Primary Care: Hematologic Disorders Flashcards
What is Anemia?
Abnormally low hgb concentration
<12 for women
< 11 in 1st tri
< 10.5 in 2nd tri
< 11 in third tri
<13 for men
What are the types of anemia?
Classified by RBC size:
- Microcytic (MCV < 80)
- Macrocytic (MCV > 100)
- Normocytic (MCV 80-100)
What Causes Microcytic Anemia?
- IDA - usually d/t chronic low volume blood loss (menorrhagia, GI bleeds/colon cancer). dietary insufficiency, pregnancy d/t increased metabolic demand
- thalassemia trait
What causes Macrocytic Anemia?
- Vit B12 deficiency - PPIs can decrease B12, iron absorption; metformin can decrease B12 absorption
- Folate deficiency
- Liver disease
- hypothyroid
What causes Normocytic anemia?
- anemia of chronic disease - reduced RBC production/lifespan d/t inflammation
hemolysis - anemia of chronic disease can contribute - sickle cell disease
- renal failure - CRF (reduced erythropoetin)
- ACUTE blood loss
What is the most common anemia
IDA
What is the etiology for IDA?
- slow, persistent blood loss (GI bleed, heavy menstrual periods)
- Inadequate dietary intake (not common)
- Metabolic demands in excess of intake - like in pregnancy
What lab values would lead to IDA?
MICROCYTIC/HYPOCHROMIC
Hgb: Low
Hct: Low
RBC: Low
MCV: Low (small size/microcytic)
MCHC: Low (pale/hypochromic)
RDW: increased (cells different sizes)
Reticulocytes: decreased
If above is on CBC –> next step ferritin for estimate of iron stores
Ferritin: low
TIBC: high
Serum FE: normal or low
What is the etiology of anemia of chronic disease?
- hypoproliferative anemia associated with underlying chronic disorders like infection, inflammatory disorders (lupus/RA), malignancy
- reduced production and repose to erythropoeitin, decreased RBC life span (CRF)
- Defect in iron reutilization
- Common in elderly/autoimmune
What are the lab values for anemia of chronic disease?
Normocytic, Normochromic, NL RDW
Hgb: Low
Hct: Low
RBC: Low
MCV: wnl
MCHC: wnl
RDW: wnl
Next step: ID cause/dictated by suspected cause (lupus, RA, CRF… ACUTE BLOOD loss also has these labs)
What is the etiology of Vit B12 deficiency anemia?
- Vit B12 deficiency alters DNA synthesis and maturation of RBCs
- Vit B12 deficiency develops secondary to lack or relative deficiency of intrinsic factor that leads to impaired vitamin B12 absorption (pernicious anemia) –> d/t autoimmune reaction involving gastric parietal cells OR hx of gastrectomy
- Secondary to nutritional deficiency of vitamin, vegan diet is at risk
-alcoholism
What are the lab values for vit B12 deficiency?
Macrocytic Normochromic
hgb: low
hct: low
rbc: low
MHC: high
MCHC: wnl
RDW high
Follow up labs: serum vit B12, RBC folate
vit B12 will be low
What is the etiology of folate-deficiency anemia?
- folate deficiency alters synthesis of DNA and RBC maturation
- folate deficiency can be caused by: malabsorption syndromes, increased demand (pregnancy), inadequate intake (alcoholics/elderly)
- certain drugs can inhibit folate absorption: antacids, H2 antagonists, PPIs, metformin
- MOST common megaloblastic anemia in pregnancy
What are the lab values for folate-deficiency anemia?
Macrocytic, Normochromic
hgb: low
hct: low
rbc: low
MCV: high
MCHC: wnl
RDW: high
Next steps: B12 and folate
- folate will be low
What is the etiology for sickle-cell anemia?
