ANEMIA

PRASIT CHANARAT, M.S.(Clin.Path)

Department of Clinical Microscopy

Faculty of Associated Medical Sciences, Chiang
Mai University

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ANEMIA
Symptoms : Pallor
Jaundice
Fatique
Palpitation
Dyspnea
Virtigo
Peptic ulcer
Glossitis
Dysphagia
etc
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 Classification of Anemia
I. Etiologic Classification
1. Impaired RBC production
2. Excessive destruction
3. Blood loss
II. Morphologic Classification
1. Macrocytic anemia
2. Microcytic hypochromic anemia
3. Normochromic normocytic anemia
III. Kinetic Classification
IV. Physiologic Classification
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 Impaired RBC Production
1. Abnormal bone marrow
1.1 Aplastic anemia
1.2 Myelophthisis : Myeloficrosis, Leukemia,
Cancer metastasis
2. Essential factors deficiency
2.1 Deficiency anemia : Fe, Vit. B12, Folic acid, etc
2.2 Anemia in renal disease : Erythropoietin
3. Stimulation factor deficiency
3.1 Anemia in chronic disease
3.2 Anemia in hypopituitarism
3.3 Anemia in hypothyroidism
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 Excessive Destruction of RBC(cont.)
Hemolytic anemia
1. Intracorpuscular defect
1.1 Membrane : Hereditary spherocytosis
Hereditary ovalocytosis, etc.
1.2 Enzyme : G-6PD deficiency, PK def., etc.
1.3 Hemoglobin : Thalassemia, Hemoglobino-
pathies

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 Excessive Destruction of RBC
2. Extracorpuscular defect
2.1 Mechanical : March hemolytic anemia
MAHA (Microangiopathic HA)
2.2 Chemical/Physical
2.3 Infection : Clostridium tetani
2.4 Antibodies : HTR, SLE
2.5 Hypersplenism

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 Blood Loss

1. Acute blood loss : Accident, GI bleeding

2. Chronic blood loss : Hypermenorrhea
Parasitic infestation

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 Macrocytic Anemia
MCV > 94
MCHC > 31
1. Megaloblastic dyspoiesis
1.1 Vit. B12 deficiency : Pernicious anemia
1.2 Folic acid deficiency : Nutritional megaloblas-
tic anemia, Sprue, Other malabsorption
1.3 Inborn errors of metabolism : Orotic aciduria,
etc.
1.4 Abnormal DNA synthesis : Chemotherapy,
Anticonvulsant, Oral contraceptives
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 Macrocytic Anemia
MCV > 94
MCHC > 31
2. Non-Megaloblastic dyspoiesis
2.1 Increased erythropoiesis : Hemolytic anemia
response to hemorrhage
2.2 Increased membrane surface area : Hepatic
disease, Obstructive jaundice, Post-
splenectomy
2.3 Idiopathic : Hypothyroidism, Hypoplastic and
Aplastic anemia
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 Microcytic Hypochromic Anemia
MCV < 80
MCHC < 31
1. Fe deficiency anemia : Chronic blood loss,
Inadequate diet, Malabsorption, Increased
demand, etc.
2. Abnormal globin synthesis : Thalassemia with or
without Hemoglobinopathies
3. Abnormal porphyrin and heme synthesis :
Pyridoxine responsive anemia, etc.
4. Other abnormal Fe metabolism :
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 Normocytic Normochromic Anemia
MCV 82 - 92
MCHC > 30
1. Blood loss
2. Increased plasma volume : Pregnancy, Overhydration
3. Hemolytic anemia : depend on each cause
4. Hypoplastic marrow : Aplastic anemia, RBC aplasia
5. Infiltrate BM : Leukemia, Multiple myeloma,
Myelofibrosis, etc.
6. Abnormal endocrine : Hypothyroidism, Adrenal
insufficiency, etc.
7. Kidney disease / Liver disease / Cirrhosis
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 Kinetic Classification of Anemia
1. Insufficient erythropoiesis
Stem cells , Hypoplastic marrow, Infiltrated BM
2. Ineffective erythropoiesis
- Megaloblastic anemia
- Thalassemia
- Sideroblastic anemia
3. Uncompensated hemolytic disease with continued
bleeding
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 Physiologic Classification of Anemia

