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BRS Year 2 > Anaemia Tutorial > Flashcards

Anaemia Tutorial Flashcards

1
Q

What are the 4 main causes that lead to anaemia?

A

Reduced production of red cells / haemoglobin in the bone marrow

Reduced survival of red cells in the circulation (haemolysis).

Bleeding / blood loss

Pooling of red cells in a very large spleen

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2
Q

A patients presents with low MCV, low Hb, low RBCs and low MCH

What is the differential diagnosis for this?

A

Microcytic anaemia (low haemoglobin count)

Issue with RBC production - could be iron deficiency or anaemia of chronic disease

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3
Q

What are the differentials for microcytic anaemia?

A

Iron deficiency anaemia, thalassaemia, anaemia of chronic disease

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4
Q

What do these test results show?

Low ferritin
Low Serum iron
High Transferrin 
Low transferrin saturation 
No increase HbA2 in Hb electrophoresis

What does this data suggest towards the cause?

A

Iron deficiency

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5
Q

What further questions would you ask to a patient presenting with iron deficiency anaemia suggestive test results?

A

Diet - vegetarian or non-vegetarian

GI symptoms e.g. dysphagia, dyspepsia, abdominal pain, change in bowel habit, haematemesis, rectal bleeding, malarna, post-menopausal bleeding

Medications - aspirin, NSAIDs, other steroids

Weight loss

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6
Q

What is haemolysis?

How long does a typical RBC last?

What is anaemia caused by haemolysis?

A

Destruction of RBCs / shortened life span or RBCs

120 days

Haemolytic anaemia - due to G6PD deficiency

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7
Q

Where is haemolytic anaemia common? And why?

A

Africa - protects against malaria

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8
Q

What is a common name for a type of haemolytic anaemia?

Who is it more common in and why?

A

Sickle Cell Anaemia (SCA)

More common in males = recessive disorder

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9
Q

What is the clinical significance between conjugated and unconjugated bilirubin?

A

UNCONJUGATED = haemolysis

Conjugated = liver disease

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10
Q

Blood count shows:
low Hb
High MCV
High reticulocytes

What does this show?

A

Reticulocyte = baby RBCs

Bone marrow trying to compensate for anaemia- likely haemolysis due to unconjugated billurubin

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11
Q

What would a blood film for G6PD deficiency show?

Why do we see this?

A

Ghost cells- shows there’s been intravascular haemolysis
Heinz body- precipitated oxidised Hb
Hemighost

These are all indicators of oxidant damage to the red cells

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12
Q

How can G6PD deficiency be confirmed?

A

By assay

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13
Q

What advice would be given to a patient with G6DP deficiency?

A

Avoid oxidant drugs
Avoid broad beans (fava beans)
Avoid naphthalene
Beware haemolysis can result from infection - be mindful getting ill can precipitate a crisis

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14
Q

What are symptoms of SLE with acquired autoimmune haemolytic anaemia?

A 
Fluctuating multi-system disorder:
Ploy arthritis
Shortness of breath
Facial skin rashes
Hepatitis
Tiredness
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15
Q

Blood tests show:

Low Hb
High Bilirubin
B12 and folate normal
High MCV

What information does this tell us?

A

Macrocytic anaemia

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16
Q

A patient with haemolytic anaemia has high LDH, why?

A

Cells are being broken down so intracellular contents are leaking out

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17
Q

What does high unconjugated bilirubin suggest?

A

Haemolytic anaemia

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18
Q

How can acquired haemolytic anaemia present and what can cause this?

A 
Non-immune:
Microangiopathic Haemolytic uraemic syndrome 
Malaria 
Snake venom
Drugs

Immune mediated:
Auto immune
Allo immune (post blood transfusion)

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19
Q

How is a direct antiglobulin test carried out?

