Anemia 101-

Case Studies

Peter A. Kouides MD
Associate Professor of Medicine,
University of Rochester School of Medicine
Attending Physician,
The Rochester General Hospital
 Anemia classification based on the mechanism

• Kinetic Classification (based on retic count)

– Decreased production
• Morpholgical classification (based on MCV)
– Microcytic
– Normocytic
– Macrocytic
– Increased destruction
• Immunological classification (based on Coomb’s test)
– Immune-mediated
– Non-immune mediated
 The Medical Student’s Approach to Anemia
1. Check the reticulocyte count to determine if the anemia is from decreased production
(“hypoproliferative”, “reticulocytopenic”) or increased destruction (“hemolytic”)/acute blood loss
(“reticulocytosis”)

2. If decreased production, narrow down the causes in terms of the MCV-

– If the MCV is low, then do iron studies then Hb electropheresis
– If the MCV is normal, check the serum creatinine and TSH, if they are WNL then consider bone
marrow exam
– If the MCV is high check a folate and vitamin B12 level

3. If the the reticulocyte count is increased-

– Check a direct Coomb’s test

4. Look at the peripheral blood smear to confirm/support the diagnosis

 Anemia Algorithm

• Patient with anemia and decreased reticulocyte count-

What is the MCV ??

Microcytic Normocytic Macrocytic:
•Vitamin-related
Fe Thal Systemic Diseases in Bone B12 , Folate
Diseases Marrow
def. •Non-vitamin:
Renal vs. Liver vs. •MDS
•MDS
Endocrine vs. •Solid Tumor
•EtOH/Liver
Anemia of •Myeloma Disease
Other: sideroblastic anemia
Inflammation
(meds,PB,Zn excess,Cu def) •Aplastic •Hypothyroidism
 Anemia Algorithm, continued
• Patient with anemia and increased reticulocyte count= HEMOLYTIC ANEMIA
 Anemia Algorithm, continued
• Patient with anemia and increased reticulocyte count-
What is the result of a Coomb’s
test ??
Negativ Positive
Intrinsic red cell (autoimmune hemolytic anemia)
Extrinsic red e
defect
cell defect

“Warm” “Cold”
Membrane

Vessel Valve Cytoplasm

Hemoglobin

Toxin
 The Attending’s Approach to Anemia

1. Stool guiacs x 3
2. If the MCV is low, then prescribe iron
3. If the MCV is high, then check a folate level and vitamin B12
level
– if folate level returns low or “indeterminate”, then begin folic acid
1 mg po qd
– if B12 level returns low or “indeterminate”, then begin IM vitamin
B12
 The Pharmacologist’s Approach to Anemia

Pharmcologically Pharmcologically
Responsive Unresponsive
Anemias (“refractory”) Anemias
• nutrient-responsive • with cellular marrow
⇒iron deficiency anemia ⇒anemia of chronic disease
⇒B12 deficiency (inflammation)
⇒folate deficiency ⇒MDS
⇒pyridoxine-responsive ⇒Metastatic tumor
sideroblastic anemia ⇒Thalassemia trait
• erythropoietin- • with hypocellular marrow
responsive ⇒aplastic anemia
⇒renal failure anemia ⇒hypoplastic AML
• synthroid-responsive
⇒hypothyroidism
• prednisone-responsive
⇒AIHA
Case #1-A 67-year-old
man is referred for
evaluation of
dyspnea. The
hematocrit is 28%,
white blood cell
count 4500/mm3,
platelet count
550,000/mm3, and
reticulocyte count
4%. The MCV is 78
and the blood smear
reveals basophilic
stippling and a small
population of
hypochromic
microcytic red cells.
Serum Fe 225, TIBC
260, Ferritin 490
 Case #2-Patient H.M.
• A 57-year-old woman presents to the clinic for
evaluation of ataxia, weakness, and parathesias.
The patient has been taking a multivitamin
preparation.
• Hematocrit is 38%
• white blood cell count 4,000; platelet count
100,000
• What tests would you order next ?
Case #3- A 65-year-old man
with a Hematocrit of 33%
and a reticulocyte count of
7% is admitted to the
hospital with right upper
quadrant abdominal pain.
Peripheral blood smear
reveals occasional
spherocytes.
 Case #4- Patient R.B.
• A 26-year-old woman presents to the hospital
with pleuritic chest pain. She gives a history of
episodic arthralgias for a number of months,
plus one episode of frank arthritis involving the
small joints of both hands occurring 2 months
prior to admission. The patient has a
hematocrit of 29%, a white blood cell count of
4000, and a reticulocyte count of 12%. The
smear reveals normocytic, normochromic red
blood cells with polychromatophilia, and
occasional spherocytes, occaisonal NRBC.
 Case #5- Patient F.D.
• A 60-year-old woman is hospitalized because of
severe fatigue and dyspnea of 2 weeks' duration.
Five years ago, the patient had a total
hysterectomy and bilateral salpingo-
oophorectomy for ovarian adenocarcinoma. She
received a course of oral melphalan as adjuvant
chemotherapy.
 Patient F.D. continued

