia

Who is IDA most common in?

2

A

most common amongst women of childbearing age, children, and those living in middle or low-income countries

49
Q

Anaemia

IDA can stem from 3 groups of issues:

A
  • Reduced iron intake
  • Increased requirements of iron
  • Iron loss
50
Q

Anaemia

Name 4 inherited types of haemolytic anaemias.

A
  • Hereditary spherocytosis
  • Glucose-6-phosphate deficiency
  • Pyruvate kinase deficiency
  • Haemoglobinopathies (sickle cell anaemia and thalassaemia)
51
Q

Anaemia

What are the 2 mechanisms of destruction of red blood cells in haemolytic anaemia?

A

intra (occurs within the circulation) and extravascular (a normal physiological process)

52
Q

Anaemia

What are red blood cell fragments on a blood film called?

A

Schistocytes

53
Q

Anaemia

When might you see schistocytes on a blood smear?

A

found in microangiopathic haemolytic anaemias (e.g. disseminated intravascular coagulation, haemolytic uraemia syndrome, HELLP syndrome) and traumatic processes (e.g. mechanical prosthetic heart valve)

54
Q

Anaemia

When might you see spherocytes on a blood smear?

A

found in hereditary spherocytosis and autoimmune haemolytic anaemias

55
Q

Anaemia

When might you see Blister or bite cells on a blood smear?

A

found in enzyme deficiencies

(e.g. G6PD deficiency and pyruvate kinase deficiency)

56
Q

Anaemia

How might we manage autoimmune haemolytic anaemias?

A

corticosteroids to reduce AB porduction

57
Q

Anaemia

What might blood count and LFTs show in haemolytic anaemia?

A
  • increased MCHC
  • raised serum bilirubin
  • raised LDH
58
Q

Anaemia

What might urinalysis show in haemolytic anaemia?

A

haemoglobinuria
or haemosiderinuria in intravascular haemolysis

59
Q

Anaemia

Which test detects the presence of antibodies bound to the red blood cell surface in vivo?

What diagnosis is this test helpful for?

A

Coombs test

  • helpful in the diagnosis of** autoimmune haemolytic anaemia**, haemolytic disease of the newborn and ABO transfusion reactions.
60
Q

Anaemia

Sideroblastic anaemia is anaemia due to defective ____ synthesis. So if If ____ is deficient, iron stays trapped in mitochondria.

A

protoporphyrin

61
Q

Anaemia

Sideroblastic anaemia can be congenital (genetic) or acquired. The most common genetic defect is an X-linked defect in the ____ gene.

A

ALA synthase

62
Q

Anaemia

Acquired causes include myelodysplastic syndromes or reversible acquired causes.

Name some reversible acquired causes.

4

A
  • Alcohol is the most common – mitochondrial poison
  • Lead poisoning – inhibits ALAD and Ferrochelatase
  • Vitamin B6 deficiency – needed cofactor for ALAS. This is most commonly seen as a side effect of isoniazid treatment for tuberculosis but can also be a side effect of linezolid therapy. This is reversible with Vitamin B6 (pyridoxine) administration.
  • Copper deficiency
63
Q

Anaemia

Which stain can we use to visualise ringed sideroblasts in bone marrow in sideroblastic anaemiar?

A

prussian blue

64
Q

Anaemia

What may be seen in sideroblastic anaemia on a peripheral blood smear?

A
  • basophilic stippling of RBCs
  • Pappenheimer bodies (basophilic granules
  • microcytic and hypochromic RBCs
65
Q

Anaemia

Lab findings of sideroblastic anaemia:
- ferritin
- TIBC
- serum iron
- % saturation

tibc - total iron binding capacity

A
  • increased ferritin
  • normal/decreased TIBC
  • increased serum iron
  • increased % saturation (iron-overloaded state).
66
Q

Anaemia

Acute management of sideroblastic anaemia (congenital)

1st and 2nd line

A

1st line: A trial of pyridoxine (50 to 200 mg/day) +/- folic acid

2nd line: Second-line therapy involves packed red blood cell transfusions + iron chelation therapy

Erythropoietin and granulocyte colony-stimulating factor may be trialled in myelodysplasia-associated refractory anaemia with ringed sideroblasts.

67
Q

Anaemia

Acute management of sideroblastic anaemia (acquired, iatrogenic, drugs)

A

withdrawing the drug and administering pyridoxine

68
Q

Anaemia

Management for sideroblastic anaemia (chronic)

A
  • Periodic phlebotomy if iron overloaded.
  • Bone marrow transplant if the patient is young and anaemia is refractory to pyridoxine with iron overload and transfusion-dependence.

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