Reduction in one or more RBC measurements: 1. RBC count 2. Hemoglobin 3. Hematocrit Anemia is never normal! Always suspect that something is going on with your patient!

Common causes:  Iron deficiency anemia (IDA)  Thalassemia Less common causes:  Anemia of chronic disease (<20%)  Sideroblastic anemia  Lead toxicity

Hematology Flashcards by katie gazda

Def of anemia…

Reduction in one or more RBC measurements:
1. RBC count
2. Hemoglobin
3. Hematocrit
Anemia is never normal!
Always suspect that something is going on with your patient!

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Size vs color of RBCs

Size= MCV (_cytic)
Color= MCH (_chromic)

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indicates degree of variation in RBC size (<15% is normal)

RDW
(how uniform RBCs are in size)

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Why would the bone marrow make small RBCs?

If it didn’t have enough iron

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Serum iron vs Serum Ferritin

Serum iron: measure of iron in circulation
Serum ferritin: measure of iron in storage (ferritin is a protein that stores iron)

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TIBC?

total iron-binding capacity – reciprocal relationship!

Ex. Egg count is high, Capacity is low= TIBC is low

Egg count is low
Capacity is high
Iron count is low
TIBC is high

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a visual description of the red blood cells; appears on CBC report
* Example: “microcytic hypochromic RBCs”
***Should always be considered when a patient presents with anemia

Peripheral blood smear

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Immature RBC

Reticulocytes
a visual description of the red blood cells; appears on CBC report
* Example: “microcytic hypochromic RBCs”
***Should always be considered when a patient presents with anemia

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Microcytic Anemias

Common causes:
 Iron deficiency anemia (IDA)
 Thalassemia
Less common causes:
 Anemia of chronic disease (<20%)
 Sideroblastic anemia
 Lead toxicity

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_What: Microcytic, hypochromic anemia
_Why: Blood loss
_Where: GI, Gyn

Iron Deficiency Anemia

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Common symptoms in young adult with IDA

Fatigue, weakness, exercise intolerance

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Young adult- middle-aged adult = Fatigue, weakness, headache, irritability, exercise intolerance

Older adult = Exacerbation of comorbidities (angina, heart failure, dementia)

IDA

Most people are asymptomatic (until 30/10)

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RBC 3.5 4.2-4.9 million/microL
HGB 9.5 g/dL 12-15 g/dL
HCT 28.6% 37-51%
MCV 72 80-96
MCH 21.6 23.7-28.4
RDW 18.6 12-17
PLT 265 150-375
Serum Fe Decreased
Serum ferritin Decreased
TIBC Elevated

IDA

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How to treat IDA?

Iron supplementation
+ foods like spinach

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Sx of iron supplementation intolerance?
Is all iron the same? How long do pts need to supplement for IDA?

Heart burn and constipation are common (esp with Fumrate)
Ferrous Sulfate is best tolerated
All Iron is Not Created Equally!
Replacement: usually 4-6 months with 150-200 mg elemental iron daily!

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Which normal lab result indicates that iron supplementation could be stopped?

Serum ferritin iron
(stored iron)

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RBC 3.5 4.2-4.9 million/microL
HGB 9.5 g/dL 12-15 g/dL
HCT 28.6% 37-51%
MCV 72 80-96
MCH 21.6 23.7-28.4
RDW 18.6 12-17
PLT 265 150-375
MPV 7.1 6.5-12
Serum Fe Normal
Serum ferritin Normal
TIBC Normal

Thalassemia

Microcytic/ hypochromic RBCs
Possible nucleated RBCs
Uneven Hgb distribution, producing “target cells”

Thalassemia

*What: microcytic, hypochromic
*Why: inherited
*Types: alpha, beta, others
*Diagnostic test: Hgb electrophoresis
*Treatment: consider reproductive counseling

Thalassemia

Do pts with thalassemia need iron replacement?

NO! – if body doesn’t need iron it will store in the liver = hepatotoxicity

What: normocytic, normochromic anemia; microcytic, hypochromic (not common)
* _Why: red blood cell life span is shortened from the normal 100-120 days to 60-90 days
* _Treatment: better control of underlying chronic disease, treatment of malignancy, or treatment of underlying cause

Anemia of Chronic disease

Vast differential diagnosis:
Anemia of chronic disease (infection, inflammation, malignancy)
Acute blood loss
Early IDA
Malignancy
Chronic renal insufficiency
Poorly managed chronic disease
Other less common diseases

Normocytic, Normochromic Anemia

What might be most helpful in determining etiology of normocytic, normochromic anemia?
1. RDW
2. Patient history
3. Reticulocyte count
4. Stool for occult blood

Patient history

A 72-year-old man has normocytic, normochromic anemia. His stool for occult blood is positive. What is the likely etiology of this anemia?

