Microcytic Anemia Flashcards
A 51 yo M presents with iron deficiency anemia. What disease should be considered in the differential?
In the U.S., iron deficiency anemia in a patient over age 50 should be considered colon cancer until proven otherwise.
}68 year old man with no past medical history presents to you his primary care physician. He has been generally healthy and so has not seen a physician in 20+ years. He notes that he is a bit more easily fatigued than in the past and gets winded with strenuous exertion. He also notes some intermittent constipation, which is only partly improved by drinking a lot of prune juice.
}He is not on medications.
}Vitals are within normal limits.
}His exam is notable for subconjunctival pallor
}Given the fatigue and pallor you decide to get a CBC
68 year-old man with hypochromic, microcytic anemia
What do you do next?
You start patient on ferrous sulfate 325mg tablet, po tid
Describe the chronology of the different sites of hematopoiesis during human fetal development.
· Yolk sac: conception -3 months
· Liver: 1 month onward
o Definitive HSCs arise at 5 months
o From weeks 6 until 6-7 months of fetal life, the liver and spleen are the main organs for hematopoiesis and continue to be sites of hemtopoeisis until about 2 weeks after birth
· Spleen: 2.5 months- 7 months
· Bone Marrow: 4 months- onward
o The bone marrow is the primary site of megakaryocyte and granulocyte production from the fifth month
What is the normal hemoglobin composition in adults?
}Hgb A1(α2β2): 95-98%
}Hgb A2(α2δ2): 2-3%
}Hgb F (fetal; α2γ2): 0.8-2.0%
What is the genotype and CP of silent carriers of alpha thalassemia?
α0 Thalassemia trait: genotype - - / αα, Mild anemia: Hgb in 10 - 14 g/dL range)
α+ Thalassemia trait: genotype
- α/ - α
What is the genotype and CP of silent carriers of beta thalassemia?
βThalassemia trait: β/ β0, Microcytosis, hypochromia, target cells
What is the genotype and CP of a pt with the beta thalassemia trait?
Genotype:
β/ β0
CP:
Microcytosis, hypochromia, target cells
What is the genotype and CP of a pt with the alpha 0 thalassemia trait?
Genotype:
- / αα
CP:
Mild anemia: Hgb in 10 - 14 g/dL range
What is the genotype and CP of a pt with the α+ Thalassemia trait?
Genotype:
- α/ - α
CP:
What are the genotypes and CP for thalassemia intermedia?
β+ Thalassemia: β+/β+ (certn mutn): Microcytosis, hypochromia, target cells
α+ and β0 Double Heterozygote: - α/ - α/β/ β0: Moderate anemia: Hgb in 6-10 g/dL range
What are the genotypes and CP for thalassemia major?
Β0 Thalassemia major: β0/β0:
What is the genotype and CP of Hemoglobin H disease?
Genotype:
- / - α
Leads to excess β chains that form Hb H
CP:
Microcyotis, hypochromia, as well as features of hemolytic anemia due to effects of the Hb H on cells
What are some complications of beta-thalassemia major?
- Transfusion-transmitted infections
- Bone expansion (“hair on end”): Thin fine linear extensions radiating out from the skull that look on an X-ray like hair standing “on-end” from the skull, an appearance associated with hemolytic anemias such as sickle cell disease and thalassemia.
- Hyopituitarism
- Excessive melanin skin pigmentation (cheeks indicated) “bronze diabetes
- Hypothyroidism
- Hyoparathyroidism
- Pulmonary htn and embolism
- Cardiomyopathy
- Venous thrombosis
- Hemosiderosis and cirrhosis of liver
Characterize the following values for a normal person:
- Bone marrow stores
- Hgb
- Ferratin
- Transferrin/ TIBC
- Transferrin Saturation %
- Serum iron
- MCV
- MCH/ MCHC
- RDW
- Red Cell Morphology
Values for a normal person:
- Bone marrow stores: 2+ to 3+
- Hgb: 13-17 g/dL
- Ferratin: 90-300 micrograms/ dL
- Transferrin/ TIBC: 300-360 micrograms/ dL
- Transferrin (Fe/ TIBC) Saturation %: 20-50
- Serum iron: 60-150 micrograms/ dL
- MCV: 80-100 fL
- MCH/ MCHC: Normal
- RDW: 11-15%
- Red Cell Morphology: uniform, normocytic, normochromic
Characterize the following values for iron deficiency without anemia:
- Bone marrow stores
- Hgb
- Ferratin
- Transferrin/ TIBC
- Transferrin Saturation %
- Serum iron
- MCV
- MCH/ MCHC
- RDW
- Red Cell Morphology
Characterize the following values for iron deficiency without anemia:
- Bone marrow stores: 1+
- Hgb: 13-17 g/ dL
