Module 2 Anemia and HIV Flashcards
What is the definition of anemia?
Reduction in RBCs, hemoglobin concentration, or hematocrit
What level of hemoglobin in women defines anemia?
Hbg <12
What is the pathophysiology of anemia?
Hgb transports oxygen to tissues. In anemia, there is a decrease in the amount of hgb, which results in inadequate oxygen being carried to tissues.
What are the three causes of anemia?
Decrease in RBCs production (proliferative disorder)
Destruction of RBCs
Blood loss
What is proliferative disorder?
Also known as a decrease in RBC production.
Happens when the bone marrow is not producing properly. Can be caused by hormone imbalances (thyroid), low iron, inflammation, etc.
What is the most common cause of proliferative disorder in women?
Iron deficiency
What is MCV (mean corpuscular volume? What is normal volume? What is normal volume called?
MCV is the size (volume) of a red blood cell.
Normal (normocytic) is 80-100%
What MCV is Macrocytic?
MCV greater than 100
What MCV is Microcytic?
MCV is less than 80
Define hypochromic. Give two examples of hypochromic anemias.
Reduction in red blood cell hemoglobin (pale in color)
Thalassemia and sickle-cell anemia
Define normochromic. Give example of normochromic anemia.
Normal amount of hemoglobin
Anemias from blood loss
What is an erythrocyte and reticulocyte?
Erythrocyte-RBC
Reticulocyte-immature RBC
What are some risk factors for anemia?
Women of African/Mediterranean, middle east, southeast Asia, Indian, and Pakistan descent.
Older women, pregnancy, acute blood loss, CKD, G6PD Deficiency, Autoimmune disorders, chronic disease
What are the differential diagnosis for anemia?
Blood loss
Malignancy
Renal Failure
What subjective data may we see with anemia?
Some may be symptomatic. Specific symptoms depend on the cause.
May see fatigue, racing heart rate, dizziness, peripheral neuropathy, fainting
Severe symptoms: breathlessness, headache, memory loss, angina
What objective data may we see with anemia?
Exam may be normal
May see pallor or tachycardia
What diagnostics may be performed for suspected anemia?
H&H, CBC with indices (MCV, peripheral smear, reticulocytes), iron stores (ferritin, iron, total iron-binding capacity, transferrin saturation percentage)
What type of anemia do these labs indicate? (micro, normo, macro)
Hgb 9.8; MCV 74; TIBC 465ug/dL; Serum ferritin 10ug/dL
microcytic anemia
What type of anemia do these labs indicate? (micro, normo, macro)
Hgb 10.0; MCV 110; TIBC 426; Serum ferritin 50ug/dL
macrocytic anemia
What type of anemia do these labs indicate? (micro, normo, macro)
Hgb 10.8; MCV 92; TIBC 360; Serum ferritin 80ug/dL
normocytic anemia
What type of anemia do these labs indicate?
Hgb 10.6; MCV 76; TIBC 283; Serum ferritin 30ug/dl
thalassemia
Which type of anemia is the most common anemia in elderly populations, and due to hypo-proliferation and reduced response to erythropoietin?
Anemia of chronic disease
A 66-year-old's recent blood tests reveal the following results: Hemoglobin - 11.1 Hematocrit - 33.3 MCV - 92 Serum iron low Serum ferritin is slightly elevated TIBC slightly elevated What type of anemia does she have?
Anemia of chronic disease
What are some types of normocytic anemia?
Acute blood loss, anemia of chronic disease, and early iron deficiency
Chronic diseases examples: Autoimmune diseases, renal failure, liver disease, cancer, IBD
What subjective and objectice data may we see with normocytic anemia?
Subjective: May be asymptomatic, Fatigue, feeling cold, dyspnea with activity
Objective: pallor, fatigue, sallow colored skin (brown/yellow), pale conjunctiva, glossitis (shiny tongue), angular stomatitis (cracked corners of mouth)
What should be included in the exam for normocytic anemia? Why/What might you find?
Cardio-pulmonary (tachycardia, tachypnea, pulmonary edema) abdomen (hepatomegaly/splenomegaly), extremities (poor cap refill, spoon-nails, pale palmar creases, brittle nails, cold hands and feet
What labs/diagnostic results do we expect with normocytic anemia from acute blood loss?