1. RPI (Reticulocyte Production Index) < 2

(Ineffective erythropoiesis)
1.1 Hypoproliferative anemia
1.2 Maturation disorder
2. RPI > 3 (Effective erythropoiesis
2.1 Hemolytic anemia
2.2 Blood loss anemia

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 Physiologic Classification of Anemia
1. RPI (Reticulocyte Production Index) < 2
(Ineffective erythropoiesis)
1.1 Hypoproliferative anemia
(normocytic normochromic, N/N)
- Hypoplastic anemia - Idiopathic/ Chemical/
Infectious / Drug --> Maturation arrest
- Myelophthisic anemia (Marrow infiltration)
- Refractory anemia (Dysmyelopoietic syndrome)

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Physiologic Class. of Anemia RPI < 2
1.1.1 N/N and normal RDW
a) BM failure
b) Decrease marrow stimulation
- Endocrine disease
- Anemia of chronic disease
- Renal disease
1.1.2 Abnormal RBC morphology & RDW
a) Oval macrocyte :- Refractory dysmyelo-
poietic
b) Dacrocytes/ tear drops :- Myelophthisic

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Physiologic Class. of Anemia RPI < 2
1.2 Maturation disorder
1.2.1 Microcytic, high RDW
a) Siderblastic (Microcytic dimorphic RBC)
b) Fe def. (Microcytic hypochromic RBC)
1.2.2 Microcytic, normal RDW
a) Heterozygous, thalassemia syndrome
b) Anemia of chronic disease
1.2.3 Macrocytic
a) Liver disease
b) Folate def.
c) Vit. B12 def.
d) Hemolytic anemia (Normocyte
polychromasia)
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 Physiologic Classification of Anemia
2. RPI > 3
(Effective erythropoiesis)
2.1 Hemolytic anemia
- Intrinsic hereditary disorder
- Extrinsic acquired disorder
2.2 Blood loss
- Acute blood loss
- Chronic blood loss (without treatment --> micro-
cytic, hypochromic anemia)
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 Evaluation of Anemia
A. Hematologic
1. Hematocrit (VPRC preferred)
2. Hemoglobin concentration
3. RBC indices : MCV, MCH, MCHC
4. Leukocyte count
5. Reticulocyte count
6. Platelet count
7. ESR (Erythrocyte sedimentation rate)
8. Stained blood smear : RBC morphology
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 Evaluation of Anemia
B. Urine analysis
1. Appearance : Color, pH, Clarity, sp gr
2. Test for protein, Bence Jones protein
3. Bilirubin, Uribilinogen
4. Occult blood
5. Microscopic examination
C. Stool
1. Appearance : Color, consistency
2. Occult blood
3. Examination for ova, parasites
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 Evaluation of Anemia
D. Serum or Plasma
1. BUN
2. Creatinine, if urea N is abnormal
3. Bilirubin : Direct, indirect
4. Protein
5. SI (Serum iron), TIBC (Total iron binding
capacity)
E. Special tests in hematology
Hb typing / Ham acid test / Coombs’ test, G-6PD,
Ferritin, Sucrose test, Autohemolysis test, Haptoglobin, et
c.
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 DDx of Common Anemia in Thailand
Hb < 9-10 gm/dL
1. Acute anemia
1.1 Acute blood loss
BP , Pulse --> Acute hemorrhage
1.2 No acute blood loss
• Jaundice, hemoglobinuria --> G-6-PD def.
• Jaundice, No hemoglobinuria --> AIHA (NCNC), HS
(Spherocycyte), hemoglobin H disease (HCMC)
• Jaundice, fever --> Malaria
• No jaundice --> G-6-PD def., Hb H, Acute leukemia
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 DDx of Common Anemia in Thailand
Hb < 9-10 gm/dL

2. Chronic anemia
2.1 No hepatosplenomegaly
• No petichiae and purpura --> Fe def. Anemia, anemia
of chronic disease, folate def.
• Petichiae & purpura --> ITP + Fe def., Acute leukemia
(Blast cell), Aplastic anemia
• Chronic disease --> Chronic renal failure, rheumatoid
arthritis, infective endocarditis, hypothyroidism,
etc.
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 DDx of Common Anemia in Thailand
Hb < 9-10 gm/dL

2. Chronic anemia
2.2 Hepatosplenomegaly
• Mongoloid face --> Thalassemia
• No Mongoloid face with lymphadenopathy --> DDx
Acute leukemia, lymphoma, TB lymph node
• Liver disease

