HEME-CBC eval, Anemia Flashcards by JHope .

What is the initial start of erythropoiesis- blood cell formation?

Tissue low oxygenation status
Kidney produce EPO=erythropoietin hormone tells stem cells in the bone marrow to make more RBC.
EPO– growth and differentiation progenitor into normoblasts–reticulocyte–loss of RNA—RBC
last 120d
MAC engulf dead RBC

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What is diff. btwn Hgb vs Hct?

Hgb- A (98%) A2 (1-2%) F (<1)concentration of the major oxygen carrying pigment of whole blood

Hct -is the percent/ratio intact red blood cells to total BV.

RBC- #/ specific volume of blood
M-Hgb<13.5 or Hct<41%

F-Hgb <12.0 or Hct < 36%

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What are changes CBC in pregnant, smoker, and Blacks?

Pregnant- changes
Smokers- High HCT d/t High CO from cigs
HIGH Altitudes High
AA- Lower Hgb

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What measure the avg size for RBC?

Mean corpuscular volume (MCV) measures the average RBC volume (size)
■ Normocytic anemia = MCV 80-100 fL
■ Macrocytic > 100
■ Microcytic < 80

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Ms. Massaro has MCV <80. What are the DDX for her microcytic anemia?

Iron deficiency Anemia
Thalassemia
Copper deficiency, zinc poison
drugs, Etoh

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Ms. Jenny has MCV >100. What are the DDX for her macrocytic anemia

Etoh abuse
Vit B12/Folate dyfx
Myeloplasitc syndrome
AML
Reticulocytosis- blood loss
Drug induced- chemo, AZT
LIver dz

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What is #1 cause of anemia in US?

GIB; LAB- Stool occult blood- guaiac
Anemia- abnormal lack of blood, color, size, etc.
1. Bleeding acute or chronic
2. Hemolysis-HSM, Jaundice, rash, dark urine, fever
3. Bone marrow- reticocyte
4. IDA- Why- folate, preg, cyanobalamin Vb12
Consider CA, vitamin, Heart Dz

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What is L reticulocyte shift?

worsening anemia and INC erythropoietin stimulation, bone marrow reticulocytes leave in earlier immature stage

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What do these conditions cause:
bone marrow suppression,
hypersplenism,
vitamin B12/folate deficiencies?

Leukopenia + anemia

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What WBC count indicates infection, inflammation, or hematologic malignancy

Leukocytosis + anemia
INC neutro- INFX, band, LEFT
INC monocytes = myelodysplasia
INC eosinophils= parasites or allergic

DEC neutrophils= s/p chemo;
DEC lymphocyte= HIV or steroid tx

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What platelet count is R/T
hypersplenism
malignancy bone marrow;
autoimmune platelet destruction; 
sepsis; 
vitamin B12 or folate deficiency

Thrombocytopenia with anemia

Low platelets

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What platelet count is R/T
myeloproliferative disease; 
chronic iron deficiency;
inflammatory,
 infectious, 
neoplastic disorders/ cancer

Thrombocytosis with anemia

High platelets

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What is w/in Hgb, forms heme, stored in ferritin, absorbed in gut, lost through mucosal exfoliating and menses?

Iron

MCC of anemia

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What are s/s of anemia

Signs:
Stool occult blood
Fall in Hgb- blood loss late
Bounding pulses
CHF, Arryhtmias, MI
Blood loss- shock death, HypoTN
Jaundice, Pallor, petechia-Liver
LAD
HSM
Bone tener

Sx
DOE
DOR
fatigue, lethargy, 
Palpitations
Dysphagia-IDA
Roaring EAR sounds

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What is workup of anemia?

CBC w/ platelets
WBC differential
Reticulocyte count- cause. LOW-aplastic anemia, BM dz.
Blood smear

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Ms. Julia is easily fatigue, tachycardia, palpitations, dysphagia; DOE,
PMH-Pica d/o
PE: smooth tongue, brittle nails, cheilosis:dry cracked mouth. What could be the cause?

DDX:
Acute or Chronic
Blood loss- GIB -*MCC of IDA NSAIDs
Iron deficiency anemia
Diet,
Celiac, IBD, Biatric surgery
Pregnancy and lactation

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What lab changes are seen as iron stores become depleted?

Low serum ferritin- 1st
LOW Transferrin, 
HIGH-Total Iron Binding Capacity; TIBC
Iron level initially normal
RBC DEC-microcytic (small, hypochromic (pale)

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What education is provided to Pt taking oral iron?

ferrous sulfate = 1st line
FeSO4 325mg PO TID ,titrate slowly
Take w/ orange juice
AVOID taking w/ milk- DEC absorptions
Dietary better- red meat, spinach, prunes, cast iron

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How often should iron be rechecked?