A

Human antibodies (immunoglobulin) bind to the antigens on saline suspended RBCs

Add to the saline suspended blood cells rabbit antibody, these bind to human immunoglobulin - causes cells to clump giving a positive DAT

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20
Q

When does Autoimmune Haemolytic anaemia occur?

A

Associated with immune system disorders:

  • Systemic auto immune disease
  • Underlying lymphoid cancer (lymphoma)

Idiopathic

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21
Q

What is unconjugated bilirubin?

A

Pre-hepatic bilirubin - has not yet passed through the liver

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22
Q

What would we see on a blood film for hereditary spherocytosis?

A

Spherocytes - reduced diameter, no central palor = suggests she has something that causes spherocytosis

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23
Q

What is hereditary spherocytosis?

A

Progressive loss of the RBC membrane - cells get more rigid = rigid spheres

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24
Q

What might we also see on a blood film for hereditary spherocytosis?

A

Polychromatic macrocytes = reticulocytes

Suggests her bone marrow is producing more RBCs than normal - to replace RBCs that are lost

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25
Q

Haemolysis VS haemolytic anaemia?

A

Haemolysis = lowered RBC lifespan <120 days

Haemolytic anaemia = cannot compensate for lowered RBC count

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26
Q

How do patients with chronic haemolysis get treated?

A

Folic acid - need due to increased DNA synthesis

Splenectomy (if severe) to increase red cell life span - spleen takes out the rigid RBCs (spehrocytes) out of the circulation

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27
Q

18 yr patient, previously diagnosed with hereditary spherocytosis, presents with acute upper right abdominal pain and tenderness
Jaundice more marked
High conjugated bilirubin

What is going on?

A

Gallstones at young age due to increased breakdown of Hb to bilirubin
Stone obstructed bile duct = obstructive jaundice
Liver = still able to conjugate bilirubin but it cannot go anywhere

28
Q

62F -

Severe tiredness
Decreased exercise tolerance 
Funny feeling on her feet - walking on cotton wool
Paler skin and yellowish tinge
Depigmentation affecting the face 
Blood test shows
Low Hb
High MCV
Low WBC
Low platelets
High unconjugated bilirubin
Low vit B12

What does this information tell you?

A

Megaloblastic anaemia due to vit B12 deficiency

29
Q

What does a blood film for megaloblastic anaemia show?

A

Hypersegmented neutrophils

Very macrocytic RBCs

Poikilocytosis - funny shaped RBCs = tear shapes, ovals, etc.

30
Q

What are differential for megaloblastic anaemia?

A

MDS (myelodysplasia)
B12 deficiency
Folate deficiency
Chemotherapy drugs

31
Q

What are megaloblastic features?

A

Megaloblasts = large with nucleocytoplasmic dissociation
Impaired DNA synthesis, nuclear maturation and cell division
Adequate cytoplasmic maturation and cell growth

So the maturation of the cytoplasm and nucleus is dyssynchronous (not synchronised) = impaired DNA synthesis

32
Q

What are B12 and Folic Acid required for?

A

Vitamin B12 is required for:

  1. DNA synthesis
  2. Integrity of the nervous system

Folic acid is required for:

  1. DNA Synthesis
  2. Homocysteine metabolism
33
Q

How can you become B12 or folate deficient?

A 
B12 deficiency:
Dietary - malnourishment, veganism
Gastric - gastrectomy,
autoimmune (pernicious anaemia)
Bowel - crohn's disease, ileal resection

Folic acid deficiency:
Reduced availability - poor diet, poverty, alcoholism, malabsorption (coeliac disease, jejunal resection)
Increased demand - pregnancy, lactation, increased cell turnover (haemolysis)

34
Q

How can B12 and folate deficiencies be treated?

A

B12 deficiency due to diet = oral supplements
B12 deficiency due to gastric or bowel issues = hydroxocobalamin injections (intramuscular)

Folic acid deficiency = oral supplements

35
Q

What neurological disorders can present due to Vit B12 and folic acid deficiency?

