Normocytic Anemia Flashcards by Derrick Obeng

What is anemia

Anemia is a decrease in the RBC measurements: RBC count (part of CBC), hemoglobin (concentration in g/dL) and hematocrit (volume % of RBC in the body)

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What is the rule of 3

Hgb = 3 * RBC count
Hct = 3 * Hgb

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What are the clinical features of anemia

Vary based on degree of anemia and onset (rapid/slow)
Can be asymptomatic
Weakness
Fatigue
Dyspnoea
Pallor - unhealthy pale appearance (skin of palms and face, also nails and conjunctivae)

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Mention the RBC indices

Mean corpuscular volume (femolitres)
Mean corpuscular hemoglobin (pg/cell)
Mean corpuscular Hgb concentration (g/dL)

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What is the normal MCHC

34g

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What is the normal MCH

27.5 to 33.2 pg/cell

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What is the normal MCV

80 to 100 fL

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What are the blood cell indices

Describe mean characteristics of RBCs
Measured by automated blood counters
Used in the evaluation of anemias

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What is MCV

The average volume of a red cell

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What is MCH

Average weight of hemoglobin inside of each red cell

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What are the classifications of anemia based on MCV

Microcytic
Normocytic
Macrocytic

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What type of anemia is MCV < 80

Microcytic

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What is macrocytic anemia

MCV > 100

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What is normocytic anemia

MCV 80-100

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Give some examples of microcytic anemias

Iron deficiency
Thalassemia
Anemia chronic disease
Sideroblastic anemia
Lead poisoning

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Give some examples of normocytic anemia

Anemia chronic disease
Hemolysis
Aplastic anemia
Chronic kidney disease

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Give some examples of macrocytic anemia

Folate/B12 deficiency
Liver disease
Alcohol use
Reticulocytosis

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What are retuculocytes

Immature red blood cells
Usually about 1-2% of RBC in peripheral blood
In anemia, the bone marrow produces more reticulocytes so the percentage of cells that are reticulocytes should increase in the setting of anemia
When there’s anemia, the kidney produces more EPO. The EPO drives the bone marrow to produce more reticulocytes

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Used in anemia to determine if bone marrow response is adequate
Should ride if bone marrow responds normally
Must be corrected for degree of anemia
If < 2% -> Inadequate bone marrow response
What might this be

Reticulocyte count

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Correct the reticulocyte count for an Hct of 11 and Retic of 8%

Corrected RC = 8% * (11/45) = 2%
45 is the normal Hct level

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What’s the equation for reticulocyte production index

Corrected retic% / Maturation time (varies - increases with decreasing Hb levels)

What RPI level is seen in patients with bone marrow failure

RPI < 2%

Which RPI percentage is a normal marrow response to anemia

> 3%

Hypochromia in blood smear is characteristic of what condition

Iron deficiency

**Spherocytes** in blood smear is characteristic of what condition

Spherocytosis

**Target cells** in blood smear is characteristic of what condition

Thalassemia

**Dacrocytes (tear drop cells)** in blood smear is characteristic of what condition

Marrow fibrosis

**Acanthocytes** in blood smear is characteristic of what condition

Liver disease (spiked RBCs)

**Schistocytes** in blood smear is characteristic of what condition

Hemolysis

What are the two causes of normocytic anemia

Decreased red cell production Increased red cell destruction/loss

What feature is characteristic of a decrease red cell production

A low reticulocyte count

What feature is characteristic of an increased red cell production in normocytic anemias

A high reticulocyte count

What are some causes of normocytic anemias

Anemia or chronic disease Chronic kidney disease (low EPO) Hypothyroidism Bone marrow failure Aplastic anemia

What are some causes of increased red cell destruction leading to a normocytic anemia

Acute blood loss Hemolysis

What is the most common cause of normocytic anemia

Anemia of chronic disease

Which anemia is common in rheumatoid arthritis

Anemia of chronic disease

Anemia in association with inflammation Common in rheumatoid arthritis, lymphoma, other chronic conditions Usually a mild anemia (Hgb > 10g/dL) Symptoms of anemia rare Often incidental finding in blood testing Microcytic in about 25% of cases **Most common** normocytic anemia What condition could this be

Anemia of chronic disease

Acute blood loss causes ……….. anemia

Normocytic

Chronic blood loss causes …….. anemia

Microcytic

Loss of iron in hemoglobin Leads to iron deficiency Common with occult GI bleeding What kind of blood loss could this be

Chronic blood loss

Loss of red cells Remaining red cells have a normal MCV What type of blood loss could this be

Acute blood loss

Which agents are used to treat chronic kidney disease causing a normocytic anemia

EPO stimulating agents Epoetin or darbepoetin (longer-acting)

Used when Hgb < 10g/dL Goal Hgb: 10 to 11.5g/dL (any higher Hg greater than this increases mortality and myocardial infarction because these drugs can cause or worsen HTN) Good response to this drug requires iron (iron deficiency -> poor response) What drug may this be

EPO stimulating agents

Specific type of bone marrow failure where there are defective stem cells which leads to an acellular or hypo-cellular bone marrow Pancytopenia Low WBC, low platelets, low RBC Low reticular count Hypo-cellular bone marrow Absence of infiltrate or fibrosis What condition may this be

Aplastic anemia

How is aplastic anemia diagnosed

Pancytopenia Bone marrow biopsy Acellular or hypocellular bone marrow Absence of cells/replacement with fat

What are some causes of aplastic anemia

Most commonly idiopathic Radiation exposure Drugs Toxins (benzene) Viruses Inherited (Fanconi anemia which develops in children)

What is the mechanism of aplastic anemia

Most cases involve autoimmune damage to stem cells even when underlying cause is present Drugs, chemicals or viruses alter stem cells Leads to autoimmune destruction Immunosuppression improves aplastic anemia

What are some drugs which could cause aplastic anemia

Chemotherapy (anticipated effect) Antibiotics (chloramphenicol and sulfonamides) NSAIDs (phenylbutazone and indomethacin) Anti-seizure drugs (carbamazepine and phenytoin) Anti-thyroid drugs (methimazole and propylthiouracil)

Infects proerythroblasts Usually causes a decrease in RBCs Pancytopenia can occur (high risk in immunocompromised patients) What virus could this be

Parvovirus B19

What are some viruses which could cause aplastic anemia

Parvovirus Acute viral hepatitis (develops weeks to months after acute hepatitis) Others: HIV, EBV, CMV

Inherited aplastic anemia Autosomal recessive or x-linked Usually presents in children less than 16 years old More than half of patients have physical deformities (short stature, malformed thumbs, hypo or hyperpigmentation, café-au-lair spots More than 13 genetic abnormalities identified May involve DNA repair enzymes What condition might this be

Fanconi anemia

What is the treatment for aplastic anemia

Stop offending agent Blood and platelet transfusions Bone marrow stimulation (GM-CSF) Immunosuppression (antithymocyte globulin - a collection of T cell antibodies, cyclosporine) Bone marrow transplant