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Y3 immunology and haematology > red cells 2 > Flashcards

red cells 2 Flashcards

1
Q

what is anaemia

A

Hb below normal for age and sex

acquired anaemias are more common

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2
Q

how to determine normal range

A

subjects w/o disease

normal distribution

mean +/- 2SD

  • excludes 5% of ‘normals’
  • think about whether the level is normal for your patient
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3
Q

factors influencing reference intervals

A 
age 
sex
ethnic origin
time of day sample taken e.g. cortisol levels 
time to analysis
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4
Q

Hb reference intervals

A

male 12-70: 140-180
male >70: 116-156

female 12-70: 120-160
female >70: 108-143

drops with age (physiological and increasing co-morbidities)

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5
Q

presentation of anaemia

A

general features due to reduced oxygen delivery to tissues;

  • tiredness
  • pallor
  • SOB
  • ankle swelling
  • dizziness (esp on standing)
  • chest pain

depends on age, speed of onset and Hb level

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6
Q

clinical features of anaemia related to underlying cause

A

evidence of bleeding

  • menorrhagia
  • dyspepsia, PR bleed

symptoms of malabsorption

  • diarrhoea
  • weight loss

jaundice
splenomegaly/lymphadenopathy

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7
Q

anaemia pathophysiology

A
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8
Q

red cell indices - what is it

A

automated measurement of red cell size and Hb content

can give a morphological description of anaemia and a clue to the cause

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9
Q

what is MCH

A

mean cell Hb

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10
Q

what is MCV

A

mean cell volume - size

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11
Q

morphological descriptions of anaemia

A
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12
Q

investigations for anaemia

A

use of discriminating test to guide further investigations

if lab is given adequate clinical info it will advise on further appropriate investigations

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13
Q

most common cause of hypochromic microcytic anaemia

investigations to check

A

iron deficiency

  • measure serum ferritin
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14
Q

common causes of macrocytic anaemia and investigations to check

A

B12/folate deficiency

bone marrow disorders also - check if B12/folate are normal

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15
Q

investigation for normochromic normocytic anaemia

A

reticulocyte count to check red cell production levels

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16
Q

what type of anaemia is this

A

hypochromic, microcytic anaemia

red cells should be only slightly smaller than the lymphocyte

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17
Q

what is seen here

A

normal red cells

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18
Q

causes of low serum ferritin in hypochromic microcytic anaemia

A

iron deficiency

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19
Q

causes of normal/increased serum ferritin in hypochromic microcytic anaemia

  • interpret w/ caution in someone who should be iron deficient
A

thalassaemia - normal iron stores but abnormal red cells

2y anaemia - cannot use iron in inflammatory condition for example

sideroblastic anaemia

  • also increases in liver disease and in inflammatory processes but may not have iron bound
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20
Q

iron metabolism

total body iron
how are levels balanced

A

total body iron ~4g

dietary intake balanced by loss

most of the body’s iron is in Hb and is recycled

no pathway for excretion of XS iron

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21
Q

what happens to absorbed iron

A

bound to mucosal ferritin and sloughed off

OR

transported across the BM by ferroportin

then bound to transferrin in plasma

stored as ferritin -mainly in liver

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22
Q

role of hepcidin

A

synthesised in hepatocytes in response to increased iron levels and inflammation

blocks ferroportin so reduces intestinal iron absorption and mobilisation from reticuloendothelial cells

