Approach to anaemia

Question 1

What is the clinical definition of anaemia?

Answer 1

Hemoglobin below normal reference range for age and sex

Question 2

What are some general symptoms and signs of anaemia?

Answer 2

Symptoms:
1) Fatigue, weakness
2) Dyspnea
3) Palpitations, worsening CHF
4) Tinnitus
5) Headache, presyncope, cognitive impairment, dizziness, apathy

Signs:
1) Pallor
2) Tachycardia
3) Bounding pulse
4) Hemic murmur
5) Cardiac failure

Question 3

What are 3 diagnostic tests used for suspected anaemia?

Answer 3

1) Full blood count
2) Reticulocyte count
3) Peripheral blood film
4) BM aspirate
5) Bilirubin (Liver panel)
6) Ferritin levels

Question 4

Pallor in the conjunctiva and not skin creases is indicative (more/less) severe anaemia?

Answer 4

Less
Conjunctival: Hb<9
Skin creases: : Hb<7

Question 5

What are the 3 main cells lines in an FBC and how are the differentiated?

Answer 5

1) Hb (RBC lysed)
- measured by photometry

2) WBC (any cell w nucleus)
- differentiated by granule content

3) Platelets (any cell w/o nucleus)
- differentiated by size

Question 6

What is pancytopenia?

Answer 6

A condition where all 3 cell lines (Hb, WBC, and platelets) are reduced

Question 7

What is bicytosis?

Answer 7

A condition where any 2 of the 3 cell lines (Hb, WBC, and platelets) are increased

Question 8

What are the 4 main red cell indices?

Answer 8

1) MCV (size)
2) MCH (avg. Hb/cell)
3) RDW (RBC width distribution: ↑% → < irregular/anicytosis)
4) Red cell count

Question 9

What are some possible findings in a peripheral blood film?

Answer 9

1) Sizes
- Macro/microcytosis
- Anisocytosis

2) Appearances
- Hyper/hypochromic
- Target cells
- Inclusion bodies

3) Shapes
- Spherocytes
- Cell fragments
- Poikilocytosis

4) Maturity
- Reticulocytes
- Erythroblasts
- Megaloblasts

Question 10

If an anemic px has low MCV, they are said to have ______ anemia. Further investigations on their _____ levels would narrow diagnostic possibilities into: ________________.

Answer 10

Microcytotic → Ferritin levels (Iron panel)

1) Low ferritin
- Fe deficiency

2) High/normal ferritin
- Thalassemia
- Inflammation anemia
- Sideroblastic anemia

Question 11

If an anemic px has normal MCV, they are said to have ______ anemia. Further investigations on their _____ levels would narrow diagnostic possibilities into: ________________.

Answer 11

Normocytic → Reticulocyte count

1) High reticulocyte (↑prod.)
- acute bleeding
- haemolysis

2) Low reticulocyte (↓ prod.)
- Renal anemia
- inflammatory anemia
- marrow disease

Question 12

If an anemic px has high MCV, they are said to have ______ anemia. Further investigations on their _____ levels would narrow diagnostic possibilities into: ________________.

Answer 12

Macrocytic → B12/Folate levels/FBP

1) Megaloblastic anemia
- B12/Folate deficiency

2) Non-megaloblastic anemia
- Reticulocytosis
- Alcohol
- Liver disease

Question 13

What are some possible causes of anemia in a px with reduced reticulocytes?

Answer 13

↓ production:
1) Hematinic deficiencies (Fe, B12, Folate)
2) Reduced globin chain (Thalassemia)
3) Bone marrow failure (inflammation, suppression, defect)
4) Insufficient EPO
5) Inability to utilise Fe

Question 14

What are some possible causes of anemia in a px with increased reticulocytes?

Answer 14

↑ loss/destruction:
1) Bleeding (surgery, trauma, menorrhagia, GI/GUT)
2) Immune-mediated hemolysis (AIHA, CHAD, PCH)
3) Non-immune hemolysis (hemoglobinopathies, infections, enzymes, mechanical)

Question 15

How does a px with iron deficiency typically present biochemically?

Answer 15

1) Ferritin <30ug/L
2) Microcytic, hypochromic anemia

Question 16

What are some possible underlying causes of iron deficiency?

Answer 16

1) Increased iron loss
- Bleeding
- Menstruation
- Drugs (eg. NSAIDS, blood thinners)
- elite athletes (fe loss thru sweat)

2) Increased iron requirement
- Pregnancy
- 0-5y/o
- adolescent girls
- women of child bearing age

3) Decrease intake/absorption
- diet
- antacids
- infections/Gi ulcers
- Foods (eg. tea, coffee, calcium, etc.)

Question 17

How is iron deficiency normally treated?

Answer 17

Oral Fe supplements
(↑Hb ~3g/dL in 3 wks; 3-6 months post-Hb normalisation for Fe store restoration)

Question 18

What are things to suspect/think of in px with iron deficiency but not responding to oral supplementation?

Answer 18

1) ensure compliance
2) Ix ongoing loss
3) Try IV iron

Question 19

How can a px with suspected hemoglobinopathies be screened?

Answer 19

Thalasseaemia screen:
1) Hb electrophoresis
2) HbH stain (moderate α thalassemia)
3) HPLC

Question 20

Why would a px with megaloblastic anemia have raised bilirubin and LDH?

Answer 20

Intra-medullary hemolysis of megaloblasts

Question 21

How is B12/folate deficiency treated?

Answer 21

B12 replacement:
1) IM B12
2) Oral B12 (if Hb normalised)

Folate replacement:
1) Oral

Question 22

What test(s) can you do to confirm hemolysis?

Answer 22

1) Reticulocyte count (high)
2) Liver f(x) test (↑ LDH, unconj. bilirubin)
3) Haptoglobin test (low)
4) PBF:
- Spherocytes (immune)
- Bite/blister cells (oxidative)
- Fragments (MAHA/mechanical)

Question 23

What test(s) can you do to confirm immune-mediated hemolysis?

Answer 23

Direct Coombs test
(polyspecific IgM, IgG or C3 reagent binds to Ab/complement coated RBCs)

Question 24

What is the first line treatment for autoimmune hemolytic anaemia?

Answer 24

Steroids

Question 25

What are 4 possible causes of secondary autoimmune hemolytic anemia?

Answer 25

1) Malignancy
(CLL, lymphomas, solid organ)

2) Infection
(Hep C, HIV, CMV, TB, pneumococcus)

3) Immune
(SLE, Sjogren’s, post-transplant, ulcerative colitis, scleroderma)

4) Drugs
(penicillin, cephalosporins, fludarabine, interferon)

Question 26

What are some indicators of blood loss in anemia?

Answer 26

1) Sudden ↓Hb
2) negative hemolytic markers (Haptoglobin, bilirubin)

Question 27

What do Schistocytes on a PBF indicate in a px?

Answer 27

MAHA (Microangiopathic Haemolytic Anaemia)

Question 28

What do Target cells on a PBF indicate in a px?

Answer 28

Thalassemia

Question 29

What are Spherocytes on a PBF indicate in a px?

Answer 29

AIHA (Autoimmune-mediated Haemolytic Anaemia)

Question 30

What do bite cells on a PBF indicate in a px?

Answer 30

G6PD Deficiency