Anaemia – in Practice Flashcards
84 year old woman:
Pins and needles in feet and hands
Feels ‘as though walking on cotton wool’
- Paraesthesia
- Peripheral sensory neuropathy
Tired and has a sore tongue
Hb 63 (108-143)
MCV 123 (82-99)
WBC 3.2 (4-10)
Plts 90 (140-400)
Film:
- Oval macrocytes
- Neutrophil hypersegmentation
What is the most likely diagnosis?
A) Iron deficiency anaemia
B) Megaloblastic anaemia
C) Acute leukaemia
D) Chronic anaemia secondary to diabetes
B
Iron deficiency = gives you microcytic anaemia so doesn’t fit with results
Acute leukaemia – blood film would likely to have blasts there
What blood tests would you do to confirm your diagnosis?
A) Plasma G-6-PD levels
B) Serum Ferritin level
C) Serum B12 and folate levels
D) Reticulocyte count, bilirubin and LDH
C
How do you confirm it is megaloblastic anaemia?
Retic count will go up if your cells are haemolysing
Need normal B12 and folate to make normal cells so they do fall apart a bit so bilirubin may be elevated but retic count will be low as she doesn’t have the fuel to make red cells properly
If the patient is thought to have pernicious anaemia, which of these is a diagnostic test?
A) Antinuclear antibodies
B) Antiendomysial antibodies
C) Anti-intrinsic factor antibodies
D) Antiparietal cell antibodies
C
This lady has a low vitamin B12, think she had pernicious anaemia
This is a specific test that gives you a diagnosis
Antiparietal cell antibodies are not specific for just pernicious anaemia
84 year old woman
How would you treat her pernicious anaemia?
Hb 63, MCV 123, WCC 3.2, Plts 90
A) Oral Vitamin B12
B) IM Vitamin B12
C) Blood Transfusion
D) Immunosupression eg.steroids
B
IM vitamin B12
problem with vitamin B12 absorption in the stomach
Cant absorb oral B12 if you don’t have intrinsic factor to bind it
84 year old woman
Differential diagnosis?
Hb 63, MCV 123, WCC 3.2, Plts 90
Blood film
Hypogranular neutrophils
Red cell anisocytosis
Myelodysplasia
22 year old female medical student:
Tired
Difficulty concentrating on work
Irritable with friends
Breathless on exercise
Denies other symptoms
Looks pale
FBC and film:
Hb 84 (120-160) MCV 77 (82-99) MCH 23 (27-32) WBC 5.7 (4-10) Plts 434 (140-400)
What is the term used to give a morphological description of this anaemia?
A) Hypochromic, microcytic anaemia
B) Macrocytic anaemia
C) Normochromic, normocytic anaemia
D) Pancytopenia
A
Pale and small cells
22 year old female medical student
What laboratory test would you do first to investigate the cause?
A. Ferritin
B. Haemoglobinopathy screen
C. Bone marrow aspirate
D. Serum Igs
A
Measure of the bodies iron stores
22 year old female medical student
- Ferritin 6.0ug/l
- What is the diagnosis?
- What questions would you ask?
- Iron deficiency anaemia
- Bleeding – menorrhagia
- Not pregnant!
- Diet – vegetarian
- No GI Symptoms
“She should be referred for GI investigations”
- TRUE
- FALSE
False
Would be good to find out about menstrual history in a young women
To look for an alternative cause of blood loss
In young women of menstruating age and no GI symptoms then no need to send for GI investigation
Iron requirement also goes up during pubertal spurt
22 year old female medical student
Hb 84, MCV 77, WBC 5.7, Plts 434
How would I advise you to treat her?
A) IV iron
B) Blood transfusion
C) Oral iron
D) Dietary advice
C
Haem iron and non-haem iron have different ways of being absorbed
Digest iron from meat much better compared to plant iron
78 year old retired surgeon:
Hb 84 (116-156)
MCV 77 (82-99)
MCH 23 (27-32)
WBC 5.7 (4-10)
Plts 623 (140-400)
- Tired
- Difficulty concentrating on crosswords
- Breathless on exercise
- Chest pain at rest
Ferritin is low
“He should be referred for GI investigations”
A) TRUE
B) FALSE
A
78 year old man
Ferratin also low
Really in a man, even a younger man who doesn’t have much GI symtology, often wondering why iron level is low and you need to think that he must be losing iron somewhere (if he has a reasonable diet)
You lose iron when you bleed and most common place is the GI tract
How would you treat him?
