More Anemias Flashcards

1
Q

Anemia of Chronic Disease:

general and labs

A

Anemia of chronic inflammation
Anemia of organ failure
Anemia of older adults

Usually normocytic
may become microcytic and hypochromic if long-standing

Mild-to-moderate anemia as a result of RBC underproduction

Low serum iron, low TIBC (transferrin), normal to increased serum ferritin

Sources: Cancer, infection, inflammation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

anemia of inflammation/chronic disease

inflammation causes

A

Inflammation causes:
1. Dysregulation of iron homeostasis (hepcidin)
Abnormal iron metabolism, trapping of iron in macrophages, iron unavailable for new hemoglobin synthesis (and unavailable for pathogens)
2. Impaired marrow RBC development
3. Blunted EPO response (CKD)
Inability to increase erythropoiesis in response to anemia
4. Increased phagocytosis of RBCs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q
A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

case study

Confirmed anemia: Hgb 11.3
MCV is Normocytic
RDW is Normal (no anisocytosis)
Iron and % sat slightly low
Ferritin Elevated

A

Normocytic Anemia likely due to: Anemia of Inflammation / Chronic Disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

ferratin

A

is iron store, will not have with iron deficiency.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

anemia of chronic disease/inflammation

Tx

A

Treat underlying disease (most important)

Erythropoietin (Procrit) if low EPO level from renal disease

PRBC transfusion

likely to be on meds for life.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

sickle cell

general

A

Irreversibly sickled cells and recurrent painful crisis (vasoocclusive phenom and hemolysis)
Group of inherited autosomal recessive disorders
More common in African American population
Causes the erythrocyte to stiffen & elongate
Sickle shape in response to lack of oxygen

Sickle cells contain abnormal hemoglobin called hemoglobin S
Sickle hemoglobin causes the cells to develop their sickle shape
Blocks blood flow causing pain and organ damage
Bone marrow is unable to reproduce RBCs quick enough

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

sickle cell

genetics

A

Both parents have Sickle Cell Trait THEN offspring has:
25% chance of disease
25% will not carry a sickle cell allele
50% will have heterozygous condition

Autosomal Recessive
Sickle cell trait
Heterozygous hemoglobin genotype AS
50% chance to pass the sickle hemoglobin gene to offspring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

sickle cell

pathology

A

Mutation occurs in the amino acid sequence of the Hgb Beta chain

RBCs become sickled when oxygen saturation is low
Impairs the flexibility of the RBCs through vessels

Repeated deoxygenation damages cells leading to permanent sickling

Sickled cells live shorter
10 to 20 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

sickle cell

Prognosis/Epidemiology

A

SCD affects approximately 100,000 Americans
SCD occurs among about 1: 365 in the black or African American population
SCD occurs among about 1:16,300 Hispanic-American births
About 1:13 black or African American newborns have sickle cell trait (SCT)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

sickle cell

Signs & Symptoms of Children

A

Anemia
Fatigue
Episodes of pain
Hand-Foot syndrome
Frequent infections
Delayed growth
Vision difficulties

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

sickle cell

delayed growth Sx in children

A

Shortened height
Smaller stature
Delayed puberty
Smaller hand and feet
Hypermetabolic syndrome
burn more calories
Poor nutrition/mineral deficiencies
Endocrine - Insulin Like Growth Factor I

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Sickle cell

PE findings

A

Hepatomegaly
Splenomegaly (in children)
Cardiomegaly
Hyperdynamic precordium
Systolic murmurs
Nonhealing cutaneous ulcers of the lower extremity
Retinopathy
Jaundice

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Sickle Solubility Test:

A

Mixture of Hgb S in a reducing solution gives a turbid appearance and normal Hgb is clear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

*Hgb Electrophoresis

A

Shows various types of hemoglobin move at varying speeds on a gel electrophoresis
Pattern of hgb electrophoresis from several different individuals
Lanes 1 and 5 are hemoglobin standards
Lane 2 is a normal adult.
Lane 3 is a normal neonate
Lane 4 is a homozygous HbS individual
Lanes 6 and 8 are heterozygous sickle individuals
Lane 7 is a patient with SickleCell disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

sickle cell

Howell-Jolly Bodies and target cells which indicate

A

hyposplenism

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Sickle Cell Disease

Dactylitis:

