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 Coombs test)
Immune-mediated
Non-immune mediated
 The Medical Students 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 Coombs 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 Inflammation Myeloma Disease
Other: sideroblastic anemia
(meds,PB,Zn excess,Cu def) Aplastic anemia 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 Coombs test ??
Negative Positive
Intrinsic red cell (autoimmune hemolytic anemia)
Extrinsic red cell
defect
defect

Warm Cold
Membrane

Vessel Valve Cytoplasm

Hemoglobin

Toxin
 The Attendings 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 Pharmacologists 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
38.4C (101.1F) 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= Macrocytic Dapsone, Pyridium=
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/L, platelet count
255,000/L, peripheral blood film - normochromic normocytic
erythrocytes with anisocytosis or poikilocytosis, MCV: 86 fl,
serum creatinine - normal.