2m- Check H/H. Repeat monthly
Takes longer if GI dz
Entire iron panel at 6m

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What can be done if the person has the following Intolerance to oral iron, refractory IDA, GI disease, uncorrectable continued blood loss?

Parenteral iron therapy

Iron- cause constipatin, GI upset, dark stools

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Which disease has more severe anemia?

Chronic Renal L/2 DEC EPO- bone marrow fails
TX-SubQ inj

Other dz
Chronic infx-
Sarcoidosis, RA
Cancer
Liver disease

●Low Hgb/Hct- define anemia
● N or  DEC MCV 78-90
● N reticulocyte count and smear
● Low serum iron, TIBC, transferrin saturation; 
● Normal or INC serum ferritin
● Low serum EPO in CKI

Lab Chronic Anemia d/o

diagnostics

What is ideal treatment for ACD?

NON needed
Replace Iron/folate/B12
INj EPO-CKI, Cancer, RA
Hemodialysis- CKI

What is the reduction in the synthesis of globin chains α or β leading to reduction in Hgb synthesis with **Microcytosis out of proportion to the degree of anemia?

Thalassemia, A/B/H

CBC: Major DEC MCV. DEC HGb, Iron.
*HCT NORMAL +/-

DX. HgB electrophoresis

What condition affects Asians, pt is clinically healthy, w/ mild microcytic anemia?

``` Thalassemia A minor trait, 2 a-globin CBC: Hct 28-40% MCV 60-75 N- RBC count Peripheral smear: microcytic, hypochromic RBC, target cells +/- N- Reticulocyte and iron HgB electrophoresis -no sig findings ```

This person will have a hemolytic s/s: HSM, Jaundice, rash, dark urine, fever anemia, pallor. 1 normal α-globin gene, and severely low MCV.

``` Hgb H CBC: very low Hgb and iron hemolytic anemia: Reticulcytsosis Hct- 22-32% MCV 60-70 Peripheral smear: hypochromia, microcytosis, target cells, poikilocytosis; abnormal shape *Reticulocyte elevated Hgb electrophoresis- H Hgb 10-40% ``` TX 1. w/ folate supplements, 3. transfusions; 4. iron chelation 5. splenectomy

An anemia via point mutations → premature chain termination or problems with transcription of RNA. L/2 to INC in Hgb A2, F, A. Excess a chains unstable and damage RBC= hemolysis

Beta Thalsessemia Mediterranean ●minor (trait): microcytic anemia ● major: Kids develop severe anemia at 6m- Hgb F doesn't switch to A: Growth failure, bony deformities, HSM, jaundice; TX-transfusions Risk- cardiac failure, cirrhosis, endocrinopathies

CBC: mild anemia, Hct 28-40%, MCV 55-75 normal RBC count ○ Peripheral smear: hypochromia, microcytosis, target cells, basophilic stippling ○ Reticulocyte- normal/slight increase ○ Hgb electrophoresis-INC of Hgb A2+F

β-thalassemia minor: | NO TX

CBC: severe anemia with very low Hct Peripheral smear: severe poikilocytosis, hypochromia, microcytosis, **nucleated RBC, target cells, basophilic stippling, ○ Hemoglobin electrophoresis- **INC Hgb F, +/-Hgb A/A2,

β-thalassemia major:

What is treated with allogenic bone marrow transplant?

**β-thalassemia major

What is result Folic/Folate and vitamin B12 deficiency?

Megaloblastic Anemias INC MCV 130-140 Peripheral blood smear: macro-ovalocytes, , *hypersegment neutrophils lobes

What is the important cofactor for enzyme reactions in humans bc we don't make it?

Vitamin B12 All from diet, animals Bound to intrinsic factor absorbed in SI-ileum Stored in Liver deficient develops >3y after absorption stops

How is B12 deficiency developed?

