Anemia

Question 1

Definition and classification

Answer 1

Definition-is the abnormal decreasing of hemoglobin (Hb) and red blood cells (RBC) level in the unit of blood volume 
Reduction in one or more of the major red blood cell (RBC) measurements:
Hemoglobin 
Hematocrit
RBC count

Classification
1. Classification according to mechanism
-Blood loss acute and chronic
   Eg Blood Loss
•Acute
•external: trauma, nosebleeds
•internal: GI bleeding, (ulcers, diverticules, varies)
•Chronic Bleeding
•GI
•Vaginal
•Nosocomial
•Fetal and postnatal
-Excessive destruction of rbcs eg hemolytic
-Impaired production of rbcs eg aplastic

2. according to reticulocyte count
   
   • Hypoproliferative eg Iron def. anemia,Aplastic anemia,Chronic disease
   • Hyperproliferative eg Hemolytic anemias
3. according to mean corpuscular volume (MCV)
   - microcytic <80 fl
   - normocytic-between 80 to 100 fl
   - macrocytic >100 fl

.macrocytic normochromic: pernicious anemia, folic acid deficiency and chronic liver disease
•normochromic normocytic: acute blood loss, and hemolytic anemias
•microcytic hypochromic: Iron deficiency anemia, thalassemia, sideroblastic anemias

3. according to severity
   - Mild – Hb level more than 9 g/dL
   - Moderate - Hb level between 9 and 7 g/dl -Severe - Hb level less than 7 g/dL

According to color index:

• Normochromic: CI=0,85 - 1
• Hypochromic: CI=<0,85
• Hyperchromic: CI= >1

Question 2

Symptoms, diagnosis and treatment

Answer 2

Diagnostic criteria for anemia-according to clinical manifestation-Weakness and fatigue are the most common symptoms of anemia.➢Decreased energy➢Shortness of breath on exertion (dyspnea)➢Palpitations (feeling of the heart racing or beating irregularly) – rapid heart rate➢Cold hands or/and feet-according to physical examination-The skin and mucous membranes are pale-according to lab test
: Complete blood count-anemia
: Stool guaiac-blood in stool
-auscultation-Heart murmur - systolic flow murmur
-Low blood pressure (hypotension)

Treatment of anemia depends on type of anemia

1. Iron defiency
   - taking iron supplements
   - Oral iron therapy-a)ferrous glutanate :1-2 tablets two or three times/day
   b) ferrous fumarate: 2 tablets/day
2. B10 defiency
   
   • oral folate supplementationfor four months or until hematologic recovery takes place
3. B12 defiency
   - Cyanocobalamin
4. aplastic anemia
   - bone marrow transplant
5. sickle cell anemia
   - bone transplant

Question 3

Iron deficiency anemia

Answer 3

It falls under microcytic hypochromic anemais.
Color index <0.85
Iron deficiency anemia develops when body stores of iron drop too low to support normal red blood cell production.
It’s under anemia caused by decreased RBC production.

Symptoms: fatigue, leg cramps, cold intolerance,
Diagnosis: complete blood count, peripheral blood smear, serum iron 50 to 150 ig/dL

Diagnostic criteria.
Symptoms: 
1) Sideropenic syndrome: -
i)Cheilosis (fissures in corners of mouth) 
ii)Koilonychias(spooning fingernails) 
iii)Smooth tongue, brittle nails, dysphagia, craving for 
specific Food .
Iv)Pica sign-eating ice,soil,charcoal

Laboratory findings:- erythrocytopenia, decreased Hb

Biochemical profile.
Ferritin, serum
Reference Range: 45-340 ng/dL
· Values less than 100 ng/dL usually indicate depleted iron stores
· Ferritin is decreased in patients with an iron-depletion state
Iron, serum
Reference Range: 50-150 ug/dL
· Useful for diagnosis of iron depletion states especially when used in combination with transferrin and transferrin saturation
· Can be used

5) Transferrin,serum
Reference Range: 200-400 mg/dL

6)Transferrin saturation

Reference Range: 20-45 %
·Transferrin saturation less than 20 % is indicative of an iron deficiency state
Treatment

Oral treatment
FerrousGluconate 1-2 tablets two or three times/day
Ferrous Fumarate 2 tablets/day
Ferrous Sulphate 3 tablets/day