A

acute pain in the hands and/or feet

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

sickle cell

risks of disease

A

Vaso-occlusion can occur in virtually every organ system, acute and chronic multisystem failure
Acute fall in hemoglobin may be superimposed upon the chronic anemia:
splenic sequestration crisis
aplastic crisis
hyperhemolytic crisis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

sicklecell crisis

general
Triggered by, lasts how long

A

Hypoxemia
Triggered by stress, surgery, blood loss, viral or bacterial infection (most common), dehydration, acidosis
Hemolyzed in the spleen
Sickling initially reversible
Becomes irreversible due to chronic sickling

Frequency peaks 19-39 years old
Significant variability in severity & frequency
Range of pain is mild to severe requiring hospitalization
Last approximately 5 to 7 days
Pain may be precipitated by weather conditions, dehydration, stress, menses, alcohol consumption, and nocturnal hypoxemia.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

sickle cell crisis

general Tx

A

IV fluids
Oxygen
Transfusion Therapy
Aplastic crisis
Hemolysis crisis
Example: patient with G6PD deficiency
CVA
Pain Crisis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

sickle cell

splenic sequestration

A

Splenic pooling of red cells produce marked fall in hemoglobin concentration and a rapidly enlarging spleen
Risk of hypovolemic shock, particularly in children

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

sickle cell

Acute chest syndrome

A

A new pulmonary infiltrate with dyspnea and hypoxia
The 2nd most common complication
25% of death in patients with SCD

Frontal chest radiograph demonstrates bilateral diffuse airspace disease (blue circle) in a patient with sickle cell disease, fever and hypoxemia. There is avascular necrosis of the left humeral head (red arrow) and replacement of the right humeral head (white arrow) because it was affected by avascular necrosis as well.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

sikle cell

complications

A
  • CVA
    Narrowing of blood vessels
    Prevents oxygen from reaching the brain
  • Vision
    Proliferative retinopathy
    Vitreous hemorrhage
    Retinal detachment
    Blindness
  • Avascular Necrosis
    Result of ischemia
  • Chronic Pain (in the absence of acute vaso-occlusive pain)
    Opioid tolerance and addiction
  • Decreased Immune reactions due to hyposplenism
  • Severe Bacterial infections
    Increased risk for infection caused by encapsulated organisms
    Streptococcus pneumonia
    Haemophilus influenza
  • Primary Pulmonary hypertension
    Increase strain on the right ventricle
    Risk of heart failure
  • Chronic Renal Failure
  • Cholelithiasis & Cholecystitis
    Excessive bilirubin production and precipitation due to prolonged hemolysis
  • Iron Overload
    Requires chelation
  • Lower extremity ulcers
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Sickle cell disease

general management, referral

A

Refer to hematologist or sickle cell center

Maintain vaccination schedule
Pneumococcal vaccine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

sickle cell

Tx

A

Transfusions
Folic Acid 1mg daily (lifelong)
Hydroxyurea- Improves overall survival and quality of life, Decreases number and severity of crises (33%), Reactivates fetal hemoglobin production in place of Hgb S
Omega-3 fatty acid supplementation
Decrease vaso-occlusive episodes
Reduce transmission needs

  • Crizanlizumab (monoclonal antibody) infusions- Reduce vasoconstrictive episodes by 44%
  • Chelating agents
    Iron overload due to transfusion therapy
  • Bone Marrow Transplant
    Only known cure (up to 80%)
    Consider if severe pain crises and recurrent vaso-occlusions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Hydroxyurea (Hydrea)

MOA, precautions, pregnancy, indications

A

Antimetabolite: MOA unclear
Usage: Sickle Cell Anemia, Chronic Myelogenous Leukemia, Polycythemia Vera, Essential Thrombocythemia
Dosage: 500mg capsule. Varies, mostly weight based

