Normocytic Anemia

Question 1

What is the second most common anemia?

Answer 1

ANEMIA OF CHRONIC DISEASE/ INFLAMMATION
–>2nd most common anemia after iron deficiency anemia

–>It is the most common anemia among inpatients

Question 2

Indicate the relative change in the following values for iron deficient anemia (IDA):

• Ferritin
• Transferrin/ TIBC
• T Saturation
• Iron
• Marrow Iron Stores
• RPI
• Sed rate (inflammatory markers)

Answer 2

Values for iron deficient anemia (IDA):

• Ferritin: decreased
• Transferrin/ TIBC: increased
• T Saturation: decreased
• Iron: decreased
• Marrow Iron Stores: decreased
• RPI: decreased
• Sed rate (inflammatory markeres): normal

Question 3

Indicate the relative change in the following values for anemia of chronic disease (ACD):

• Ferritin
• Transferrin/ TIBC
• T Saturation
• Iron
• Marrow Iron Stores
• RPI
• Sed rate (inflammatory markers)

Answer 3

Indicate the relative change in the following values for ACD:

• Ferritin: normal to increased
• Transferrin/ TIBC: decreased or normal
• T Saturation: low normal
• Iron: decreased
• Marrow Iron Stores: increased
• RPI: decreased
• Sed rate (inflammatory markers): increased

Question 4

ID: 68 yo man with normocytic anemia

History of present symptoms:
“Progressive midepigastric pain over 6 months and a 30 lb weight loss.”

Past Medical History
Asthma
Normal colonoscopy 2 years ago

Social History
Retired teacher. Married. Three grown children
No history of tobacco, drug or alcohol use

Family medical history
Mother died of complications from diabetes
Father alive and well
No other family medical issues

Medications
Inhalers

Physical exam:
Stable vitals
Cachectic appearing man with tenderness to palpation in midepigastric area and RUQ,

Reticulocyte count: 1% (RPI = 0.48)
Iron studies:
↓Fe = 30 µg/dL (40-160 µg/dL)
↓TIBC = 190 µg/dL (205-395 µg/dL)
↓TS = 15 % (25-45 %)
↑Ferritin = 500 ng/mL (20-300 ng/mL)

What could be a potential diagnosis?

Answer 4

Pancreatic Adenocarcinoma

Inflammatory state
–>Anemia of a chronic disease

Question 5

What is the treatment for ACD (anemia of chronic disease)?

Answer 5

Ideally treatment of the underlying disease/disorder

Supportive care:
Transfusions if severe anemia present

Erythropoietin in some instances

Question 6

What is aplastic anemia?

Answer 6

“Aplastic anemia” is a misnomer because the disorder is defined as pancytopenia with an empty bone marrow

Anemia is often less of a clinical problem than the leukopenia (low WBCs) and thrombocytopenia (low platelets) which are also present

Question 7

What are the causes of primary aplastic anemia?

Answer 7

–> Idiopathic (most common)

–> Fanconi Anemia: most often inherited in an autosomal recessive pattern,

Question 8

What are the causes of secondary aplastic anemia?

Answer 8

SECONDARY ANEMIA
--> Radiation
--> Chemotherapy (alkylating agents)
--> Other drugs: chloramphenicol
	antiepileptic drugs
--> Benzene
--> Viruses: parvovirus, Epstein-Barr

Question 9

How do you treat aplastic anemia?

Answer 9

Aplastic anemia can be treated effectively by :

–>bone marrow transplantation.

[target] LYMPHOCYTES

• -> Cyclosporine
• -> Cyclophosphamide
• ->Anti-thymocyte globulin (ATG) may also reverse it when due to immune suppression.

[target] PLURIPOTENT HSC
–>Growth factors (erythropoietin, G-CSF may also be used).

[target] LEUKOCYTES/ GRANULOCYTES
–> blood transfusions, increase leukocytes

Question 10

Describe the etiology of anemia of chronic kidney disease

Answer 10

• Decreased erythropoietin due to decreased renal cortical cells
• ->Typically when kidney function Frequent phlebotomy
• ->Blood loss in the dialysis circuit
• ->Uremic platelet dysfunction: bad kidney
• Shortened RBC survival
• -> Uremic RBCs less deformable and more prone to mechanical destruction

Question 11

What is the treatment for anemia of chronic kidney disease?

Answer 11

Treatment= erythropoietin

Question 12

What are the possible etiologies of hypo proliferative normocytic anemias?

Answer 12

Drugs
–>E.g., chemotherapy

Infiltration of the bone marrow by
–>Malignancy or infection

Endocrine
-->Hypothyroidism
-->Panhypopituitarism
-->Low testosterone 
(generally mild)

Question 13

What happens to the heme ring when rbcs are broken down.

Answer 13

Heme ring is metabolized to bilirubin and transported to liver where it is excreted into bile

Question 14

Provide an example of an inherited anemia

Answer 14

–> Sickle cell anemia

–>G6PD deficiency:X-linked recessive pattern.

Question 15

Provide an example of an acquired anemia

Answer 15

Autoimmune hemolytic anemia

Question 16

Provide an example of an anemia with intravascular hemolysis

Answer 16

Paroxysmal nocturnal hemoglobinuria

Question 17

Provide an example an anemia with extravascular hemolysis

Answer 17

Hereditary spherocytosis

Question 18

Provide an example of an anemia with an intrinsic origin of RBC damage

Answer 18

G6PD deficiency

Question 19

Provide an example of an anemia with an extrinsic origin of RBC damage

Answer 19

TTP: thrombin thromobocytopenic purpura

Question 20

Describe the pathophysiology of intravascular hemolysis

Answer 20

–>Release of hgb and enzymes into the circulation

–>Haptoglobin (Hp) binds the Hgb

–>The haptoglobin-Hgb complexis removed by theRES

–>Prevents iron-utilizing bacteria from benefitting from hemolysis.

–>Not absolutely distinct from extravascular hemolysis

Question 21

What are the clinical manifestations of intravascular hemolysis>

Answer 21

Pallor, fatigue, tachycardia
Jaundice
Blood-tinged plasma
Blood-tinged urine