MCV: 80-100,
ferritin normal
reticulocyte high
TIBC normal
How can normocytic anemia be treated?
Early iron deficiency anemia: diet change-increase iron-rich foods
Chronic Disease: referral for disease
Follow up with CBCs and iron studies collab with specialist
What are the two most common Microytic anemias?
Iron deficiency anemia and thalassemia
Note: these are the ones we will see most often in women
What subjective data may we see with microcrytic anemia? What should be sure to ask about?
Fatigue, weakness, tachycardia/palpitations, lightheaded, dyspnea on exertion
Medications- antacids, H2 blockers, PPIs, NSAIDs, ASA, Zinc
Menstrual hx
PICA
Melena in stool
What objective data may we see in microcytic anemia?
Pallor, sallow skin, fatigue, pale conjunctiva, angular stomatitis, atrophic glossitis
What should be included in the exam for microlytic anemia? Why/What might you find?
Cardio-pulmonary (tachycardia, tachypnea, pulmonary edema) abdomen (hepatomegaly/splenomegaly), extremities (poor cap refill, spoon-nails, pale palmar creases, brittle nails, cold hands and feet
What labs/diagnostic results do we expect with microlytic iron deficiency anemia?
MCV: <80 H/H: Low Serum Iron: low Ferritin low Retic low TIBC high MCHC <27
How can microcytic anemia be treated?
Facilitate absorption-increase diet of animal protein, avoid tannins, iron overload, antacids
Supplemental iron (ferrous sulfate 325 po 1-3 times a day (slow Fe, Feratab)
Recheck H&H in 2 months
In pregnancy: treat with elemental iron 60-120 mg daily then decrease to 30 mg once normalized
What is the inherited form of hemolytic anemia? What patient are highest risk?
Thalassemia (microcytic)
Women of African/Mediterranean, middle east, southeast Asia, Indian, and Pakistan descent.
When do I need to order electrophoresis?
When a patient has relatives with thalassemia or suspected thalassemia
What subjective and objective data do we see with thalassemia?
Subjective: may be asymptomatic or have mild-severe anemic symptoms
Objective: Pallor, sallow skin, fatigue, pale conjunctiva, angular stomatitis, atrophic glossitis
What lab results do we expect to find in alpha thalassemia?
Ferritin: normal Reticulocyte: normal TIBC: normal MCV: <80 H/H: low RBC: Normal-elevates 4 genes-one or all four are damaged or missing
What lab results do we expect to find in beta thalassemia?
Ferritin: normal to high Reticulocyte: low TIBC: normal MCV: <80 RBC: normal or elevated 2 genes
How do we manage Thalassemia?
DO NOT treat with iron, may cause severe organ damage
Refer to hematologist
Blood transfusions
Genetic counseling
What are the most common causes of macrocytic anemia?
Nutritional deficiency (B12 or Folate)
Pernicious Anemia
Alcohol abuse
Hypothyroidism
What can cause vitamin B12 deficiency? Why is it important?
B12 is needed to make red blood cells and to keep nerve cells healthy
Can be caused by inadequate intake, intrinsic factor deficiency (pernicious anemia or gastrectomy, chron’s, malabsorption)
What subjective data do we see in vitamin B12 deficiency?
Memory issues, fatigue, SOB, diarrhea, pain/tingling, peripheral neuropathy, depression, irritability, difficulty walking
Medications: antacids, H2, PPIs, metformin
Medical sx history: thyroid disorder
alcohol use
What patients we most often see pernicious anemia in?
The elderly and chronic disease
What objective data may we see with vitamin B12 deficiency?
Jaundice, glossitis, unstable gait, neuro symptoms (positive Romberg, cognitive impairment if severe)
What diagnostics would we use for macrocytic anemia?
CBC with diff RBC indices Folate Vitamin B12 (Serum Cobalamin) Serum Homocysteine Methylmalonic Acid Anti-intrisic factor antibodies
What lab results may we find with vitamin B12 deficiency?
