Beruflich Dokumente
Kultur Dokumente
Objective
Recognize
Approach to Dx
Hx- age, duration, onset, subjacent illness, blood loss (GI, menstruation, surgery), diet, medications, toxic exposure, occupation, Family Hx, Social Hx PE- complete exam including skin (jaundice, petechiae), HEENT, Abdomen (hepatosplenomegally), lymphatics, rectal, and pelvic
(WBC, RBC, HCT, HGB, PLT, indices- MCH, MCHC, MCV, RDW)
Peripheral
Reticulocyte count
Retic count = % immature RBC Normal 0.5-1.5% (for non-anemic) <1% Inadequate production >=1% Increased production (? adequacy)
Reticulocyte Correction
%Retic count frequently overestimates Retic count should be compared to nonanemic RBC count to assess adequacy of response Corrected Retic count = %Retic X HCT/45
Correction for left shift Retic lifespan is increased in blood RPI = % Retic X Hct/45 X 1/CF Hct Correction factor (CF) 40-45 1.0 35-39 1.5 25-34 2.0 15-24 2.5 Normal RPI = 1 (for non-anemic pt) RPI < 2 : hypoproliferative RPI >=2 : hyperproliferative
Hypoproliferative
Hyperproliferative
- Iron def. anemia - B12/folate def. - Chronic disease - Sideroblastic anemia - Aplastic anemia - Myeloproliferative
Peripheral smear
Optimal
RBC morphology
7-9 Qm with 1/3 central palor Lifespan of 110-120 days About the size of nucleus of normal lymphocyte Poikilocytosis & Anisocytosis
Basophilic stippling
Precipitated RNA lead or heavy metal poisoning ETOH abuse Hemolytic anemia
Burr cells
Altered lipid in cell membrane artifact Uremia Renal failure gastric CA transfused old blood
Elliptocytes/ovalocytes
Abnormal cytoskeletal proteins Hereditary elliptocytosis
Schistocyte/helmet cells
Fragmented (mechanical or phagocytosis) DIC TTP HUS Vasculitis prosthetic heart valve severe burns
Sickle cells
Molecular aggregation of Hgb-S SS, SC, S-thal rarely S-trait
NRBC
Common in newborn severe degree of hemolysis
Spherocyte
Absent central palor look smaller Hereditary spherocytosis immune hemolytic anemia
Stomatocyte
Mouth like Membrane defect Smear artifact Hereditary stomatocytosis Liver disease
Target cells
Increased redundancy of membrane hemoglobinopathies thalassemia liver disease
Distorted drop shaped Smear artifact myelofibrosis promyeloblastic leukemia space occupying lesions of marrow
Differentials
H&P Indices
(MCV, MCHC, RDW) RBC Morphology Retic response Other labs as needed
Micro
Normo
Macro
Iron panel
Retic
Retic
Low
High
Iron/B12/Folate
**Normal
B12/Folate
B12 Low
High
Folate/Low
Normal
Yes
MMA/Homocysteine
No
Coombs (+)
Coombs (-)
Normal Go to **
Microcytic anemia
inc/nl dec
Thalassemia
Normal to inc. RPI Normal RDW Target cells Mentzer index <13 =MCV/RBC Youdens index - using RDW & Mentzer index
- sensitivity = 82% - specificity = 80%
Thalassemia continues
Alpha-thalassemia SE Asia & Africa aaaa - normal aaaa^ - silent carrier aaa^a^ - trait (mild) aa^a^a^ - HbH (Bart) hemolytic disease a^a^a^a^ - hydrops fetalis (stillborn) Beta-thalassemia Mediterranean Beta-thal minor one beta gene, increased HbA2/HbF Beta-thal major 2 beta genes, severe, failure to thrive, sig HbF
Sideroblastic anemia
Accumulation of mitochondrial iron in erythroblasts Hereditary Drugs - INH, lead, zinc, alcohol, chloramphenicol, cycloserine, plavix Hypothermia Confirm w/ BM Bx
Sample question #1
Anemia of chronic disease is due to inadequate production of, or poor response to, which one of the following? A. B. C. D. E. Iron Folate Erythropoietin Ferritin Hemosiderin
AFP, Nov. 15, 2000
Infections: TB, SBE, osteo, chronic UTI or pyelo, fungal Malignancy: mets, leukemia, lymphoma, myeloma
Chronic inflammatory disorders: RA, SLE, Sarcoid, collagen vascular disease, polymyalgia rheumatica, chronic hepatitis, decubitus ulcer
Macrocytic anemia
Macro
RPI >= 2
RPI < 2
No
Coombs test
Yes
MMA High
Homocysteine High
Sample question #2
Which of the following tests can be useful in determining if an elderly patient has folate deficiency? A. B. C. D. RBC folate concentration Serum homocysteine level Serum ferritin level Serum methylmalonic acid level
AFP, Oct. 1, 2000
Consider Liver, Renal, Endocrine (thyroid), alcohol, drugs Consider anemia of chronic disease Get Bone Marrow Biopsy Myelodysplastic Myeloproliferative Leukemia, Lymphoma, Multiple Myeloma
Fanconi anemia congenital Direct stem cell destruction external radiation Drugs - chloramphenicol, gold, sulfonamides, felbamate Other Toxins - Solvents, degreasing agents, pesticides Viral infection - parvovirus B19, HIV, other Idiopathic
Yes
No
Investigate source
Peripheral smear
Coombs (DAT)
Sample question #3
Of the following laboratory results, which one does not occur in hemolytic anemia?
A. B. C. D. E.
RBC morphology Serum haptoglobin Serum LDH Unconjugated bilirubin Hemoglobinuria Hemosiderinuria
Positive
Negative
Episodic - G6PD def., PNH Hemoglobinopathy - Sickle, crystals or target cells Elliptocytosis Spherocytosis DIC, TTP
Severe anemia in newborns Adults symptomatic Jaundice Splenomegaly Fluorescent screening test Quantitative test
HbSC disease
Mild hemolysis Splenomegaly Lysine substitution HbC crystals bar of gold Hgb electrophoresis
Sickle and SC crystals Washington monument Less crises More retinopathy/aseptic necrosis
Rare chronic condition Recurrent abdominal pain, vomiting, headaches, eye pain, thrombophlebitis Episodic Hgb in urine, Hemosiderinuria Abnormal cell membrane - increased lysis by complement Screening - Sucrose hemolysis test Confirm - Acid hemolysis test (Hams test)
Thrombocytopenia Microangiopathic hemolytic anemia Neurologic symptoms and signs Renal failure Fever
Idiopathic - 37 % Drug-associated - 13 % Autoimmune disease - 13 % Sepsis - 9 % Pregnancy - 7 % Bloody diarrhea - 6 % Hematopoietic cell transplantation - 4 %
DIC Depletion of clotting factor (TTP normal) Thrombocytopenia Bleeding (64%) Renal dysfunction (25%) Hepatic dysfunction (19%) Respiratory dysfunction (16%) Shock (14%) Thromboemboli (7%) Central nervous system involvement (2%) Sepsis, trauma, malignancy
TTP-HUS / DIC
Yes
No
Investigate source
Peripheral smear
Coombs (DAT)
Questions?