Precautions:
Avoid use of live vaccines during hydroxyurea therapy
Radiation recall
Use with antiretroviral therapy, risk of pancreatitis, hepatotoxicity, and peripheral neuropathy
Discontinue at least 3 months prior to conception
Pregnancy: May cause fetal harm

27
Q

hydroxyurea (hydrea)

side effects

A

Side Effects:
Myelosuppression
Macrocytosis
Secondary Leukemia
Skin Cancer
Rash
Hepatotoxicity
Nausea/vomiting

28
Q

thalassemias

definition

A

Reduced alpha or beta globin chain synthesis
-Leads to decreased hgb synthesis  intramedullary and peripheral hemolysis
-Hypochromic microcytic anemia

β-Thalassemia
Point mutation resulting in reduced (beta+) or absent (beta0)beta globin chain synthesis
α-Thalassemia
Gene deletion causing reduced alpha globin chain synthesis

29
Q

thalassemias

classification

A

-Hypochromic microcytic anemia

30
Q

thalassemia

epidemiology

A

Association with malaria
Southeastern and southern Asia, Middle East, Mediterranean countries, and northern and central Africa
Prevalence in these regions up to 10%
Rate in U.S. unknown as no effective screening in place

31
Q

thalassemia

pathophys

A

Unequal production of one of the globin chains—imbalance in chain ratio
Mechanisms
β-Thalassemia
α-Thalassemia

32
Q

Categories of Thalassemia

Thalassemia trait

A

Lab features without clinical significance (mild microcytic anemia)
>= 2 intact globin chains

33
Q

categories of thalassemia

Thalassemia intermedia

A

Occasional treatment needed and/or moderate clinical impact
Chronic hemolytic anemia

34
Q

categories of thalassemia

Beta Thalassemia major

A

Life threatening and/or transfusion dependent
Severe anemia
Growth failure
Bony deformities
abnormal facial structure (prominent forehead and flattened nose due to expansion of facial bones to accommodate hyperplastic marrow)
pathologic fractures
Hepatosplenomegaly and jaundice

35
Q

Β-Thalassemia

general

A

With reduced β-chains
Bone marrow becomes hyperplastic
Bony deformities
Osteopenia
Pathologic fractures

36
Q

β-Thalassemia minor

general

A

β-Thalassemia minor
Heterozygous mutation
Clinically insignificant microcytic anemia

37
Q

β-Thalassemia minor

Lab Evaluation

A

HgB F is fetal hemoglobin

38
Q
A

Red blood cells (RBCs) from a patient with β-thalassemia minor, showing microcytic, hypochromic RBCs with target cells, other poikilocytes, and basophilic stippling (arrow).

39
Q

β-Thalassemia Intermedia

general

A

β-Thalassemia intermedia
Homozygous mutation but higher rate of beta-globin synthesis
Chronic hemolytic anemia
Clinical features (as adults)
Hepatosplenomegaly
Bony abnormalities

40
Q

β-Thalassemia Intermedia

Lab Evaluation
Perph smear

A

Moderate anemia
RBC: normal or ↑
Hct: 17-33%
MCV: 55-75fL
Peripheral blood smear: microcytic hypochromic anemia
Target cells
Basophilic stippling
Reticulocyte count: ↑
Iron studies: Normal
Hemoglobin electrophoresis:
Increased Hgb A up to 30%
Increased Hgb A2 up to 10%
Increased Hgb F , 6-10%

41
Q

β-Thalassemia Intermedia:

Treatment

A

Refer to hematologist
May require transfusions during periods of stress
Offer genetic counseling

42
Q

β-Thalassemia Major

general

A

“Cooley anemia”
Homozygous mutation
Normal at birth
Within 6 months develops severe anemia

43
Q

β-Thalassemia Major

Clinical features (as children)

A

Clinical features (as children)
Stunted growth
Bony deformities
Abnormal facial structures
Pathologic fractures
Hepatosplenomegaly (from constant hemolysis)
Jaundice (hemolysis)
Thrombophilia

fetal hemoglobin is not affected by thalassemia

44
Q

Β-Thalassemia major

bony deformities

A

Abnormal facial structure
Prominent forehead and flattened nose due to expansion of facial bones to accommodate hyperplastic marrow

45
Q
A

Severe osteoporosis, pseudofractures, thinning of the cortex, and bowing of the femur.