Ferritin: normal Reticulocyte: low TIBC: normal MCV: >100 B12: low Folate: normal H/H: low WBCs and platelets: low peripheral smear: abnormal Anti intrinsic factor antibodies Methylmalonic acid: elevated homocysteine: elevated
What lab results may we find with Folate deficiency?
Ferritin: Normal Reticulocyte: Low TIBC: Norma MCV: >100 B12: Normal Folate: Low Methylmalonic acid: normal Homocysteine: elevated
What are some management options for B12 deficiency?
Packed RBCs, oral Vitamin B12, injected B12, referral
What is the schedule for Vitamin B12 medications (both injections and oral)?
Injections:
Week 1:daily injections
week 2:twice weekly
weeks 3-6: once weekly followed by monthly for life
Oral: 1-2 mg by mouth daily
What are some of the causes of folate deficiency?
Decreased dietary intake malabsorption pregnancy alcoholism cancer medications
Which is the most common macrocytic anemia?
Folate Deficiency
What subjective and objetive data may we see for folate deficiency?
Subjective:
Rarely symptomatic
Medications: methotrexate, metformin, sulfa, anticonvulsants
Review Alcohol consumption
Objective: nearly none-depends on labs
How do we differentiate folate vs B12 deficiency?
Methylmalonic acid. Normal with elevated cyctine indicated folate deficiency
What is the management of folate deficiency?
Folic acid- 1 mg per day for 6 months (400 mg daily for pregnant or childbearing age)
High folic acid diet (cheese, eggs, greens, meats, and some breads-cooking can destroy folic acid). Vitamin C also needed for absorption
Periodic testing
What is the important teaching for iron supplementation?
Iron should be taken between meals with vitamin C
Cooking may destroy folic acid
Stools may be black or tarry
GI discomfort may occur
What are some of the complications seen with Iron deficiency anemia during pregnancy?
preterm birth, low birth weight, learning deficits
What are some complications seen with anemia?
Fatigue, falls, cardiovascular compromise
What are some complications seen with vitamin B12 deficiency?
Irreversible neurological damage (if untreated for >3 months) and mental status changes
What is a complication seen with folate deficiency?
Neural tube defects
Who may we refer anemic patients to?
Nutritionist
Hematologist
Genetic counselor
What is most important during an exam of a patient presenting with anemia?
a thorough history and head to toe exam
What labs/diagnostic results do we expect with normocytic anemia from chronic disease?
MCV: 80-100 Hgb 10-11 Serum iron low Ferritin normal or high Retic low TIBC low or normal
What labs/diagnostic results do we expect with normocytic anemia from early iron deficiency?
MCV: 80-100 Hgb 10-11 Serum iron low Ferritin low Retic low TIBC high
What are the common types of normocytic anemia?
Early iron deficiency anemia Acute blood loss Anemia of Chronic Disease Aplastic Anemia Sickle Cell Anemia
What are the CBC and iron indices? What do they mean?
MCV- size of the red blood cell
Peripheral smear- looks at the shape of the red blood cell
Reticulocytes- decreased production of RBCs or increased loss
Serum Ferritin-tells us how much-stored iron there is
Serum Iron- the plasma iron concentration
total iron binding capacity- how much iron the blood can carry if the transferrin is totally saturated
Explain the pathophysiology of HIV
Human immunodeficiency virus is a retrovirus.
The virus infects the CD4 T lymphocytes
decreasing the amount of CD4 T lymphocytes
resulting in a decreased immune system
What are the risk factors for HIV?
Vaginal or anal sex
Sharing needles/syringes
Blood products-this is a low risk due to testing
Occupation- ex. first responders/healthcare workers
Pregnancy – to child
Breastfeeding – to child
What testing/lab monitoring is required for PrEP?
Patient must be HIV negative.
Renal function should be monitored
Over 50 y/o and creat >30 monitor every creat every 6 months
All other monitor every 6-12 months
What are the medication options for PrEP?
•Transgender women and men - Emtricitabine (F) 200mg in
combination with tenofovir alafenamide (TAF) 25mg (also
know as Descovy) – 90 Day supply
•Women and men - Emtricitabine (F) 200mg in combination
with tenofovir disoproxil fumarate (TDF) 300mg (also know
as Truvada) – 90 Day supply
•cabotegravir (CAB) injections approved for those at substantial risk
What patient education should be reviewed with patient on PrEP?
