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3.2. Medicine > Haematology: Anaemia > Flashcards

Haematology: Anaemia Flashcards

1
Q

At what Hb levels is a pt considered anaemic?

A

Men - Hb 13 g/dL (130 g/L)

Women - Hb 11.5 g/dL (115 g/L)

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2
Q

What are the generalised symptoms of anaemia?

A

Lethargy

Fatigue

Shortness of breath

Palpitations

Angina/intermittent claudication

Pallor

Tachycardia

Systolic flow murmur

Cardiac failure

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3
Q

For a patient with suspected anaemia what features of a Hx should be explored?

A

Occupation = lead exposure (present like iron def), paints, solvents

Dx = chemotherapy, haematinics

Co-morbidities

Diet/bowel habits = steatorrhoea (malabsorption/pancreatitis), vegetarian, weight loss

Blood loss = trauma, surgery, pregnancy, abortions, menorrhagia, malena, PR, haemoptysis

FH = bleeding disorders, abnormal Hb, gallstones, splenectomy (ITP - increased destruction of RBC autoimmune)

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4
Q

For a patient with suspected anaemia what features of an examination should be explored?

A

GI = malnutrition, cachexia, pallor (assess in sunlight), nail changes - koilonychia (spooning, iron def), brittle nails (iron def)

Palmar erythema (oestrogen level changes), purpura, facial puffiness

Cardiomegaly, hepatosplenomegaly

Liver disease = gynaecomastia, change in testicular size, spider naevi

Neurological = paraesthesia, posterior column defect - defect in position sense, proprioception

PR exam

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5
Q

Outline the morphological approach to differentiating the type of anaemia

A

Microcytic (MCV <80)

  • Most common iron def (bleeding)
  • Reduced heme synthesis (LAL need to be converted to heme, by LAL dehydrogenase - inhib by lead)
  • Reduced globin prod = thalassaemia

Macrocytic

  • Reduced B12, folate
  • Liver disease - alcohol (also has toxic effect on bone marrow)
  • Hypothyroidism (hashimoto’s)
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6
Q

How can ferritin be used to help Dx anaemia?

A

Low = diagnostic of iron def

High = acute phase protein in inflam (anaemia of chronic disease)

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7
Q

How should anaemia be investigated?

A

Microcytic = look for source of bleeding - Lab tests = serum iron, ferritin, transferrin sat, total iron binding capacity

Macrocytic = shillings test for pernicious anaemia (destruction of parietal cells = low intrinsic factor = low absorption of B12 in ileum)

DCT - direct coombs test
PNH - cold autoimmune destruction of RBC

Decreased prod investigations = bone marrow aspiration + biopsy

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8
Q

How should anaemia be treated?

A

Blood loss = transfusion (short term)

Chronic = EPO injections

Iron supplementation

B12/folate supplements

Autoimmune = steroids, immunosuppressant - azathioprine (need to have serial blood tests to make sure the bone marrow is not suppressed), splenectomy (HS, HE) (give pneumococcal vaccine - capsulated bacteria removed in the spleen)

Bone marrow transplant

Chemotherapy

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9
Q

How can reticulocyte count help differentiate anaemia?

A

Raised = normal response to anaemia, haemolysis, bleeding, splenic sequestration

Low = bone marrow failure

  • microcytic = iron def, thalassemia, AoCD
  • normocytic = acute blood loss, AoCD, renal failure, marrow infiltration
  • macrocytic = vit B12 def, folate def, liver disease, reticulocytosis
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10
Q

Where is iron absorbed?

A

Duodenum

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11
Q

What is ferroportin?

A

Transmembrane protein

Transports iron out of duodenal mucosal cells

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12
Q

What is ferritin?

A

How iron is stored in duodenal mucosal cells

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13
Q

What is transferrin?

A

Iron is transported in the blood bound to transferrin

Protein made by the liver

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14
Q

What causes iron supplies to be insufficient?

A

Decreased intake = malnutrition, poor absorption

Increased loss = bleeding

Increased demand = pregnancy, growth

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15
Q

What are the signs of iron def?