• Three years ago a restaging

laparotomy reveals no evidence
of tumor, and blood counts were
normal.
• Now, except for a temperature
of 38.4°C (101.1°F) and pallor,
she has normal findings.
• Laboratory studies: Hematocrit
17%, MCV 108 fL. , WBC
4,500, platelet count 50,000,
reticulocyte count 0.8%
 MDS vs. Folate/B12 Deficiency
• Think of MDS when the anemic patient is elderly and the
MCV is increased
• in one study of the elderly, MDS was the fourth most
common cause of anemia after:
– acute blood loss/Fe Deficiency
– anemia of chronic disease
– anemia of renal insufficiency
• the B12 level can be borderline low in elderly patients but
it is not true B12 deficiency if-
– a serum total homocysteine level is normal
– a urine methylmalonic acid level is normal
 Case #6- Patient G.D.
• A 28 year-old black man plans a trip to India and
is advised to take prophylaxis for malaria. Three
days after beginning treatment, he develops dark
urine, pallor, fatigue, and jaundice
• Hematocrit is 26% (it had been 43%), MCV 100;
WBC 3.4, Platelets 199,000
 Patient G.D. continued

• Reticulocyte count 13%

• What test should be
diagnostic?
• And, why do I say
“should” instead of “is
diagnostic”?
 Drugs Causing Anemia
LESS COMMON- MORE COMMON-
Decreased Production: Increased Destruction
Anti-Tb drugs= (Hemolytic):
Sideroblastic Anemia Qunidine, PCN, Aldomet=
Chloramphenicol, Auto-immune Hemolytic
Valproic acid= Anemia
Pure Red Cell Aplasia Primaquine,Nitrofurantoin,
AZT, Dilantin= Dapsone, Pyridium=
Macrocytic Anemia G6PD Deficiency
 Case # 7
A 21-year-old woman with sickle cell anemia has had a fever and severe pain in the
right shin for 3 weeks. The painful area is hot, swollen, tender and indurated.
 Case #8
• A 66-year-old-man presents with increased fatigue and anemia. Hypothyroidism
was detected 3 years ago and thyroid hormone therapy was administered. Anemia
was diagnosed 2 years ago, but findings on bone marrow examination were normal,
and there was no response to oral therapy with iron. Sexual function has diminished
during the last 2 years. He has a blood pressure of 90 Hg systolic and 60 mm Hg
diastolic, pallor, absence of axillary hair, and sparse pubic hair. There is no
gynecomastia, but the testicles are soft, and the prostate gland is small. The result of
an examination of the stool for occult blood is negative. Laboratory studies:
hematocrit 36%, leukocyte count 5800/µL, platelet count 255,000/µL, peripheral
blood film - normochromic normocytic erythrocytes with anisocytosis or
poikilocytosis, MCV: 86 fl, serum creatinine - normal.