Educated on the importance of daily medication, STI counseling, and condom use.
Educate on risk to kindey and liver
Educate on need to be HIV negative and no prior Hep B treatment (increased risk of resistant HIV if not) [black box warning]
What are our differential diagnosis for HIV?
Mono
Flu
Yeast infection
Lymphoma
What subjective data may we see with HIV?
- Varies by stage of disease
- May be asymptomatic
- Fever
- Night sweats
- Fatigue
- Chronic yeast infections
What objective data may we see with HIV?
- Lymphadenopathy
- Vaginal yeast or lesions
- Oral lesions
When should patients be screened for HIV?
USPSTF: 15-65, pregnant. Those outside ranges that are high risk should be screened
CDC: 13-64 with an opt-out option, yearly for high-risk, pregnancy with opt-out
What diagnostics should be performed to screen for HIV?
Nucleic acid Test (NAT)- is extremely expensive and used less. Can detect earlier after exposer (10-33 days)
HIV 1,2-has less false positives
How is HIV managed? What consults if any?
- Referral for immediate treatment of HIV
- GYN care-NP and CNM can perform. All contraceptives ok. At risk of pap abnormalities and lesions
- Dermatology issues-CNM can manage fungal infections and skin conditions
- Prenatal care-CNM may provide in collaboration with HIV specialist
What labs should be monitored on a patient with HIV?
CD4 count and viral load
What education is important for patient with and without HIV?
- STI prevention
- Disclosure is recommended
- Continued care – team approach
- PrEP is available
- Early and consistent treatment is crucial
What are some complications associated with HIV?
- Lymphoma
- TB
- Coinfection with Hep C or Hep B
- Cardiovascular disease
- Drug to drug interactions
What can be given to a patient exposed to HIV?
Postexposure Prophylaxis
Medication given after exposure to prevent HIV (Occupational and Nonoccupational)
What are the CDC guidelines for Postexposure Prophylaxis (PEP)
- Use of rapid antigen/antibody (Ag/Ab) combination HIV tests
- 3-drug antiretroviral nPEP regimens
- Follow up labs
- Take within 72 hours after exposure – the sooner the better. Treat without delay.
- Take for 28 days
- Can be used in pregnancy
- Baseline and follow up labs – serum creatinine and creatinine clearance, LFTs
- Transitioning from nPEP to PrEP
What are our medication choices for PEP?
A 3-drug regimen consisting of tenofovir DF 300 mg and fixed dose combination emtricitabine 200 mg (Truvadac) once daily with
raltegravir 400 mg twice daily or dolutegravir 50 mg once daily
What education should be reviewed with a patient starting PEP?
•advise patients of need to begin PEP within 72
hours of exposure and continue PEP for full 28-day
course
•review possible side effects from PEP, including
–fatigue
–nausea
–diarrhea
–rash
•review possible toxicities, including liver and kidney
dysfunction, and lab monitoring schedule to detect
these and prevent lasting complications
What follow up monitoring should be performed on a patient exposed to HIV on PEP?
•monitor complete blood count (CBC), electrolytes, renal function, and liver function tests during treatment to ensure no toxicities are developing (typically around 2 weeks after starting therapy)
•repeat testing for HIV–perform HIV serology at 6 weeks, 3 months, and 6 months after exposure (although 6-month testing not recommended by some agencies as 99% of infected
patients have antibodies at 3 months)
–testing may be done only at 6 weeks and 4 months if combination HIV antibody/p24 antigen (Ab/Ag) testing is used and is negative at both time points
Which type of anemia affects 10-15% of premenopausal women, represents 25% of all anemia cases, and is often due to slow, persistent blood loss?
Iron deficiency anemia
How soon should the CBC be rechecked after starting treatment with ferrous sulfate and dietary education for a patient with iron deficiency anemia?
7-8 weeks
Nonpharmacologic management of a patient with a hemoglobin of 8.0, MCV of 68, low serum ferritin, and a high TIBC includes:
Diet with increased iron content
A 22-year-old patient presents to review labs.
Laboratory Results:
Hgb - 9.8
MCV - 68
TIBC - 502
Serum ferritin - 9ug/dL
What is the most important data to obtain from the patient?