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 Mechanisms of Anemia
Production Disorders:
✹Hematopoietic Cell Damage
-Drugs, Radiation, Infections, Toxins
✹Factor Deficiency
-Iron (Heme Synthesis)
-Vitamin B12 (DNA Synthesis)
-Folate (DNA Synthesis)
 Mechanisms of Anemia

Survival Disorders:
✹Blood Loss - External or Internal
✹Red blood Cell Destruction
-Hemolytic Anemias
 Anemia
Manifestations - Cause & Chronicity
Nonspecific Signs and Symptoms
✹Weakness, Malaise, Fatigue
✹CNS hypoxia - Headaches, Faintness,
Dimness of Vision
✹Skin Pallor, Thinning and Inelasticity
✹Nail Brittleness
✹Angina Pectoralis (if ASCVD)
Production Disorder - Iron Deficiency

✹Most Common Nutritional Deficiency

✹Required in Hemoglobin Synthesis
Heme + Globin Chains = Hemoglobin
✹Occurs in RBC Cytoplasm ⇒
Hypochromic Microcytic Anemia
 Iron Metabolism

✹Iron is Absorbed Primarily in Duodenum

- 25% of Heme-Bound Iron (Red Meat)
- 1-2% of Non-Heme Iron
✹Body Losses of Iron are Limited
- 1-2 mg/Day By Epithelial Cell Shedding
✹Mucosal Block - Maintains Balance
 Transferrin

✹Transport Protein For Iron In Blood

✹Fully Saturated Transferrin = TIBC
300 - 350ug/dl Fe
✹Normal Transferrin - 1/3 Filled With Iron
100 - 120ug/dl Fe (Serum Iron)
 Iron Storage

Ferritin - Protein Iron Complex

*Found In All Tissues
*BM, Liver (Transferrin)
*Spleen (RBC Breakdown)

Hemosiderin - Breakdown Product of

Ferritin
 Development of Iron Deficiency
✹Depletion of Stores
⇓ Serum Ferritin
⇓ Stainable BM Iron

⇑ Transferrin (↑ TIBC) ⇓ Serum

Fe

⇓ Transferrin Saturation
✹
Iron Deficiency Anemia Laboratory Findings

✹Hypochromic Microcytic Anemia

(↓ RBC Count, ↓ MCV)
✹↓ Serum Ferritin Levels
✹ ↓ Transferrin Saturation
(↓ Serum Fe, ↑ Transferrin)
 Causes of Iron Deficiency

✹External Blood Loss - Most Common

Female Genital Tract
Gastrointestinal Tract
✹↑ Demand - Infancy, Pregnancy
✹Dietary Deficiency - Rare
(Vegetarian Diets)
✹Intestinal Malabsorption Syndrome
 Iron Deficiency
Clinical Manifestations

✹Anemia - Non-Specific Findings

✹Koilonychia
✹Plummer-Vinson Syndrome
-Hypochromic Microcytic Anemia
-Atrophic Glossitis
-Esophageal Webs (Dysphagia)
Koilonychia - Iron Deficiency
Hypochromic Microcytic Anemia (Iron Deficiency)
 Vitamin B12 Absorption
B12

B12 Parietal cells -

Stomach produce IF
IF

IF Ileum -
B12 IF receptors
B12
IF
B12
 Vitamin B12 Deficiency
●Western World - Pernicious Anemia
Autoantibodies (Serum and Gastric)

IF B12
Parietal
IF
Cell
⇓ IF Function ⇓ Gastric Production
 Production Disorder -
Vitamin B12 or Folate Deficiency
Megaloblastic Anemias
✹Impaired DNA Synthesis (Nucleus)
✹Function - Transfer of Carbon Groups
✹Affects All Rapidly Dividing Cells
-Mouth - Atrophic Glossitis
-GI tract - Intestinal Malabsorption
 Megaloblastic Anemia
Peripheral Blood
✹RBCs - Large Oval Macroovalocytes
- MCV > 100u3
✹Anemia Due To Ineffective Hematopoiesis
- Autohemolysis of Megaloblasts
(Circulating Large RBCs Destroyed)
✹Hypersegmented Neutrophils
✹Thrombocytopenia, Neutropenia (Severe)
Macroovalocytes and Hypersegmented Neutrophil
 Vitamin B12 Deficiency - Cause