How would I advise you to treat him?
A) IV iron
B) Blood transfusion
C) Oral iron
D) Dietary advice
B
Probably admit this chap and give blood transfusion
Chest pain at rest is unstable angina and high chance this man would have MI if left at home
Not making enough red cells to perfuse his cardiac muscle properly
IV iron doesn’t work much quicker than oral iron
In this situation, cause of unstable angina give blood
Hypochromic, microcytic anaemia with normal ferritin - what is a possible cause?
A. Hereditary spherocytosis
B. G6PD deficiency
C. Sickle cell anaemia
D. Thalassaemia trait
D
A. You get spherical cells
All are haemolysing
Carrier of thalassemia gives you small cells often confused with iron deficiency
what is the structure of normal adult haemaglobin?
Adult haemoglobin (HbA) composed of haem molecule and:
- 2 alpha (a) chains
- 4 alpha genes
- 2 beta (b) chains
- 2 beta genes
Normal Adult Hb
- Hb A (aabb) – 97%
- Hb A2 (aaδδ) – 2%
- Hb F (aaγγ) – 1%
2 carriers of beta thalassaemia trait are partners and are planning a pregnancy.
What is the chance that they will have a baby affected by beta thalassaemia major?
A) 1 in 4 (25%)
B) 1 in 2 (50%)
C) 1 in 5 (20%)
D) Unknown without knowing the specific mutations
A
Hypochromic, microcytic anaemia:
What are Other causes apart from iron deficiency
•Normal ferritin
Thalassaemia trait
Secondary anaemia/anaemia of chronic disease:
- More usually normochromic, normocytic
- Normal or elevated ferritin
- Ineffective iron utilisation
what is the Role of Hepcidin in anaemia of chronic disease?
Role of Hepcidin in anaemia of chronic disease –blocks ferroportin
34 year old waiter:
Tired
Noticed yellow eyes
Hb73 (140-180)
MCV 98 (82-99)
MCH 32 (27-32)
WCC 7.2 (4-10)
Plts 480 (140-400)
Blood film shows spherocytes. What other investigations would you order?
A) Reticulocyte count
B) Bilirubin, LDH
C) Serum haptoglobin
D) DAGT (Coombs test)
E) All of the above
E
Spherocyte don’t have pale area in middle
Large grey cells are the immature red blood cells coming out the marrow
LDH is another molecule coming from red cell breakdowns so will be high aswell
C will be low
34 year old waiter
DAGT is positive
What is the diagnosis?
A. Autoimmune haemolysis
B. Hereditary spherocytosis
C. G6PD deficiency
D. Microangiopathic haemolysis
A
34 year old waiter:
If DAGT negative is there an alternative diagnosis?
What questions could you ask?
- previous episodes
- family history
- any precipitants eg. viral infection, drugs
Hereditary spherocytosis
34 year old waiter:
Noticed yellow eyes
Pain in left chest
Breathless, fever
Ankle ulcer
crutch
Hb 73 (140-180)
MCV 98 (82-99)
MCH 32 (27-32)
Blood film shows sickle cells. What other lab investigations would you order?
A) Reticulocyte count
B) Bilirubin, LDH
C) Haemoglobinopathy screen
D) All of the above
WCC 7.2 (4-10)
Plts 530 (140-400)
D
34 year old waiter
Diagnosis - Sickle cell disease- HbSS
What is unlikely to be the cause of his pain?
A) Bony crisis
B) Pneumonia
C) Pulmonary Embolism
D) Splenic infarction
D
D because adults with sickle cell disease often don’t have much of a spleen at all that infarcted as a child
Painful sickle cell crisis- management should include:
A) Analgaesia
B) Oxygen
C) Fluids
D) All of the above
D
Oxygen saturation above 95%
What has precipitated it is the other thing
34 year old waiter:
Management should include what?
Analgaesia-usually require opiates
Oxygen
Fluids
Antibiotics if fever
Thromboprophylaxis
Consider blood transfusion if severe anaemia, stroke or chest crisis
Call haematology Registrar!
Sickle cell – chest crisis
what is it?
Chest crisis:
- Close observation as can deteriorate rapidly
- Worsening hypoxia
- Fever
- Chest pain
- Infiltrates on chest X-Ray
- Transfusion-top up or exchange
