Is a sign of disease

Not a final diagnosis

The goal of the diagnostic

evaluation is to determine
the cause of anemia

Reduction in the hemoglobin concentration or

red blood cells per cubic millimeter below the
range of values occurring in healthy persons.

ANEMIA (WHO criteria)

Age

Hb (g/dl)

6 mo - < 5 yrs

< 11

> 5 yrs

< 12

Biconcave shaped disc with no nucleus

Large surface area facilitates the
uptake of O2 and CO2
25 trillion RBCs in the human body

NORMAL BLOOD SMEAR

Erythropoetin
Metals - Fe, Mangenese, cobalt
Vitamins B12, B6, folate, thiamine,
riboflavin, patethoic acid, C, E
Amino acids
Hormones GM-CSF, Stem cell factor,
thyroxine and androgens

Hematopoiesis

It is important to establish :
A single cell line problem (red blood
cells)
Or
A multiple cell line problem (red cell,
white cell, and platelets)
Usually indicates bone marrow
involvement, immunologic
disorders,
peripheral destruction of cells

1.

Disorders of effective red cell production

a. Marrow failure
b. Impaired erythropoietin production
c. Abnormalities of cytoplasmic
maturation
d. Abnormalities of nuclear maturation
e. Dyserythropoietic.

2.

Disorders of increased red cell destruction

a.
b.
c.
d.
e.
f.
g.
h.
i.

Defects of hemoglobin
Defects of the red cell membrane
Defects of red cell metabolism
Antibody-mediated
Mechanical injury to the erythrocyte
Thermal injury to the erythrocyte
Oxidant-induced red cell injury
Paroxysmal nocturnal hb-uria
Hypersplenism

3.

Blood Loss

1.
2.
3.
4.
5.

Detailed history and physical examination

Complete blood count.
Determination of morphologic
characteristics and RDW.
BMP (if required).
Determination of underlying cause of
anemia by additional test.

1. Maternal

history
2. Family history
3. Patient history

Pregnancy/delivery complications
Anemic during pregnancy
Pica/ nonfood product ingestion
Drug ingestion

Anemia
Jaundice
Splenomegaly
Gallstones
Cancer
Transfusion
Bleeding disorders

Anemia (acute or chronic)

Acute or recent infection,
Evidence of chronic disease/ infection,
Easy bruising/blood loss,
Prematurity,
Hyperbilirubinemia,
Diet history,
Medications,
Endocrinopathy,
Liver disease

Several clues to the etiology :

Tachycardia
acute process with
poor compensation.
Normal HR
more chronic process
Jaundice
hemolytic process
Splenomegaly
inherited
hemolytic anemia, malignancy,
portal hypertension

BLOOD SMEAR
Microcytic Anemia (MCV<80fl)
Normocytic Anemia (MCV 80100 fl)
Macrocytic Anemia (MCV >100
fl)

Age (yrs)
1 - 3 days
0.5 2
24
57
8 11
12 14
15 17
18 19

MCV (fl)
95 - 121
70 - 84
73 - 85
75 - 87
77 - 90
78 - 91
78 - 94
80 - 100

ANEMIA
MCV
MICROCYTIC

NORMOCYTI
C
Reticulocyte
count

Iron
Deficiency
High
Coombs Test
Negative
Thalassemia
Bilirubin
Chronic
Normal
High
disease
Hb-pathy
Lead
Membrane defect
Hemolyti
Hemorrhag
poisoning
c infection
e Secondary : drugs,

MACROCYTI
C

Positive
Autoimmune
Isoimmune

Coombs
test

ANEMIA
MCV
MICROCYTIC

NORMOCYTIC MACROCYTI
C
Reticulocyte

Leukocyte &
Platelets

Low

Normal

Malignancy

Pure red cell aplasia

Diamond Blackfan
Transient
erythroblastopenia

Aplastic
Anemia

Increased
Infection

ANEMIA
MCV
MICROCYTIC

MACROCYTIC
Folate
deficiency Vit
B12 defic.
Aplastic
anemia
Preleukemia
Liver disease

NORMOCYTI
C

RDW (Red cell distribution width) =

variation of the erythrocyte volume distribution.
(N = 11.5 14.5%)
Normal RDW = homogen, slight anisocytosis
RDW = heterogen, anisocytosis (++)
Reticulocyte = indicator of bone marrow activities
Anisocytosis = variation in size
Poikilocytosis = variation in shape

Look at : RBC count (erytrocyte count),

RDW, retyculocytes, blood smear

Erytrocyte RDW
Trait Thal

N
ADB
Thal

N /

Retic

Slide
poikilositosis (+)

N /

anisositosis (+),

hipokrom
poikilositosis,
anisositosis (++)
hipokrom

Defects of hemoglobin : sickle cell

Defects of the red cell membrane :
spherocytosis
Defects in red cell metabolism : G6PD, pyrivate
kinase deficiency
Immune hemolysis
Physical / chemical damage to red cells
Infectious agent-induced damage : malaria
Paroxysmal nocturnal hb-uria (PNH)

History
P.E.
Lab : - elevated reticulocyte count
- Coombs test
- Hb electrophoresis
- osmotic fragility
- specific enzyme assay
- blood smear