Western World - Pernicious Anemia

✹Autoimmune Disorder
-Autoantibodies to IF and Parietal Cells
-Chronic Atrophic Gastritis
-Achlorhydria - Absent HCL
✹⇑ Incidence of Other Autoimmune
Disorders
 Vitamin B12 Deficiency
Additional Causes:
✹Inadequate Diet - Rare (>20yr Stores)
-Foods Containing Animal Protein
-Microorganisms Synthesize
-Stored in Liver, Reabsorbed in Bile
✹Gastrectomy, Ileal Resection
✹Malabsorption States, Gastric Atrophy
✹Diphyllobothrium Latum - Fish Tapeworm
Megaloblastic Anemia - Bone Marrow

Nuclear- Cytoplasmic Asynchrony:

✹Erythroid Series (Hallmark Changes)
-Megaloblasts
-Erythroid Hyperplasia
✹Myeloid Series
✹Megakaryocytic Series - (Infrequent)
Normal Erythroids (Left); Megaloblasts (Right)
 B12 and Folate in DNA Synthesis

dUMP dTMP DNA

Thymidylate
Synthetase
FH4 (Folate) Methyl Cobalamin

Cobalamin
N5 - Methyl FH4 (Vitamin B12)
 Vitamin B12 Deficiency
✹Clinical - Similar to Folate Deficiency But
Demyelinating Neurologic Disorder
- Affects Both Sensory and Motor Tracts
- Lack of Correlation With Anemia
✹Parenteral B12 - Improves Anemia,
+/- Resolution of Neurologic Symptoms
✹Caution! Anemia of B12 Deficiency Also
Improves With Folate Supplementation
 Vitamin B12 Deficiency
Laboratory Findings:
●Low Serum Vitamin B12 Levels
●Normal RBC Folate Levels
●Abnormal Schilling Test - Impaired
Absorption of Radioactive Vitamin B12
Correctable by Addition of IF
●Anti-Intrinsic Factor Antibodies (Anti-
Parietal Antibodies Less Sensitive)
 Causes of Folate Deficiency

✹Dietary Deprivation
- Widely Distributed in Foods
(Uncooked Vegetables, Fruits, Liver)
- Limited Body Stores (Wks-Months)
- Chronic Alcoholics, Elderly, Indigent
✹Malabsorption (Upper 1/3 Intestine)
- Intestinal Disease (Sprue, Celiac Dx)
- Chronic Drugs (Dilantin)
 Folate Deficiency
✹Increased Requirements - Pregnancy
✹Impaired Utilization - Folic Acid
Antagonists (Chemotherapy Drugs)
Laboratory Findings:
✹Red Blood Cell Folate - Reflects Tissue
Content of Folate Throughout Body
✹Serum Folate - Levels Fluctuate Based on
Recent Intake, Do Not Reflect Stores
 Anemia of Chronic Disease
✹Normochromic Normocytic Anemia
(or Hypochromic Microcytic)
✹Chronic Disorders (Inflammation or
Tissue Necrosis)
-Chronic Microbial Illnesses
-Chronic Immune Disorders
-Neoplasms
✹Often ↓ TIBC, ↑ Ferritin
 Anemia of Chronic Disease
Defect
Storage Iron
IL-1
TNF α
γ IFN
Erythroid Precursors
(Insufficient Erythropoietin)
Bone Marrow Storage Iron (Blue)
 Hematopoietic Cell Damage
Aplastic Anemia

Bone Marrow Aplasia (Lack of Cells)

✹Failure of Multipotent Stem Cell
- T-cell Mediated Suppression or
- Genetic Damage
✹Bone Marrow - Markedly Hypocellular
✹Peripheral Blood - Pancytopenia
- Normochromic Normocytic RBCs
Markedly Hypocellular BM - Aplastic Anemia
 Aplastic Anemia

Causes of Stem Cell Failure

✹Idiopathic (>50%) - Poor Prognosis
Especially If < 40 Years Old
✹Whole Body Irradiation
✹Viral Infections - Most Common
After Non-A/Non-B Hepatitis
✹Chemical Agents and Drugs -
Reversible and Non-Reversible
 Myelophthisic Anemia

BM Replacement ⇒ BM failure:
●Metastatic Carcinoma Most Common
●Destruction By Non-Neoplastic Process
is Less Common i.e. Fibrosis, Infection
●Peripheral Blood Cytopenias, Immature
Circulating Cells
Breast Cancer Replacing BM
ANEMIA

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