Anemia Flashcards
_______
is defined as a reduction in red blood cell numbers or
a haemoglobin (Hb) level below the normal reference
level for the age and sex of that individua
Anaemia
The WHO defines anaemia as haemoglobin
_______ for men,_______ for women and______
in pregnant women and school-aged children.
<130 g/L
<120 g/L
<110 g/L
In Australia, most people with anaemia will have
iron deficiency ranging from up to _______ for children
to ________ for menstruating females.
5%
20%
The incidence of haemoglobinopathy traits,
especially _________ is increasing in
multicultural Western societies
thalassaemia,
If a patient presents with precipitation or
aggravation of myocardial ischaemia, heart failure
or intermittent claudication, consider the possibility
of _________
anaemia
The serum ________level, which is low in cases of
iron-deficiency anaemia, is probably the best test to
monitor iron-deficiency anaemia as its level reflects
the amount of stored iron.
ferritin
Give some unusual features of anemia:
• dyspnoea on exertion • palpitations • angina on effort • intermittent claudication • pica—usually brittle and crunchy food, e.g. ice (iron-deficiency anaemia
Non-specific of anemia signs include
pallor, tachycardia, systolic
flow murmur and angular cheilosis.
Specific of anemia signs include
jaundice—haemolytic
anaemia, and koilonychias (spoon-shaped nails)—
iron-deficiency anaemia
The history may indicate the nature of the problem
___________: inadequate diet, pregnancy, GIT
loss, menorrhagia, NSAID and anticoagulant
ingestion
iron deficiency
The history may indicate the nature of the problem
___________inadequate diet especially
with pregnancy and alcoholism, small bowel
disease
folate deficiency:
The history may indicate the nature of the problem
__________previous gastric surgery,
ileal disease or surgery, pernicious anaemia,
selective diets (e.g. vegetarian, fad)
vitamin B12 deficiency:
________abrupt onset anaemia with mild
jaundice
haemolysis:
The various types of anaemia are classified in terms
of the red cell size—the_______
mean corpuscular volume
(MCV):
- microcytic—MCV _____
- macrocytic—MCV_____
- normocytic—MCV _______
≤ 80 fL
>100 fL
80–100 fL
the anaemia of
______ can be macrocytic in addition to the
more likely normocytic;
hypothyroidism
_____ is the most common cause of anaemia
worldwide
It is the biggest cause of microcytic
anaemia,
Iron deficiency
the main differential diagnosis of
microcytic anaemia being a _____ and ____
haemoglobinopathy such
as thalassaemia
Lab features of IDA
• Microcytic anaemia
• Serum ____ level low (NR: F 15–200 mcg/L: M
30–300 mcg/L)
• Serum _____ level low
ferritin
iron
Non-haematological effects
of chronic iron deficiency
- Angular cheilosis/stomatitis
- Glossitis
- Oesophageal webs
- Atrophic gastritis
- Brittle nails and koilonychias
Cause of IDA: physiological
1
2
3
- Prematurity, infant growth
- Adolescent growth
- Pregnancy
s.Fe ↓; s.ferr ↓; transferrin ↑
Investigations: Therapeutic trial of iron; GIT
evaluation for blood loss
Iron deficiency
s.Fe N or ↑; s.ferr N or ↑
Investigations: Haemoglobin investigation,
e.g. electrophoresis
Haemoglobinopathy (e.g.
thalassaemia
s.Fe N or ↑; s.ferr N or ↑
Investigations: Bone marrow examination
Sideroblastic anaemia (hereditary
Occasionally microcytic
s.Fe ↓; s.ferr N or ↑; transferrin ↓
Anaemia of chronic disease
Example of macrocytic
With megaloblastic changes
1
2
3
Vitamin B12 deficiency
Folate deficiency
Cytotoxic drugs
s.B12 ↓; rc.Fol N or ↑
Investigations: IF antibody assay; Schilling test
Vitamin B12 deficiency
s.B12 N; rc.Fol ↓
Folate deficiency
Appropriate setting; s.B12 N; rc.Fol N
Cytotoxic drugs
Examples of macrocytic without megaloblastic
- Liver 2. disease/alcoholism
Myelodysplastic disorders (including
sideroblastic anaemia)
Appropriate setting; uniform
macrocytosis; s.B12 N; rc.Fol N
Liver function tests
Liver disease/alcoholism
Specific peripheral blood findings;
s.B12 N; rc.Fol N
Bone marrow examination
Myelodysplastic disorders (including sideroblastic anaemia
Examples of normocytic
Myelodysplastic disorders (including
sideroblastic anaemia
Chronic kidney disease
Endocrine disorders (e.g. hypothyroidism
Isolated anaemia; Retic ↑
Acute blood loss/occult
Specific red cell changes; Retic ↑
Investigations: s.Bil and s.LDH ↑; s.hapt ↓ specific
tests for cause
Haemolysis
Isolated anaemia; Retic ↓
Chronic kidney disease
T or F, if GI bleeding is suspected, do FOBT
false. Do gastroscopy and colonoscopy
CBC of IDA
- Microcytic, hypochromic red cells
- ____________ (variation in size), _______(shape)—pencil-shaped rods
Anisocytosis
poikilocytosis
IDA
- Low serum iron level
- Raised _________
- _________low (the most useful index
iron-binding capacity
Serum ferritin level
__________is increased in iron deficiency, but not in
chronic disease. It is very helpful therefore in
differentiating iron deficiency from other forms.