A

Koilonychia

Angular stomatitis

Atrophic glossitis

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16
Q

How does iron def appear on a blood film?

A

Microcytic

Hypochromic

Poukilocytosis

Anistocytosis

Pencil cells

Target cells

17
Q

What investigations should be performed when iron def is suspected?

A

Blood film

Serum iron = low

Ferritin = low (if inflam cause then it may be high)

Total iron binding capacity = raised

18
Q

How is iron def treated?

A

Oral ferrous sulphates 200mg BD
- should raise Hb by 1g/dl/week

SE = epigastric pain, nausea, altered bowel habit and dark stools. If the side effects are intolerable alternative iron salts should be tried.

19
Q

What are the symptoms and signs of vit B12 and folate def?

A

General signs and symptoms of anaemia

B12 = peripheral neuropathy, low mood and poor memory

Folate = neural tube defects in utero, and an increased risk of heart disease and stroke

20
Q

Hoes does vit B12 and folate def appear on a blood film?

A

Macrocytic

21
Q

What is pernicious anaemia?

A

loss of gastric parietal cells and lack of intrinsic factor leading to an inability to absorb vitamin B12

22
Q

What is the pathophysiology of AoCD?

A

Depressed production and response to erythropoetin

Ferritin synthesis may also be unregulated by proinflammatory cytokines diverting iron into the reticuloendothelial system

Increased hepcidin reduces the amount of iron being absorbed from the intestines

Up regulation of white cells causes fewer stem cells to differentiate into red blood cells.

23
Q

What is sickle cell anaemia?

A

Autosomal recessive pattern which results in a point mutation. This results in a hydrophilic amino acid in the b Hb chain being replaced by a hydrophobic amino acid.

Over time this reduces the elasticity of the RBC and leads to sickling.

Sickle cells have a reduced life span and have difficulty travelling through microcirculations, occluding vessels resulting in infarction

24
Q

What can bring about a sickle cell crisis?

A

Dehydration, infection, hypoxia, hypothermia, stress/emotion and surgery.

Signs and symptoms of a crisis include those of anaemia and pain.

25
Q

What investigations should be performed if sickle cell is suspect?

A

Blood count = Hb may be 6-8 g/dl during crisis but will usually be higher at other times. Reticulocytes raised

Blood film = sickle cells.

Sickle cell solubility test will be positive but doesn’t differentiate between sickle cell anaemia and sickle cell trait.

Hb electrophoresis is used to confirm a diagnosis and can differentiate between sickle cell anaemia and sickle cell trait. It can also detect other combinations of abnormal haemoglobins which can cause sickle cell disease such as HbSC (HbS and HbC).

26
Q

How is sickle cell managed?

A

Patient education = avoiding triggers, early recognition and prompt management of crisis and the importance of vaccinations/prophylactic penicillin.

Packed red cell transfusions or red cell exchange should be given in specialist centres when necessary e.g. for heart failure, splenic sequestration, aplastic crisis.

Hydroxycarbamide may reduce rate of painful crisis and is used as secondary prophylaxis.

27
Q

How should thalassemia be investigated?

A

Blood film = microcytic cells and target cells

DNA analysis = mutation

Bone marrow = hypercellular

Hb electrophoresis = presence of an abnormal form of Hb

28
Q

What are the causes of haemolytic anaemia?

A

Membrane disorder = hereditary spherocytosis

Hb disorder = sickle cell, thalassaemia

Metabolic disorder = G6PD def

Autoimmune

Prosthetic heart valves

Malaria

Ingestion of drugs or chemicals causing oxidative stress

29
Q

What are the components of a haemolytic screen?

A

Blood film

Bilirubin - raised

LDH - raised

Haptoglobin - decreased as it mops up free Hb

Reticulocytes - raised to compensate haemolysis

Direct Coombs test - detect Ab

30
Q

How is autoimmune haemolytic anaemia treated?

A

Corticosteroids

Splenectomy

Immunosuppression

31
Q

How is aplastic anaemia managed?

A

Immunosuppression - antilymphocyte globulin (ALG) with cyclosporin

Stem cell transplant

Haematopoietic growth factors

3.2. Medicine (58 decks)

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