Beruflich Dokumente
Kultur Dokumente
ANEMIA
Lisa Mohr, MD
Mike Tuggy, MD
Objectives
Review basic science of the RBC
Define Anemia
Review key aspects of history, physical
and lab evaluation
Review a systematic approach to the
differential diagnosis
Case-based application of clinical
concepts
Transferrin
iron transporter
Ferritin
iron binder, measure of iron stores, *also
acute phase reactant*
Definitions
Anemia-values of hemoglobin, hematocrit
or RBC counts which are more than 2
standard deviations below the mean
HGB<13.5 g/dL (men) <12 (women)
HCT<41% (men)
<36 (women)
CASE
ML is a 64-year old male who has not had
any primary care for several years. When
he tried to give blood last week, he was
told that he was anemic. He presents to
your clinic for evaluation.
What would you do??
Exertional dyspnea
Dyspnea at rest
Fatigue
Signs and symptoms of hyperdynamic state
Bounding pulses
Palpitations
Hypovolemia
Fatiguablitiy, postural dizziness, lethargy,
hypotension, shock and death
Laboratory Evaluation
Initial Testing
CBC w/ differential (includes RBC indices)
Reticulocyte count
Peripheral blood smear
Iron Deficiency
Iron Studies
Hemolysis
Serum LDH, indirect bilirubin, haptoglobin, coombs,
coagulation studies
Differential Diagnosis
Classification by Pathophysiology
Blood Loss
Decreased Production
Increased Destruction
Classification by Morphology
Normocytic
Microcytic
Macrocytic
Blood Loss
Acute
Traumatic
Variety of sources
Melena, hematemesis, menometrorrhagia
Chronic
Occult bleeding
Colonic polyp/carcinonma
Decreased Production
Infectious
Neoplastic
Endocrine
Nutritional Deficiency
Anemia of Chronic Disease
Decreased Production
INFECTIOUS
Bacterial
Tuberculosis
MAI
Viral
HIV
Parvovirus
Decreased Production
NEOPLASTIC
Leukemia
Lymphoma/Myeloma
Myeloproliferative Syndromes
Myelodysplasia
Decreased Production
ENDOCRINE
Thyroid Dysfunction
Hypothyroidism
Erythropoietin Deficiency
Renal Failure
Decreased Production
NUTRITIONAL DEFICIENCY
Iron
B12
Folate
Macrocytic Anemia
MCV > 100
Megaloblastic:Abnormaliti
es in nucleic acid
metabolism
B12, Folate
Nonmegaloblastic:Abnormal
RBC maturation
Myelodysplasia
Microcytic Anemia
MCV <80
Reduced iron
availability
Reduced heme
synthesis
Reduced globin
production
Microcytic Anemia
REDUCED IRON AVAILABILTY
Iron Deficiency
Deficient Diet/Absorption
Increased Requirements
Blood Loss
Iron Sequestration
Microcytic Anemia
REDUCED HEME SYNTHESIS
Lead poisoning
Acquired or
congenital
sideroblastic anemia
Characteristic smear
finding: Basophylic
stippling
Microcytic Anemia
REDUCED GLOBIN PRODUCTION
Thalassemias
Smear Characteristics
Hypochromia
Microcytosis
Target Cells
Tear Drops
Fe deficiency
Without anemia
Fe deficiency
With mild anemia
Fe deficiency
With severe
anemia
Serum Iron
60-150
60-150
<60
<40
Iron Binding
Capacity
300-360
300-390
350-400
>410
Saturation
20-50
30
<15
<10
Hemoglobin
Normal
Normal
9-12
6-7
Serum Ferritin
40-200
<20
<10
0-10
Differential Diagnosis-Revisited
Classification by Pathophysiology
Blood Loss
Decreased Production
Increased Destruction
INCREASED DESTRUCTION
Immune Mediated
Non-immune Mediated
Increased Destruction
IMMUNE MEDIATED
Cold Agglutinin
Paroxysmal nocturnal hemoglobinuria
Post mycoplasmal hemolytic anemia
Warm Agglutinin
Drug induced
Autoimmune hemolytic anemia
Transfusion reaction
Increased Destruction
NON-IMMUNE MEDIATED
Extra-corpuscular
Macro-circulatory
Hypersplenism
Extracorporeal circulation
Micro-circulatory
DIC
TTP
HUS
Intra-corpuscular
RBC Wall (membrane or enzyme defects)
Heme or globin abnormalities (HbS, C)
More on M.L.
P.E. findings
Initial Thoughts?
Blood loss?
Age places him at risk for colon CA
Decreased Production?
Alcohol use, Iron deficiency
Increased Destruction?
Darker urine lately
Further Work-up
CAGE questions
Peripheral Blood Smear
Reticulocyte count
Iron Studies
Ferritin
TIBC
% Saturation
Urinalysis
FOBT or colonoscopy referal
More Results
CAGE screen reveals no positive responses
Smear reveals microcytic, microchromic RBCs
Retic count is interpreted as low
Urinalysis negative for hemoglobin
FOBT: not completed by patient
Iron Studies
Ferritin: 10
TIBC: 350
% Sat: 15
Whats next?
Rule out Sources of Bleeding
Counseling regarding colon CA and referral for
colonoscopy
Diagnosis
Colonoscopy revealed
small suspicious lesion in
sigmoid colon, pathology
revealing
adenocarcinoma.
Excised surgically, no
mets.
Routine labs, one year
later, reveal an HCT of
40%. He feels better
than ever!
References
Schrier, Stanley.Approach to the patient with
anemia. Up to Date. 2004
Schrier, Stanley. Anemia of Chronic Disease. Up
to Date. 2004
Schrier, Stanley. Anemias due to decreased red
Cell Production. Up to Date 2004
Schrier, Stanley. Causes and diagnosis of
anemia due to iron deficiency. Up to Date. 2004
Tierney, et al. Anemias. Current Medical
Diagnosis and treatment. 2003. Pp469-489