1. MC- Pernicious anemia = lack of intrinsic factor in stomach, bariatric gastrectomy, parietal cell damage 2. H. pylori 3. Competition for vitamin B12 in the gut 4 Pancreatic insufficiency 5. DEC ileal fx- resection; Crohn’s

Ms. Massaro has smooth, shiny tongue; dyspepsia, anorexia, diarrhea, Pale, jaundice; *paresthesias, dysequilibrium, *dementia. PE:, pale, decreased position or vibration What workup is next? What else is considered?

``` VB12 deficiency CBC- MCV-110-140, WBC- +/- DEC, pancytopenia Smear Reticulocyte- DEC Low serum B12 ``` DDX- DM

What is result of parenteral vb12 1000mcg IM monthly?

Hypokalemia ``` For Pernicious Anemia: 2 months 100mcg IM daily/1 week THEN, weekly x 1 month THEN, monthly for life PO- for life IM quick 1000mcg ```

What is difference btwn folate and B12 defiency?

FOLATE- **No neurologic abnormalities SX- fatigue, tachycardia, palpitations, DOE Labs- **NO WBC abnormality, MCV 110-140, DEC reticulocyte, RBC folate NORMAL- B12 Causes- alcoholics, anorexia, overcooked, PHY, sulfsalzine, MTX, Preg, skin d/o, dialysis

What is key treatment for folate deficiency?

Folic acid 1mg PO qd- fruits and veggies TX- GI dz, Alcohol abuse, etc RAPID symptoms improved Recheck 2m

Which anemia is RBC survival reduced and the bone marrow in unable to sufficiently compensate?

Hemolytic Anemias * *Reticulocytosis- INC count 15-25% * *HCT- dec >3%/wk ETi- G6PD, malaria. Intrinsic- acquriedd Extrinsic- Liver, Infx, Leukemia Intravascular Destruction- transfusions

What diagnostic study is a normal plasma protein that binds and clears Hgb released into the plasma produced in liver, APR?

DEC in serum haptoglobin- **KEY DX of hemolysis INC LDH- microangiopathic hemolysis and others (also cancer) HSM Petechia Jaundice

What are micturition concerns with intravascular hemolysis?

Hemoglobinuria | hemosiderin - iron storage complex in cells

Which LFTs and Lipid panel suggest hemolysis?

INC UNconjugated Bilirubin

Mr. Heme c/c fatigue, palpitations, DOE. PE- tachycardia. Smear show bite-like denatured hemoglobin precipitates..Which condition?

Heinz body prep | hemolytic anemia

Mrs. Heme smear shows helmet cells-flat top, and red cell fragments?

microangiopathic hemolytic anemia | Thromocytopenia

Ms. Tboz is 45yo w/ chronic pain, slow growth as a child. PE- ulcers on tibia CHF VA- retinopathy Mild jaundice

Sickle cell anemia-AR- Chronic hemolytic anemia, enzyme dfx hemoglobinopathy- substitute DNA error 8% of AA d/t malaria protection progression LOW O2-Affects S-Hgb chain- form polymers that damage RBC membrane- sickling AS trait-60% A + 40% S SS- 90% S+ 10% F TX- LIVE 40-50yo

Ms.Tboz c.c of chest pain after recent URI. Vital- low grade fever for 24h.

Sickle cell crisis- acidosis, hyoxemia. Hr-days All organs- cluster of sickled cell occlude vasculature Spleen sequestered sickled cells BM decompensated Acute from dehydration, hypoxia, infx., Spontaneous

What does Howell jolly bodies along with sickled cells indicate?

DX- confirmed by Hgb electrophoresis Hyposplenism- splenic infarction- splectomy VC** ``` LABS nucleated RBC Target cells CBC- Hct 20-30%, Reticulocytosis- 10-25% INC ** WBC INC 12-15k Thrombocytois INC indirect/uncong Billi ```

Ms. Tboz daughter Psmear show folded, partially shaped RBC, with inc. target cells. What is the condition?

Hgb SC disease (trait) Pita bread Canoes

Ms.Tboz c.c of chest pain after recent URI. Vital- low grade fever for 24h. what is TX?

SC crisis TX: oxygen, fluids, blood transfusion, and infection Maintenance- Folate ACdi

What is important w/ Pt education for prevention of SC crisis?

Hydroxyurea 500-750mg/d PO -DEC frequency of pain crises TX for SC Allogenic bone marrow transplant- young Immunization **-Pneumococcal***

Ms. Tboz has 30% loss of BV w. sx dizzy, SOB, fatigue? What is next step?

RBC transfusion 10/30 Rule Hgb<10g/dl Hct <30% Ea unit of RBC- will INC HCT 3-4%, HgB 1g Goal 9-10% inc

What are concerns about transfusions?

``` Replace fluids Rapid loss- control bleeding Cross reaction of antibodies Type O universal Monitor- N/V fever w/in 24-48h ```

Ms. Tboz has more than one type/cause of anemia w/ abnormal variability in blood cell lines circulation. This may be: Aplastic anemia, myelodysplastic syndrome, leukemia Nothing is improving w/ transfusion, or Hydrourea. What is next?

Refer to Hematoloy or Oncology