It is an indirect marker of what is happening in
the bone marrow
Soluble transferrin receptor factor
in iron deficiency, the serum iron and ferritin levels
are low and the transferrin high, but the serum iron
level is also low in ___________
all infections—severe, mild and
even subclinical—as well as in inflammatory states,
malignancy and other chronic conditions
Serum ferritin estimations are spuriously raised in 1 2 3
liver
disease of all types, chronic inflammatory conditions
and malignanc
______is normally raised in
pregnancy.
transferrin
How to give oral Iron
oral iron (ferrous sulphate 1–2 tablets daily
between meals for 6 months) e.g. Ferro-
Gradumet with orange juice or ascorbic acid
until Hb is normal
How to give parenteral iron
parenteral iron preferably by IV infusion
is probably best reserved for special
circumstances (there is a risk of an allergic
reaction). Avoid blood transfusions if
possible
• Anaemia responds after about _____weeks and is
usually corrected after _____months (if underlying
cause addressed). 1
• Oral iron is continued for ______months to
replenish stores.
• Monitor progress with regular serum levels.
• A serum ferritin level ______ generally
indicates adequate stores.
2
2
3 to 6
ferritin
> 50 mcg/L
Things to consider in failure to tx
• poor compliance
• continuing blood loss
• malabsorption (e.g. severe coeliac disease)
• incorrect diagnosis (e.g. thalassaemia minor,
chronic disease)
• bone marrow infiltration
This inherited condition is seen mainly (although not
exclusively) in people from the Mediterranean basin,
the Middle East, north and central India and South-
East Asia, including south China
Thalassaemia
The ______form is a very severe congenital
anaemia needing lifelong transfusional support but
is comparatively rare, even among the populations
prone to thalassaemia
homozygous
The key to the diagnosis of _______thalassaemia minor is significant microcytosis
quite out of proportion to the normal Hb or slight
anaemia, and confirmed by finding a raised HbA 2 on
Hb electrophoresis.
heterozygous
Treatment of thalassaemia major is transfusion
to a high normal Hb with packed cells plus
______
desferrioxamine.
This Hb variant is common throughout South-East
Asia. 4 It has virtually no clinical effects in either the
homozygous or heterozygous forms, but these people
have microcytosis, which must be distinguished from
iron deficiency
Haemoglobin E
if the HbE gene is combined
with the thalassaemia gene, the child may have a
lifelong anaemia almost as severe as ______
thalassaemia
major.
AED associated with Marcocytosis
Phenytoin
Primidone
Phenobarbitone
Abx associated with Marcocytosis
Cotrimoxazole Pyrimethamine
(incl. Fansidar and Maloprim)
Zidovudine
Cytotoxics associated with Macrocytosis
Azathioprine
Methotrexate 5-fluorouracil
These conditions have been recognised under a
variety of names, such as ‘refractory anaemia’ and
‘preleukaemia’, for a long time, but only relatively
recently have they been grouped together. They are
quite common in the elderly but may be seen in any
age group
Myelodysplastic syndromes
MDS:
They are usually
associated with progressive intractable _________ and ___________or both, and progress slowly but
relentlessly to be eventually fatal, terminating with
infection, haemorrhage or, less often, acute leukaemia
neutropaenia
or thrombocytopenia
Although well recognised, this is a much less common
cause of macrocytosis than the foregoing conditions.