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23
Q

iron absorption in duodenum

A

Fe2+ > Fe3+

transported from enterocytes and macrophages by ferroportin

transported in plasma bound to transferrin

stored in cells as ferritin

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24
Q

how common is iron deficiency anaemia

A

commonest cause of anaemia worldwide

25
iron deficiency anaemia - hx
description not a diagnosis so need to establish cause ``` hx: dyspepsia, GI bleed other bleeding e.g. menorrhagia diet, NB children and elderly increased requirement - pregnancy ```
26
iron deficiency anaemia - signs on exam
signs of iron deficiency: koilonychia atrophic tongue angular cheilitis abdo and rectal
27
causes of iron deficiency anaemia
GI blood loss menorrhagia malabsorption - gastrectomy, coeliac
28
management of iron deficiency
correct deficiency: - oral iron usually sufficient - IV iron if intolerant or oral - blood transfusion rarely indicated correct the cause: - diet - ulcer therapy - gynae - surgery
29
causes of increased reticulocyte count in normochromic normocytic anaemia
acute blood loss | haemolysis
30
causes of normal/low reticulocyte count in normochromic normocytic anaemia
2y anaemia hypoplasia marrow infiltration
31
what is 2y anaemia
'anaemia of chronic disease' 70% normochromic normocytic 30% hypochromic microcytic
32
what causes 2y anaemia what should you look for
defective iron utilisation - increased hepcidin in inflammation - ferritin normal/elevated (acute phase reactant) identifiable underlying disease - infection, inflammation, malignancy, renal impairment
33
haemolytic anaemia | - what happens
accelerated red cell destruction (reduced Hb) compensation by bone marrow (increased retics) level of Hb - balance between red cell production and destruction often have normochromic picture
34
where can haemolysis occur
can be extra or intravascular
35
causes of haemolytic anaemia
congenital: - hereditary spherocytosis - G6PD deficiency - haemoglobinopathy (HbSS) acquired: - extravascular: AI haemolytic anaemia - intravascular: mechanical (e.g. artificial valve), severe infection/DIC, PET/HUS,TTP
36
causes of acquired haemolytic anaemia
immune - mostly extravascular non-immune - mostly intravascular
37
what is a direct antiglobulin test
implies immune basis for haemolysis detects antibody/complement on red cell membrane reagent contains either: anti-human IgG, anti-complement reagent binds to Ab/complement on red cell surface and causes agglutination in vitro
38
what will be on the surface of the red cells if the patient has immune haemolysis
antibodies
39
results of DAT test
+ve - immune mediated | -ve - non-immune mediated
40
tests for immune haemolysis
warm auto-antibody -AI, drugs, CLL cold auto-antibody - CHAD, infections, lymphoma alloantibody - transfusion reaction DAT will be +ve in all these circumstances
41
what is seen here
immune haemolysis - mostly extravascular spherocytes on film agglutination in cold AIHA
42
what is seen here
red cell fragments - schistocytes seen in intravascular haemolysis
43
diagnosis of haemolytic anaemia
is pt haemolysing? - FBC - anaemic, increased reticulocyte count, blood film - high serum bilirubin (unconjugated/indirect), high lactate dehydrogenase - low serum haptoglobin
44
how to determine the mechanism of haemolytic anaemia
hx and exam blood film DAT urine for haemosiderin/urobilinogen
45
management of haemolytic anaemia
support marrow function - folic acid for all correct cause: - immunosuppression if AI: steroids, treat trigger e.g. CLL, lymphoma - remove site of cell destruction: splenectomy - treat sepsis, leaky prosthetic valve, malignancy etc if intravascular consider transfusion
46
different types/causes of macrocytic anaemia
47
what causes megaloblastic anaemia
B12/folate synthesis - can also affect other organs: neurological symptoms (subacute combined degeneration of the cord in B12 deficiency)
48
causes of B12 deficiency
pernicious anaemia gastric/ileal disease - absorption problem
49
causes of folate deficiency
dietary increased requirements - haemolysis GI pathology e.g. coeliac disease
50
vitamin B12 absorption
dietary B12 binds to intrinsic factor B12-IF complex attaches to specific IF receptors in distal ileum vit B12 bound by transcobalamin II in portal circulation for transport to marrow and other tissues
51
where is intrinsic factor secreted
gastric parietal cells
52
where is intrinsic factor secreted
gastric parietal cells
53
skin appearance of megaloblastic anaemia
lemon yellow tinge - bilirubin, LDH - red cells friable
54
what class of anaemia is seen here
megaloblastic appearance - oval macrocytes - neutrophil hypersegmentation
55
what is pernicious anaemia
commonest cause of B12 deficiency in western pops AI disease antibodies against: - intrinsic factor (diagnostic) - gastric parietal cells (less specific) malabsorption of dietary B12
56
why does pernicious anaemia take 1-2yrs to develop
stores last a long time so you use these up before symptoms develop
57
treatment of megaloblastic anaemia
replace vitamin B12: - IM injection - loading dose then 3mthly maintenance folate: - oral replacement - ensure B12 normal if neuropathic symptoms
58
other causes of macrocytosis that don't necessarily cause anaemia
alcohol drugs - methotrexate, antiretrovirals, hydroxycarbamide disordered liver function hypothyroidism myelodysplasia

Y3 immunology and haematology (20 decks)

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