Clinical Presentation of Anemias - Weir 03.17.15 Flashcards
What red cell morphology is most suggestive of autoimmune hemolysis?
Microspherocytes
What simple test best defines inadequate marrow function in anemic patient?
Reticulocyte count
What are the two most important reasons to perform a physical exam in an anemic patient?
To help determine cause and severity
What is important in your clinic visit with an anemic patient?
History, physical, CBC, blood smear, and reticulocyte count are ALL important
What signs might tell you about the severity of an anemia?
Tachycardia, tachypnea, orthostatic hypotension
What signs might tell you about the cause of an anemia?
EXAMPLES:
- Short fingers: sickle cell
- Glossitis: iron deficiency or pernicious anemia
- Purpura: TTP
- Bruising: iron deficiency, and other anemias
What things might you look at/for in the physical exam of an anemic patient?
- Pallor
- Facial structure
- Oral mucosa
- Hands
- Hepatosplenomealy
- Lymphadenopathy
- Telangiectasia
What do you see here?
- Cachexia and hepatosplenomegaly in chronic myeloproliferative disorders
What do you see in these images?
- Pallor from anemia: conjunctiva, sublingual area, and hand on left (compared to normal control on right)
What about this?
- Hereditary telangiectasia: vascular malformations on face, lips, and hands -> patient presented with iron def anemia due to recurrent bleeding from GI tract telangiectasia
What do you see going on here?
- Smooth tongue and koilonychea (thin, brittle nails with a concave edge) in iron deficiency
What are the tests included in a complete blood count (CBC)?
- Red Cells
- Hct/Hgb
- MCV
- RBC
- RDW (red cell distribution width): variation in size; early sign of iron def (microcytic anemia)
- White cells
- Neutrophils, lymphocytes, monocytes, blasts, eosinophils, basophils
- Platelets
Which CBC parameter is most important in the dx of iron deficiency?
Ferritin
Practice and know these.
Good job!
What are some WBC and RBC abnormalities you might see on a blood smear?
- WBC abnormalities: inflammatory or malignant
- Red Cell abnormalities:
- Micro/macro
- Schistocytes (red cell destruction)
- Spherocyctes (hemolytic anemia)
- Sickled cells
- Target cells (thalassemias)
- Teardrops (thalassemias)
- Platelet estimate and abnormalities
Identify these RBCs and their associated pathologies.
- A: normal red cells
- B: target cells (thalassemias)
- E: tear drops (anything that infiltrates bone marrow)
- F: microspherocytes (autoimmune hemolytic anemias; small cell with no central pallor)
- G: ovalocytes (hemolytic anemias, thalassemias)
- H: blister cell (G6PD deficiency)
- I: bite cells (G6PD deficiency)
- J: schistocytes (when RBCs get sliced)
- K: sickle
- L: red cells with dehydration artifact
You know what to do.
- A: Howell-Jolly body (spleen didn’t take it out; post-splenectomy patient)
- B: nucleated red cell (highly stimulated bone marrow or infiltration)
- D: malaria (plasmodium vivax trophozoites)
- E: lead poisoning (coarse basophilic stippling)
- F: Heinz body -> inclusions in RBC composed of denatured Hgb (post-splenectomy pt; thalassemias)
What do you see here? Don’t need to dx necessarily, but what are they?
- A: giant, hypersegmented neutrophil (vitamin B12 def)
- B: hypersegmented neutrophils (from antifolate chemo)
- C: Dysplastic neutrophil in case of myelodysplastic syndrome
- D: degenerating neutrophil
Think this is next week.
- CLL (chronic lymphocytic leukemia/lymphoma): smudge cells, and most cells lymphocytes
- HCL: hairy cell leukemia (very rare disease)
- SMZL: splenic marginal zone lymphoma
- NK: NK leukemia
- FL: follicular lymphoma
- PCL: plasma cell leukemia
- ALL (acute lymphoblastic leukemia): blasts
- BL: Burkitt lymphoma
- PLL: prolymphocytic leukemia
- LBCL: large B-cell lymphoma
- ATLL: adult T-cell lymphoma/leukemia
What do you consider if the reticulocyte count is elevated? Also, what do you see in this blood smear?