- Ferratin: < 90 micrograms/ L, lower than normal
- Transferrin/ TIBC: 300- 390 micrograms/ dL
- Transferrin Saturation %: 30%
- Serum iron: 60-150 micrograms/ dL
- MCV: 80-90 fL
- MCH/ MCHC: lower than normal
- RDW:>15%
- Red Cell Morphology: microystosis, hypochromia, anisocytosis
Characterize the following values for iron deficiency with mild anemia:
- Bone marrow stores
- Hgb
- Ferratin
- Transferrin/ TIBC
- Transferrin Saturation %
- Serum iron
- MCV
- MCH/ MCHC
- RDW
- Red Cell Morphology
Characterize the following values for iron deficiency with mild anemia:
- Bone marrow stores: none
- Hgb: 9-12 g/dL
- Ferratin: <45 micrograms/ L (much less than normal)
- Transferrin/ TIBC: 350-400 (elevated)
- Transferrin Saturation %: <15% (decreased)
- Serum iron: <60 (decreased)
- MCV: 70-80 fL (decreased)
- MCH/ MCHC: very decreased
- RDW: 16% (very increased)
- Red Cell Morphology: microcytosis, hypochromia, anisocytosis, some poikolcytosis
Characterize the following values for iron deficiency with mild anemia:
- Bone marrow stores
- Hgb
- Ferratin
- Transferrin/ TIBC
- Transferrin Saturation %
- Serum iron
- MCV
- MCH/ MCHC
- RDW
- Red Cell Morphology
Characterize the following values for iron deficiency with mild anemia:
- Bone marrow stores: None
- Hgb: 6-7 g/dL
- Ferratin: <20 micrograms/ L
- Transferrin/ TIBC: >400 micrograms/ dL
- Transferrin Saturation %: < 10%
- Serum iron: <40 micrograms/ dL
- MCV: < 70 fL
- MCH/ MCHC: greatly decreased
- RDW: >17%
- Red Cell Morphology: Very pronounced, microcytosis, hypochromia, anisocytosis, and poikolocytosis
Can you diagnose anemia based on serum iron?
Iron (Fe)- you cannot diagnose iron deficiency on the basis of serum iron, must investigate ferratin
}68 year old man with no past medical history presents to you his primary care physician. He has been generally healthy and so has not seen a physician in 20+ years. He notes that he is a bit more easily fatigued than in the past and gets winded with strenuous exertion. He also notes some intermittent constipation, which is only partly improved by drinking a lot of prune juice.
}He is not on medications.
}Vitals are within normal limits.
}His exam is notable for subconjunctival pallor
}Given the fatigue and pallor you decide to get a CBC
What is the full work up for this pt?
CBC
Peripheral smear
Reticulocyte count
RPI
Iron studies
What diagnosis should you be suspicious of in a pt over age 50 with iron deficient anemia in the U.S.?
In the U.S., iron deficiency anemia in a patient over age 50 should be considered colon cancer until proven otherwise
What is the etiology of congential sideroblastic anemia?
Explain the subclassifications of acquired sideroblastic anemias.
Characterize the labs for sideroblastic anemias.
}Serum Iron: High
}Increased ferritin levels
}Normal or decreased total iron-binding capacity
}High transferrin saturation
What is the treatment for sideroblastic anemias?
What are the occupational, environmental, recreational, and miscellaneous sources of lead poisoning?
Occupational:
–>Printers
–>painters
–> plumbers
–>welders
–>radiator and auto repairers
–>lead miners; smelters;
–>battery manufacturers
–>cable makers
–>gun makers
–>construction, demolition;
Environmental
–>Inhalation of lead dust from demolition sites
–>contaminated clothes
–>inhalation of fumes or dust contaminated with lead
Recreational:
–>Target shooting in indoor firing ranges
–> hobby ceramicists
–>moonshine whiskey
Miscellaneous:
–>Herbal medicines
–>traditional Mexican remedies
–>cooking in clay pots
–>lead-glazed ceramic ware
–>retained bullets after gunshot
What is the CP of lead poisoning?
}Lead line on gums
}Neurological findings:
–>Motor neuropathy (lead palsy)
–>Autonomic neuropathy causing abdominal pain and ileus (lead colic)
–>Insomnia, irritability, psychosis
}The diagnosis is established by blood lead determination.
What is the pathophysiology of lead poisoning?
}Lead inhibits both heme and globin synthesis
}It interferes with RNA breakdown, which causes the accumulation of denatured RNA in blood cells, resulting in basophilic stippling
}↑Fe, and ringed sideroblasts in
the marrow
Where does iron accumulate in sideroblastic anemia
What is the treatment for lead poisioning?