Iron deficiency anemia
Anemia secondary to GI bleed
Anemia secondary to malignancy
B12 deficiency anemia

Anemia secondary to malignancy
- malignancy can cause normocytic/ normochromic changes

Is this pt anemic? How to describe? RBC 3.8 4.2-4.9 million/microL HGB 9.8 g/dL 12-15 g/dL HCT 27.8% 37-51% MCV 103 80-96 MCH 26.5 23.7-28.4

Yes, Macrocytic/ normochromic

Common macrocytic anemias

B12 deficiency Folate deficiency

What: macrocytic anemia Presentation: asymptomatic patient OR unexplained neuro symptoms, cognitive changes, “burning tongue”

B12 deficiency Folate deficiency

Who does B12/ Folate deficiency usually affect? How to treat?

Who: older adults, alcoholics, malnourished, bariatric/gastric surgery patients, strict vegans/vegetarians Treatment: B12 and/or folate supplementation

Causes of b12 deficiency

Pernicious anemia Inadequate dietary intake of B1 (not found in plant sources) Gastrectomy, bariatric surgery (absorption) PPIs, metformin, colchicine, impaired metabolism, methotrexate H. Pylori

PA is an autoimmune condition that prevents formation of the vitamin B12-intrinsic factor complex = increases risk of GI cancer

Pernicious Anemia

Causes of folate deficiency

Inadequate dietary intake Increased requirements (pregnancy) Intestinal malabsorption

How to manage pt with Vit B12 or folate deficiencies? Symptomatic vs asymptomatic

If patient is asymptomatic: can treat both orally: - B12 (1,000-2,000 mcg daily) - Folate 1mg daily * IF patient is symptomatic: consider treating both IV. - B12: lifelong treatment needed if cause is not reversible (like PA) - Folate: 1-4 months or until hematologic recovery

Expected outcomes of neuro deficits after Tx b12 deficiency

Expected outcomes of neuro deficits after Tx b12 deficiency Usually reversible. Sx improvement within 5-10 days *Reticulocyte count rapidly increases and peaks 7-10 days after treatment initiated

Why are older adults at more risk of B12/ Folate deficiency?

pH in stomach rises = less acidic and thus they absorb less B12 and folate

How do PPIs affect folate and B12 ?

Pts on PPPT have less acidity in stomach = absorb less

Decrease in platelet count (< 150,000) * Rest of CBC is usually normal - Petechiae and purpura (does not itch and usually feels well otherwise)

Thrombocytopenia

Reasons for thrombocytopenia

* Recent infection (viral, bacterial) * Idiopathic * Drug-induced * SLE * Antiphospholipid syndrome * Leukemia * Others

How to manage thrombocytopenia?

* Referral to hematologist * Prednisone for 4-6 weeks; may need daily course for chronic ITP * Minimal activity to prevent injury or bruising (e.g., no contact sports) * Avoidance of aspirin

________ are the same as “segs” = polys

Neutrophils

Patient Norms WBC 3.2 4-15 RBC 4.01 (L) 4.5-5.60 HGB 11.4 (L) 13.7-17.3 HCT 34.8 (L) 37.5-51.0 MCV 103.7 (H) 83.4-96.0 MCH 28.1 27.8-32.5 MCHC 34.0 32.5-35.4 RDW 18 (H) 12-17 PLT 316 150-375 MPV 8.1 6.5-12 POLY% 47.5 (L) 55-75 LYMPHS% 42.1 (H) 30-40 MONO% 9.8 (H) 0-9 EOS% 0.3 0-6 BASO% 0.3 0-6 What labs to run next?

Viral infection > 24 hours with macrocytic, normochromic anemia - Polys and lymps are 1st responders - If low poly and elevated lymph think Viral (numerically close ) - Monos- don’t come to help fight infections for at least 24 hours Run B12/ Folate labs next

WBC 14.9 (H) 4-11 RBC 4.08 4.2-4.9 HGB 10.0 (L) 12-15 HCT 30.0 (L) 37-51 MCV 70.4 (L) 73-85 MCH 21.2 (L) 23.7-28.4 MCHC 29.4 (L) 31.3-35.7 RDW 19.6 (H) 12-17 PLT 315 150-375 MPV 7.1 6.5-12 POLY% 76 (H) 55-75 LYMPHS% 10 (L) 30-40 MONO% 11.9 (H) 0-11 EOS% 0.1 0-6 Bands 2.0 Anemia? Differentials ? Anemia recent onset?

Microcytic, hyperchromic Differentials: IDA, thalassemia, lead toxicity Yes Anemia is recent because the high iron RDW tells us that the cells vary largely in size. If anemia had been going on (>120 days) the big/ normal size cells would have died off leaving uniformly small cells and a normal RDW - Bands shows immature white blood cells … should be worried if seen in central circulation

WBC 16.9 4-11 RBC 4.08 4.2-4.9 HGB 11.0 (L) 12-15 HCT 33.0 (L) 37-51 MCV 70.4 (L) 73-85 MCH 21.2 (L) 23.7-28.4 MCHC 33.4 31.3-35.7 RDW 19.6 (H) 12-17 PLT 155 (L) 150-375 MPV 7.1 6.5-12 POLY% 51 (L) 55-75 LYMPHS% 12 (L) 30-40 MONO% 16.9 (H) 0-12 EOS% 0.1 0-6 Blasts 20 Interpretation?

Microcytic, hypochromic Bone marrow problem.. - Presence of Blasts shows VERY immature RBCs in circulation = refer to hematology ASAP - High mono=going on > 24 hours