Chronic hemolytic anemia characterized by sickle-shaped RBCs
- autosomal recessive disorder where Hgb S develops instead of hgb A
- persons with ssd are homozygous for Hgb S
- prevalent in AA ancestry, also mediterranean
Labs:
hgb 7-9
mild leukocytosis
reticulocytosis
Hgb S 85-95% in SCD; 40% in trait
What is the etiology of beta thal/alpha thal?
through inherited genetic variation, small (microcytic), pale (hypochromic) cells that are all around the same size (NL RDW)
autosomal recessive
alpha thal: asian, african ancestry (AAA)
beta thal: african, mediterranean, Middle Eastern (BAMME)
What are the lab values of beta thal/alpha thal?
microcytic, hypochromic, RDW wnl
hgb: low
hct: low
RBC: ELEVATED (make extra RBCs because they are small and pale)
MCV: low (microcytic)
MCHC: low (hypochromic)
RDW: wnl - all new cells are the same size
Next steps: hgb electrophoresis for evaluation of hemoglobin variants
What are the causes of drug-induced macrocytosis, usually without anemia?
excess alcohol - most common (>/= 3 drinks/day for women, 5 for men))
Anti-epileptic drugs (carbamazepine, phenytoin)
methotrexate
Lab values for macrocytosis without anemia:
hgb: wnl
hct: wnl
mcv: increased (macrocytic)
MCHC: wnl
RBC: wnl
Treatment for macrocytosis without anemia?
Reversible when use of offending medication is discontinued… but usually not a reason to curtain the drug’s use, except for excessive alcohol intake
S/S of ALL anemia
fatigue, weakness, exertional dyspnea, lightheadedness, anorexia
PE: palor, tachycardia, tachypnea
S/S of specific to IDA
pica, HA
PE: nail changes (spoon shaped koilonychias); brittle nails, brittle/fine hair
S/S specific to B12 deficiency anemia
insidious onset
GI disturbances - anorexia, bloating, diarrhea
SORE tongue
neurologic: peripheral paresthesia, ataxia
loss of taste and smell
PE: smooth, beefy-red tongue (glossitis), hepatomegaly/splenomegaly, jaundice, ataxia (+ Romberg), hyperactive reflexes, peripheral loss of sensation, change in mental state
S/S specific to Sickle cell anemia
vaso-occlusive crisis: malaise, chills, pain esp in bones, abdomen, chest, lower legs, HA, epistaxis, vomiting, difficulty walking
PE: jaundice, cardiomegaly, renal disease
S/S specific to folate deficiency
dryness of skin and mucous membranes
brittle nails and hair
IDA Treatment
ID the cause of IDA and treat it!
Non Pharm:
- diet with increase iron content
- check 3 weeks after initiation of tx, and recheck in 6-8 weeks
- check every 3 months until stable
- continue increased iron at least 2-3 months after stable to increase stores
Pharm:
-Ferrous sulfate –> may need to continue 4-6 months to replenish iron stores; may d/c when serum ferritin is >/= 50mg/L
Patient ed:
- Iron absorption may be inhibited with concurrent use of antacids or calcium supplementaion
- Iron inhibits tetracycline absorption
- constipation and black stools are common SEs
- take with vit C to help absorption
- take on empty stomach to increase absorption
- take with food to decrease GI upset
Tx of anemia of chronic disease
treat underlying condition
Tx of vit B12 deficiency anemia
Vitamin B12 injections IM daily for 1 week, then weekly until Hct is wnl, then monthly for life
CI:
- alcohol decrease B12 absorption
-avoid if hypersensitivity to cobalt
Tx for Folate deficiency anemia
Nonpharm: increase dietary sources of folic acid: legumes, leafy green vegetables, fruits, liver
Pharm:
- folic acid
CI
- long term corticosteroid use increases folic acid requirements
- folic acid may inhibit absorption of tetracyclines, can lower some anticonvulsant drugs
Sickle cell anemia tx
treat infections to decrease risk of crisis
maintain oxygenation and hydration
What supplements increase risk of bleeding?
Ginseng, Gingko, Fish oil
What is neutrophilia and what is it associated with?
Increased neutrophils
bacterial infection
Increased Bands (young neutrophils) indicative of infection
What is lymphocytocis and what is it associated with?
increased lymphocytes
virus
What is monoocytosis and what is it associated with?
Increased monocytes/macrophages
cleans up debris –> elevated levels associated with the END of an infection
What is Eosinophilia and what is it associated with?
increased eosinophils
allergens, parasites (worms, wheezes, weird diseases)
What is Basophilia and what is it associated with?
Increased basophils
anaphylaxis