Red blood Cell Transfusion

Question 4

Vitamin B12 deficiency anemia

Answer 4

Diagnostic criteria vitamin B12
-history anamnesis -alcoholism, gastric ulcers, gastritis
-clinical manifestation-signs of anemia(fatigue ,pallor),jaundice,neurological disturbances eg :peripheral neuropathy-tingling, numbness,pins-and needlessensation, coldness
:neuropyschriatric diseases eg depression ,dementia
-peripheral bloodsmear
:Macro-ovalocytic and hyperchromic
:Polychromasia
:Hypersegmented neutrophil

Treatment of B12 defiency

• healthy lifestyle-avoid taking alcohol
• food rich in b12 -eg especially those who are vegan should eat meat
• Im supplementation of B12 eg cyanocobalamin
• treat underlying disease eg chronic pancreatitis

Question 5

Aplastic anemia

Answer 5

Definition
Aplastic anemia is a syndrome of bone marrow failure characterized by peripheral pancytopenia and marrow hypoplasia.

Classification

1. according to reticulocyte count- hypoproliferative
2. due to impaired production of rbs
3. acquired or congenital

Causes

• idiopathic
• drug induced eg chloramphenicol
• viral infections-Hiv
• toxins -pesticides

Diagnostic criteria aplastic anemia
-clinical manifestation -
:Anemia
:Bleeding: Ecchymoses ,Bleeding gums, Epistaxis
:Infections: Fever,Mouth ulcers
-blood analysis-Pancytopenia and reticulocytopenia
-bone marrow aspiration-hypocellularity aplastic bone marrow with increased fat spaces

Treatment aplastic anemia

• treat underlying disease
• bone marrow transplant
• immunosupression drugs eg azathioprine
• glucocorticoids
• Antilymphocyte or Antithymocyte globulin
• Thymectomy : for Adult Pure Red Cell Aplasia
• Cyclosporine

Question 6

Hemolytic anemia

Answer 6

The loss of red cells either through hemorrhage or through premature destruction of the red blood cells (hemolysis) is called hemolytic anemia.

• The life span of RBC shortens then its normal
• Normochromic anemia
• Reticulocytosis(increased reticulocytes) - in response to increased destruction of RBC

SYMPTOMS:

• Abnormalpalenessor lack of color of the skin
• Dark-colored urine
• Fever
• Weakness
• Confusion
• Fatigue

CLASSIFICATION:
Combs +
Immune hemolysis 
Drug related hemolysis 
Blood transfusions 
Infection 
Cancer 
Combs -
erythrocyte membrane and enzymatic defects and hemoglobin abnormalities. Some hereditary disorders include the following:G6PD deficiency
Herediditary spherocytosis
Sickle cell anemia
Thalassemia
According to reticulocyte count 
Hyperproliferative 

The acquired hemolytic anemias can be classified into five categories.
I.Entrapment
II.Immune
a)Warm-reactive (IgG) antibody
b)Cold-reactive IgM antibody (cold agglutinin disease)
c)Cold-reactive IgG antibody (paroxysmal cold hemoglobinuria)
d)Drug-dependent antibody
III.Traumatic hemolytic anemia
IV.Hemolytic anemia due to toxic effects on the membrane
V.Paroxysmal nocturnal hemoglobinuria

Question 7

Symptoms, diagnosis and treatment

Answer 7

Diagnostic criteria 
Serum unconjugated bilirubin :increased 
Serum LDH: increased 
Serum haptoglobin:decreased 
Urine hemoglobin:present 
Urine hemosiderin :present 
RBC lifespan :decreased 
Reticulocyte count:increased 
There may be splenomegaly

Peripheral blood smear microscopy:
- Fragments of RBCs (schistocytes) can be present
- Spherocytes, small size of RBCs
•Level of unconjugated billirubin in blood is elevated, lead to jaundice sometimes
•If Coombs test + (autoimmune hemolysis)
•Hemosiderin in urine (indicates chronic intravascular hemolysis)
•Other lab:
- direct antiglobidin test
- glucose-6-phosphate dehydrogenase screen

Symptoms of hemolytic

General anemia
pallor, fatigue, SOB on exertion
Acute chest syndrome
cough, dyspnea, chest pain, fever

Infection
malaise, cough and chest pain, diarrhea and/or vomiting

Jaundice
Yellowing of skin and eyes

Treatment
Splenectomy
Corticosteroids
Ferrous sulfate