A

Vit B12: dementia, SACD (sub-acute combined degeneration) of spinal cord

Folic acid: developmental neural tube defects

36
Q

Areas of depigmentation suggests?

A

Vitiligo

37
Q

What does a medical history of other autoimmune conditions suggest?

A

Autoimmune - pernicious anaemia

Due to vitiligo which is already an autoimmune condition

38
Q

Summarise megablastic anaemia and its causes:

A

Anaemia due to asynchronous nucleocytoplasmic maturation in the bone marrow

Most common causes = Vit B12 and/or folic acid deficiency

39
Q

Define the terms:

Macrocytic anaemia
Pernicious anaemia
Megaloblastic anaemia

A

Macrocytic anaemia = anemia with small RBCs

Pernicious anaemia = autoimmune

Megaloblastic anaemia = nucleus and cytoplasm maturation in bone marrow not synchronised; B12 or folic acid deficiency

40
Q

Case Study:
45M - severe rheumatoid arthritis
Has taken NSAIDs over time and corticosteroids for chronic inflammation

Anaemic - Hb 85
Hb used to be 115 at previous attendance

MCV = 70 = normal
Reticulocytes = 54 x 10^9 = lower end of normal 
Platelets = 550 x 10^9 = high

What does the FBC suggest?

A

Low reticulocyte for anaemia

High platelet count = due to inflammation

Hb = low

Microcytic anaemia

41
Q

What are common causes for microcytic anaemia?

A

Iron deficiency

42
Q

Patient’s blood test shows:

Hb low 
MCV low
Ferritin high 
Serum iron low 
Transferrin low 
Transferrin saturation normal 
ESR 79 mm/hr

Which of these results are most important and why?

A

Ferritin high (can be normal in iron deficiency)
Serum iron low
Transferrin low

Free iron = v. toxic to the body, normally have v.low serum iron

In blood iron is bound to transferrin, in organs iron is bound to ferritin

43
Q

What does a blood film for anaemia of chronic disease show?

A

Hypochromic, microcytic, RBCs

Rouleaux (aggregations of RBCs)

44
Q

What does the high ferritin count suggest?

What does the low transferrin count suggest?

A

High ferritin = high storage of the iron in the organs

Low transferrin = inappropriately low as it should be raised to allow for iron to be transported around the body where it is required

45
Q

What is the likely diagnosis?

A

Anaemia chronic disease - characteristic findings =
Low / normal transferrin when it should be high whilst you’re anaemic

And typically high ferritin

46
Q

Chronic disease anaemia VS iron deficiency anaemia:

A 
Disease | Anaemia of Chronic Disease | Iron Deficiency Anaemia 
Hb | low | low
MCV | low/normal | low
Ferritin | high | low
Serum iron | low | low
Transferrin | low/normal | high
Transferrin saturation | normal | low
ESR | high | (may be) high
47
Q

What is anaemia of chronic disease?

A

Anaemia in unwell patients with no obvious cause e.g. no bleeding, no haeomlysis, no marrow infiltration, no iron / B12 / folic acid deficiency

Caused by inflammation - e.g. from infections, TB, HIV, autoimmune disorders, rheumatoid arthritis, malignancy etc.

Must treat it which allows anaemia to get better

48
Q

What is iron haomeostatis?

A

Excess iron = potentially toxic to organs esp. heart and liver

No physiological mechanism to remove iron from the blood

Therefore, iron absorption is tightly controlled - regulated by hepcidin (hepcidin blocks absorption and release of storage iron)

49
Q

What happens to hepcidin production when there is increased inflammatory (like in anaemia of chronic disease)?

How does this cause an erythropoeitin production issue eventually leading to anaemia?

A

Hepcidin production is increased

Hepcidin reduced iron absorption, iron transport and iron availability
This decreases EPO (erythropoeitin) production leading to anaemia

50
Q

What are the 3 common causes of reduced red cell survival?

