Clinical Approach to Anemia

Question 1

What test is most helpful in Dx of Fe deficiency?

Answer 1

Ferritin

Question 2

What red cell morphology is most suggestive of autoimmune hemolysis?

Answer 2

Microspherocyte

Question 3

What simple test best defines inadequate marrow function in an anemic pt?

Answer 3

Reticulocyte count

Question 4

Having a hyposegmented (2 lobes) neutrophil in a smear is a sign of:

Answer 4

myelodysplasia

Question 5

If you see a smear with a TON of lymphocytes and they all appear “smeared”, what is going on?

Answer 5

Chronic Lymphocytic Leukemia (CLL)

Question 6

If you see a “hairy” lymphocyte in a peripheral smear, think:

Answer 6

Hairy Cell Leukemia (HCL)

Question 7

What is a normal reticulocyte percentage and count?

Answer 7

0.5-2.5% or 25-125x10^9

Question 8

How do you calculate the corrected reticulocyte count? How do you determine if it is an adequate response?

Answer 8

(RC % x hct)/45
< 3 inadequate
> 3 adequate

Question 9

What happens to reticulocyte count in acute blood loss and hemolytic anemia?

Answer 9

elevates

Question 10

What happens to reticulocyte count in chronic blood loss?

Answer 10

drops due to Fe deficiency

Question 11

Levels of these 5 things will be elevated in hemolytic anemia.

Answer 11

LDH
Bilirubin 
Haptoglobin
Plasma Free Hb
Urine hemosiderin

Question 12

In warm IHA, what antibody isotype will be specific for RBCs?
What causes it?

Answer 12

IgG
penicillin alters RBC surface proteins and IgG attacks them.
Complement may also be present

Question 13

In cold IHA, what antibody isotype will be specific for RBCs?
What causes it?

Answer 13

IgM
Mono (viral)
Mycoplasma pneumonia (bacterial)
“IgM tends to drop off in the central body and it tends to be complement mediated, alone” - Dr. Weir

Question 14

If you have yet unexplained anemia after smears, antibody tests, and cell counts, and a low retic. count, what do you do next?

Answer 14

Bone marrow analysis. Since you have ruled out blood loss, anemia may be due to lack of production.

Question 15

Your pt has macrocytic anemia. What are you going to look for first?

Answer 15

Reticulocyte count

Question 16

Your pt has macrocytic anemia and elevated reticulocyte count. What is in your differential?

Answer 16

hemolysis

acute blood loss

Question 17

Your pt has macrocytic anemia and low retic. count. What are you going to look for now?

Answer 17

B12 and folate levels

Question 18

Your pt has microcytic anemia. What are you going to look for now?

Answer 18

Ferritin levels

Question 19

Your pt has microcytic anemia and low ferritin levels. What are you going to look for now?

Answer 19

Evaluate for blood loss

Question 20

Your pt has microcytic anemia and normal ferritin levels. What are you going to do now?

Answer 20

Hb electrophoresis to evaluate Hb type (HbA, HbA2, HbC, HbSC, HbH)

Question 21

Your pt is anemic. What are the possible causes?

Answer 21

Decreased RBC production
Increased RBC destruction
Blood loss
Sequestration of blood

Question 22

What are the possible causes of decreased production of RBCs leading to anemia?

Answer 22

Malnutrition (Fe, B12, folate)
Infections (HIV, mycobacterial pneumonia, mononucleosis)
Inflammation (RA, SLE, other chronic infl. conditions)
Endocrine dysfunction (hypothyroidism, etc.)
Metabolic dysfunction (renal insufficiency, etc)
toxins (lead, drugs, EtOH, etc)
Bone marrow failure
Infiltration (fibrosis or tumor of bone marrow)

Question 23

When testing for autoimmunity to determine the cause of hemolysis, what test is rapid and sensitive?

Answer 23

Direct Coomb’s

Question 24

If your pt has hemolytic anemia and is Coomb’s negative, what else are you looking for?

Answer 24

microangiopathic or non-microangiopathic hemolytic anemias.

Question 25

Your pt has microangiopathic hemolytic anemia. What are the potential causes of this?

Answer 25

** look or schistocytes! **

DIC, TTP, HUS, prosthetic heart valves, malignant hypertension

Question 26

Your pt has non-microangiopathic hemolytic anemia. What are the potential causes of this?

Answer 26

congenital conditions:
membrane (hereditary spherocytosis), Hb (sickle cell, thals), enzyme dysfunction (G6PD deficiency)
acquired conditions:
infection, lead tox., paroxysmal nocturnal hemoglobinurea (PNH)

Question 27

What is the most common hereditary enzyme defect leading to non-microangiopathic hemolytic anemia? What’s another important one that leads to non-microangiopathic hemolysis?

Answer 27

G6PD deficiency (cell cannot prevent oxidative damage, macrophages destroy cells in spleen); pyruvate kinase deficiency (no ATP, cell explodes from osmotic pressure)

Question 28

Is pernicious anemia common among the causes of anemia?

Answer 28

No

Question 29

Most anemias are microcytic, macrocytic, or normocytic?

Answer 29

85% are normocytic