It is usually caused by lack of intrinsic factor due to
autoimmune atrophic changes and by gastrectomy
Vitamin B12 deficiency
(pernicious anaemia
Vitamin B12 deficiency may also
be seen together with other deficiencies in some cases
of ______ and _____
malabsorption and Crohn disease
causes of Vit B12 deficiency:
- atrophic gastritis
- H. pylori infection
- H 2 receptor blockers
- PPI drugs
- other drugs, e.g. OCP, metformin
- chronic alcoholism
- HIV
- strict vegan diet
B12 deficiency:
The clinical features are anaemia (macrocytic),
weight loss and neurological symptoms, especially a
_____. It can precipitate ________of the cord.
polyneuropathy
subacute combined
degeneration
Tx of B12 replacement therapy
• Vitamin B 12 (1000 mcg i.e. 1 mg) IM injection; body stores (3–5 mg) are replenished \_\_\_\_\_\_\_ • Maintenance with \_\_\_\_\_
• Can use crystalline oral B12
after 10–15
injections given every 2 to 3 days
1000 mcg injections every
third month
Folic acid deficiency:
Diagnostic test: serum folate (normal range 7–45
nmol/L) and ______—best test (normal
>630 nmol/L)
red cell folate
Folic Acid Def
The main cause is poor intake associated with
old age, poverty and malnutrition, usually associated
with ____
alcoholism
Folic Acid Def
It may be seen in malabsorption
and regular medication with anti-epileptic drugs
such as ______.
phenytoin
Folic Acid deficiency
It is rarely, but very importantly,
associated with pregnancy, when the demands of
the developing fetus together with the needs of the
mother outstrip the dietary intake—the so-called
_______which, if not
recognised and treated immediately, can still be a
fatal condition.
‘pernicious anaemia of pregnancy’
Folic acid requirement per day
5–10 mcg/day.
Oral folate 5 mg/day to replenish body stores (5–10 mg).
This takes ____________.
Vitamin B 12 is usually given unless levels normal.
about 4 weeks but continue for 4 months
This is the most common cause of normocytic
anaemia and is usually due to haematemesis and/or
melaena
Acute haemorrhage
Intercellular iron transport within the marrow is
suppressed in inflammation so that, despite normal
iron stores, the developing red cells are deprived of iron
and erythropoiesis is depressed
Anemia from chronic inflammation
This is often associated with anaemia due to failure
of erythropoietin secretion and is unresponsive to
treatment, other than by alleviating the insufficiency
or until erythropoietin is administered
Anemia from CKD
Suspect_______if there is a reticulocytosis,
mild macrocytosis, reduced haptoglobin, increased
bilirubin and urobilinogen
haemolytic anaemia
Hemolytic anemia:
The more common of the
congenital ones are hereditary spherocytosis, sickle
cell anaemia and deficiencies of the red cell enzymes,
pyruvate kinase and G-6-PD, although most cases of
G-6-PD deficiency haemolyse only when the patient
takes oxidant drugs such as ______ and _______
sulphonamides or eats
broad beans—‘favism’.
_______include those of
the newborn due to maternal haemolytic blood group
antibodies passing back through the placenta to the
fetus, and adult anaemias due to drug toxicity or to
acquired auto-antibodies
Acquired haemolytic anaemias
Acquired antibodies resulting on hemolytic anemia include:
About half of the latter
are idiopathic and half associated with non-Hodgkin
lymphomas, and the anaemia may be the presenting
sign of lymphoma
Acquired antibodies resulting on hemolytic anemia
Some of these antibodies are active
only at cool temperatures—__________;
others act at body temperature and are the more
potent cause of autoimmune haemolytic anaemia
cold agglutinin disease
This may be due to foreign tissue, such as carcinomatous
metastases or fibrous tissue as in myelofibrosis;
it may also be due to overgrowth by one or other
normal elements of the bone marrow, as in chronic
myeloid leukaemia, chronic lymphocytic leukaemia
and lymphoma, as well as by acute leukaemic tissue
Bone marrow replacement
Bone Marrow replacement:
A _______picture, in which immature red
and white cells appear in the peripheral blood, is often
seen when the marrow is replaced by foreign tissue.
leuco-erythroblastic
Important causes of anaemia in childhood include 1 2 3
iron-deficiency anaemia (quite common),
thalassaemia major, sickle-cell anaemia and
drug-induced haemolysis
Key to dx of hemoglobinopathies
children of Mediterranean,
South-East Asian, Arabic or African–American
descent, especially with a family history, normal
ferritin level or anaemia resistant to iron therapy.