A

Hereditary spherocytosis
Autoimmune haemolytic anaemia
G6DP deficiency

51
Q

What are the 3 common causes of reduced red cell production?

A

Iron deficiency anaemia
Anaemia of chronic disease
Megaloblastic anaemia

52
Q

What is meant by the terms:

Microcytic
Macrocytic
Normocytic

What are each of these normally accompanied by?

A

Microcytic - RBC smaller than normal, usually also hypochromic

Macrocytic - RBC normal, usually also normochromic

Normocytic - RBC larger than normal, usually also normochromic

53
Q

Can anaemia be classified on basis of cell size?

A

Yes

54
Q

What does microcytic anaemia indicate?

A

Generally indicates defect in haem synthesis:

  • Iron deficiency anaemia
  • Anaemia of chronic disease

Or defect in globin synthesis (thalassaemia):

  • Defect in alpha chain synthesis (alpha thalassaemia)
  • Defect in beta chain synthesis (beta thalassaemia)
55
Q

How does iron deficiency anaemia and thalassaemia differ in an FBC?

A 
Condition | Iron deficiency anaemia | Thalassaemia trait
Hb | low | low
MCV | low | low
MCH | low | low
MCHC | low | preserved
RBC | low | high
Ferritin | low | normal
56
Q

How can thalassaemia be distinguised between alpha and beta?

A

Hb electrophoresis:

Alpha = normal
Beta = Hb A2 raised
57
Q

What does macrocytic anaemia indicate?

A

Lack of vitamin B12 or folic acid (megaloblastic anaemia)
Use of drugs interfering with DNA synthesis
Liver disease and ethanol toxicity
Haemolytic anaemia (reticulocytes increased)

58
Q

What can lead to haemolysis?

A

Reduced erythrocute function due to:

  • Loss of integrity of membrane e.g. hereditary spherocytosis, autoimmune haemolytic anaemia
  • Change in Hb structure and function e.g. sickle cell anaemia (SCA)
  • Change in cellular metabolism e.g. G6PD deficiency
59
Q

What may cause normocytic anaemia?

A
  1. Recent blood loss e.g. GI haemmorrhage, trauma
  2. Failure of RBC production e.g. early stages of iron deficiency, bone marrow failure or suppression (chemotherapy), bone marrow infiltration (leukaemia)
  3. Pooling of RBCs in the spleen e.g. hypersplenism (liver cirrhosis), splenic sequestration in SCA (sickle cell anaemia)
60
Q

What are some clinical signs of iron deficiency anaemia?

A

Koilonychia

Glossitis Angular stomatitis

61
Q

What are causes of iron deficiency anemia?

A

Increased loss (blood loss):

  • Commonest cause in adults
  • Hookworm commonest cause worldwide
  • Menstrual (menorrhagia)
  • Gastrointestinal (often occult)

Insufficient iron intake:

  • Dietary
  • Vegetarians
  • Malabsorption
  • Coeliac disease (gluten-induced enteropathy)
  • H. pylori gastritis

Increased iron requirements:

  • Physiological
  • Pregnancy
  • Infancy
62
Q

If a patient presents with weight loss, change in bowel habits, rectal bleeding and iron deficiency anaemia, what investigations would you do?

A

Investigate blood in stool: faecal immunological test

GI investigations: Upper GI endoscopy, duodenal biopsy, colonoscopy

63
Q

What are symptoms of iron deficiency anaemia?

A

Tiredness
Lethargy
Breathlessness at rest, worst on exertion
Ankle swelling at end of day

64
Q

In what 2 conditions are spherocytes seen in?

How can I differentiate between the two?

A

Hereditary spherocytosis
Acquired autoimmune haemolytic anaemia

Use direct antiglobulin test to differentiate- positive for AAHA

65
Q

What is laboratory evidence of haemolytic anaemia?

A

High LDH
Unconjugated hyperbilirubinemia
Reduced haptoglobins
High reticulocytes

BRS Year 2 (110 decks)

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