Menstrual history
Which of the following are causes for macrocytic anemia?
- Chronic inflammation, hemolysis, renal failure
- Gastritis, thalassemia, inadequate diet
- Pernicious anemia, sideroblastic anemia, hyperthyroidism
- Folate deficiency, liver disease, hypothyroidism
Folate deficiency, liver disease, hypothyroidism
A patient has normocytic, normochromic anemia with a slightly elevated ferritin level. Which of the following choices will best treat the cause of this patients anemia?
Optimal management of their rheumatoid arthritis
It is important to discern thalassemia minor from iron deficiency anemia because…
Iron overload has dangerous complications
Macrocytic normochromic anemia can be caused by
Folic acid deficiency
A 55-year-old with a history of chronic gastritis is concerned about numbness in their fingers and toes. They have also been having difficulty with balance.
Physical findings include decreased vibratory sense, loss of proprioception, and positive Romberg.
Which of the following is the most appropriate treatment?
Vitamin B12 and folate supplementation
A 55-year-old patient with anemia has labs rechecked. Follow-up lab results are: H/H-10.6/31.8 MCV-68 MCHC-30 RDW-14.5 Serum iron-36 Serum ferritin-7 TIBC-480 Transferrin saturation-6 Reticulocyte count-120,000 u/L Fecal occult blood-Positive Hemoglobin electrophoresis-99% Hgb A1 Peripheral smear-Positive microcytosis, Positive hypochromic Platelets-341 Which of the above results would help distinguish the cause of the anemia?
Fecal occult blood test
What Is the first lab value we should look at when a patient is anemic?
MCV
What are the diagnostics for Thalassemia?
Hemoglobin electophoresis
How is thalassemia managed?
DO NOT give iron
Some patients need blood transfusions
Which of the following is normocytic? Iron deficiency anemia Vitamin B12 Thalassemia Anemia of chronic disease
Anemia of chronic disease
What type of anemia do the following labs indicate? Ferritin-low Retic-low TIBC-high MCV- <80 Serum Iron-low
Microcytic–»iron deficiency anemia
TIBC shows us this is not thalassemia-if it was it would be normal
Why is ferritin so important when it comes to iron deficiency anemia?
It measures the stored iron and is the first lab value to change. A low H/H is a late indicator of anemia
What are some of the objectives we may find with a patient with Vitamin B12 deficiency?
Jaundice Neuropathy Angular stomatitis Glossitis Unstable Gait Cognitive Impairment Positive Romberg
Neuro will not resolve if not treated early
What are some causes of VB12 deficiency?
Intrinsic factor deficiency Malabsorption issues (I.e. chrons, IBs, stomach sx)
What other labs should be reviewed with VB12 deficiency?
Serum coballum
Folate
Homocystine
Methylmalonic acid
A 76-year-old patient with Lupus (managed by another provider) and no complications presents with a normal exam and the following labs: H/H: 11.3/33 MCV: 94 Serum iron-low Ferritin-slightly elevated TIBC-normal
What does she have and how should we educate her?
iron deficiency of chronic disease
Education: diet-green leafy veggies, vaccine review
A 76-year-old patient presents with these labs: H/H: 11.3/33 MCV: 72 Retic: low Serum iron: low Ferritin- low TIBC: high What anemia does she have? What may be causing it (I.e. most common cause)?
Iron deficiency anemia
Most commonly: Bleeding-possibly GI due to age
What education should we give patients taking iron?
Iron supplements should be taken with orange juice to assist with absorption
May cause GI upset-should be taken on an empty stomach but can be taken with meal if needed
May cause stomach cramps and nausea
Avoid calcium and dairy within a few hours
Will take 1 month to improve
What is the leading cause of iron deficiency anemia in elderly women?
GI bleed
What are the types of microcytic anemia?
Iron deficiency - most common
Thalassemia
When would we treat for iron deficiency anemia versus not treat?
When to treat: acute blood loss impaired absorption pregnancy heavy mensural bleeding GI blood loss Chronic kidney disease Gastric bypass inflammatory bowel disease dietary deficiency
When not to treat:
early iron deficiency anemia, especially if asymptomatic