B thalassemia major

46
Q

β-Thalassemia Major

Lab Evaluation

(without transfusion)

A

Severe anemia
Hct: < 10% without transfusions
Peripheral blood smear: microcytic hypochromic anemia
Severe poikilocytosis
Target cells
Basophilic stippling
NRBCs (nucleated immature RBCs)
Hemoglobin electrophoresis
Minimal Hgb A
Variable Hgb A2 seen
Predominantly Hgb F

47
Q

β-Thalassemia Major

A

Red blood cells from a patient with β-thalassemia major. Note basophilic stippling, microcytosis, hypochromia, target cells, nucleated red blood cells, and red cell fragments.

48
Q

β-Thalassemia Major

Treatment

A

Refer to hematologist

  • Transfusion therapy (Transfusion dependant)
    Scheduled
    Causes hemosiderosis (iron deposition in organs)
    Heart failure
    Cardiac arrhythmias
    Cirrhosis
    Endocrinopathies
    Pseudoxanthoma elasticum
  • Iron chelation (oral or parenteral)
  • Allogenic stem cell transplant
    80% long term survival in children (before organ damage occurs)
49
Q

α-Thalassemia categories

α-Thalassemia Minor

A

2 α-globin genes
Hct 28–40%
MCV 60–75

50
Q

A- thalessemia

Hemoglobin H disease

A

1 α -globin gene
Hct 22–32%,
MCV 60–70

51
Q

A thalassemia categories

Hydrops fetalis

A

No α -globin genes

52
Q

α-Thalassemia Minor

general

A

2 alpha globin genes present
Homozygous or heterozygous
Clinically normal with mild microcytic anemia
Normal lifespan

53
Q

α-Thalassemia Minor

labs

A
54
Q

Hemoglobin H Disease

general and clinical features

A

HgB H disease
1 alpha globin chain intact
Alpha chains are reduced, beta chains pair together to form Hb H
Chronic hemolytic anemia

Clinical features
Pallor
Splenomegaly

55
Q

Hemoglobin H Disease:

Lab Evaluation

A

Anemia present
RBC: normal or increased
Hct: 22-32%
MVC: 60-70fL
Peripheral blood smear: Marked microcytic hypochromia
Target cells

Poikilocytosis
Reticulocyte count: Increased
Hemoglobin electrophoresis: Hemoglobin H 10-40%

56
Q

Hemoglobin H Disease

A

Red blood cells from a patient with hemoglobin H disease, incubated with brilliant cresyl blue, which have acquired fine, evenly dispersed granular inclusions and “golf ball” appearance.

57
Q

Hemoglobin H disease

Hemaglobin H

A

HbH has a high affinity for oxygen and is an ineffective supplier of oxygen to tissues under physiologic conditions.

RBCs that contain HbH are sensitive to oxidative stress

58
Q

Hemoglobin H Disease

Tx

A

Refer to hematologist
Transfusions not normally needed
Folic acid 1mg PO daily
Avoid iron supplementation and oxidative drugs (sulfonamides)
May develop hemolytic exacerbation requiring PRBC transfusion
Infection
Bone marrow stress
Offer genetic counseling

59
Q

α-Thalassemia Major

A

Hydrops fetalis
No functional alpha globin chain

Results in stillbirth

60
Q

thalassemia

gold standard for Dx

A

Electrophoresis is Gold Standard for diagnosing thalassemia

61
Q

mild Thalassemias

Tx

A

Mild thalassemias (α-thalassemia or β-thalassemia minor/trait)

Usually require no treatment
Identify in order to avoid repeated evaluations for iron deficiency and inappropriate administration of supplemental iron
May require transfusion during infection/stress

62
Q

Thalassemia

Tx

A
63
Q

Thalassemia

Prognosis

A