- Acute GI blood loss (if you lose blood chronically, you actually become iron deficient and your retic count goes down)
- Hemolytic anemia
- Polychromatophilic cells: basophilic due to increased RNA content (usually larger than normocytic RBCs) -> surrogate marker for reticulocytosis (underestimate)
What are the important reticulocyte count values? What do you see in this image?
- 0.5%-2.5% normal -> if really anemic, % doesn’t really tell you right answer b/c it is % of the total
- Absolute #: 25-125 x 10^9
- Corrected retic count: retic count% X Hct/45
- Reticular inclusions in RBCs (precipitated ribosomes exposed to brilliant cresyl blue) -> the more immature the retic, the more reticulin precipitation occurs (can also be mistaken for Howell-Jolly or Heinz bodies)
What tests might you order if you were concerned about hemolysis?
- LDH: goes up when RBCs are destroyed
- Indirect Bilirubin
- Serum Haptoglobin: binds free Hgb, so haptoglobin will drop
- Plasma Free Hemoglobin: IV hemolysis
- Urine Hemosiderin: no red cells, but Hb more indicative because red cells could be from damage when putting in catheter, or other trauma
- If no blood loss and reticulocytes are up, want to see if there is hemolysis
What are the indications for bone marrow examination?
- Multiple cell lines affected
- Unresolved hyporegenerative (low reticulocyte count) anemia, i.e., unexplained anemia with low retic count
- Abnormal cells in peripheral blood
- REMEMBER: these cells are the cells that are making blood
What are the 4 major categories of anemias?
- Decreased production
- Increased destruction
- Blood loss
- Sequestration
What 8 things should you consider when you have a pt with a decreased production anemia?
- Nutritional
- Infectious
- Inflammatory
- Endocrine
- Metabolic
- Toxins
- Bone marrow failure
- Infiltration
What should you be thinking when a patient comes in with an increased destruction anemia (i.e., categories)?
- Immune: warm or cold
1. Use Coomb’s test to determine if immune or not - Non-immune: Coomb’s (-), so do blood smear to see if there are schistocytes or not
1. Microangiopathic
A. DIC, TTP, HUS
B. Prosthetic valve
C. Malignant HTN
- Non-microangiopathic
A. Congenital (hx helpful here)
- Membrane: hereditary spherocytosis most common
- Enzyme (i.e., G6PD most common, then pyruvate kinase)
- Hgb: sickle, thalassemias
B. Acquired
- Infection
- Lead
- PNH (only acuired membrane disorder)
What should be your differential (focus on tests) for decreased red cell mass?
- Low reticulocyte: B12, folate, ferritin, LDH, Spe TSH, ESR, CRP -> tests directed by smear, H&P
1. Bone marrow exam or ultrasound/CT for splenomegaly - Elevated reticulocyte
1. Coomb’s (+): seek primary cause
2. Coomb’s (-)
A. Blood smear microangiopathic
- Coag tests for DIC, TTP, HUS, MH
B. Not microangiopathic
- Congenital: tests for HgB, membranes, enzymes
- Acquired: tests for PNH, infections, lead
- Blood loss
What are the major categories of macrocytic anemia?
- Low reticulocyte count
1. Low B12, folate
2. Normal B12, folate
A. TSH, ETOH, and standard eval
- Elevated reticulocyte count
1. Hemolysis
2. Acute blood loss - NOTE: these are often complicated and intermixed, so you have to be careful, i.e., don’t forget mixed anemias
What are the major categories of microcytic anemia?
- Low ferritin
1. Evaluate for blood loss - Normal ferritin
1. Hgb electrophoresis
A. Normal
- High RBC, healthy -> alpha thal
- Low RBC -> standard anemia workup
4 key things not to forget…
- Sequestration, i.e., in the spleen (could be hidden in obese patient)
- Blood Loss: could be occult
- Volume Expansion: Hct %, so blood volume can affect it
- Ineffective Erythropoiesis
