Anaemia

• Definition

1) It is a pathological condition in which the

haemoglobin level of the blood goes down below thelower limit of the normal range of the age and sex ofthe individual.

OR

2) It is a pathological condition in which the RBC charring capacity of blood is decrease.

OR

3) It is a pathological condition in which the RBC count or haemoglobin concentration or both goes down.

CLASSIFICATION

Mainly two types :

1. Morphological anaemia :-

based on absolute indices of morphological changes seen in RBC in peripheral blood smeared .

Which is follow by pathologist.

2. Etiological anaemia:-

based on cause of anaemia . Which is follow by clinician to know the cause so that can be treated.

Morphological Anaemia• Based on the value of absolute indices of

morphological changes in RBC. like change in size , shape and concentration of Hb.

• On the base of change in RBC ; three subtypes of morphological anaemia is there:-

1. Normocytic normochromic2. Microcytic hypochromic 3. Macrocytic normocromic

• Absolute indices are three:1. M.C.V = Mean corpuscular volume.2. M.C.H =Mean corpuscular haemoglobin.3. M.C.H.C=Mean corpuscular haemoglobin

concentration.

ATEOLOGICAL ANAEMIA This classification is based on the etiology (cause) of anaemia.

1. Due to blood loss(post haemorrhagic)• acute blood loss :

Like in accident, surgery ,APH ,PPH , etc…• Chronic blood loss:

Eg. Piles ,peptic ulcer , hook-warm infection, etc….

2. Due to deficiency of haemopoatic factor OR Nutritional anaemiaeg: Fe –deficiency anaemia

Vit-B12 or folic acid deficiency anaemai.

3. APLASTIC ANAEMIAcaused by bone marrow failure

4. Haemolytic anaemia:

It is divided in to two subtypes

A) Intracorpuscular : thalassaemias , haemoglobinopthis

B)Extracorpuscular: malaria, haemolytic disease of new born, incompatible blood

Clinical feature of Anaemia

Lassitude FatiguePalpitationBreathlessness on exertionDimness of visionInsomniaAnginaTingling sensationPallorness of skin , mucous membrane, conjunctivaTrechycardia

Systolic murmur

oedema

Amenorrhea

Menorrhagia

Attacks of giddiness

Headache

Drowsiness

Flatulence of abdomen after eating

( In mild anaemia there may not be any symptoms)

Anisocytosis : Increase variation in size of RBC.

normal size of RBC= 6.7-7.7 µ (normocyte)

o average -7.2 µ

• Larger than 8µ is

called- Macrocyte.

• Smaller than 6µ is

Called- Microcyte.

Poikilocytosis : increase variation in shape of RBC.

eg. Sickle shaped or oval shaped.

Hypochromasia :central pallor area of RBC is increased more than 1/3rd . seen in Fe deficiency anaemia, thalassaemias , sideroblastic anaemia.

Most common type of anaemia.

More common in vegetarian people than non-veg people.

because non-vegetarian food is rich in iron.

• Contain heam-Fe which is ferrous form of iron does not need HCL of gastric juice and vitamin for absorption.

• Easily absorbed.

• Absorbed in duodenum and upper jejunum.

In vegetarian Fe is in ferric form.

Need HCL of gastric juice and vitamin to convert into ferrous form.

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Source of iron :-

Non –vegetarian food rich in iron :

liver , kidney , egg-yolk, meat , fish fat.

Vegetarian food rich in iron:

cereal pulse base diet is rich in iron.

dark green vegetable like spinach , leafy vegetables , dry fruits , whole pulses like channa, rajma , bajra etc… , jiggery , dates , banana , apple etc..

Daily requirement= 18 mgm/day ( in adult)

Daily loss = 0.5 to 1.0 mgm/day

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Body iron store in hair , nails , sweat etc..

Absorption :-

-> depend upon need of body.

-> controlled by mucosal block.

-> in anaemic person more absorption.

-> increased by vit-C , gastric juice,

-> decreased by milk , antacids , phylates , tannin etc..

AETIOLOGY

1. Blood loss.

Acute chronic

-accident - piles

-APH - hook warm infection

-PPH - bleeding from peptic ulcer

-menorrhagia - intestinal malignancy

- apistexis

In India malaria and hook worm infection are most common cause for chronic blood loss

2. Increase requirement of iron:

eg. Growing age , pregnancy , lactation etc..

3. Inadequate dietary intake:eg. Due to poverty , anorexia(in TB, cancer) , vegetarian diet

4. Decrease absorption of iron:eg. Partial or total gastectomy, achlohydria ,

intestinal malabsorbtion in coeliac disease

Lab Diagnosis1) Hb – decreased

2) RBC count – decreased

3) PCV – decreased

4) Absolute indices-

M.C. V

M.C.H ALL are decreased

M.C.H.C

5) P.s – anisocytosis and Poikilocytosis.

microcytic hypochromic RBC

6) Reticulocyte count – may be normal , decreased or slightly increased(normal in adult->0.2-2% , in infants 2-6%, total 24000-48000/cumm)

7) WBC count - normal

8)Differential count – normal

9)Platelet count – normal or slightly increased in case of bleeding.

10)Bone marrow biopsy – hyper cellular due to erytheiod hyperplasia

11)Parssian blue stain – Negative.(shows absence of iron store in REcell of bone marrow)

12)Biochemical findings –A. Serum iron level -> decreased(normal 18-

180µgm/day)

DifferenceHeam iron

It is in ferrous form

Can be easily absorbed

Soluble

Vit-C and HCL is not needed.

High bio availability

Found in non-veg food i.e red meat

NON HEAM IRON

It is in ferric form.

Has to be converted in to ferrous form and then absorbed

Insoluble

Gastric HCL make is soluble & vit-C convert it in ferrous form.

Low bio availability

Found in vegetarian food.

Etiology & Pathogenesis:-

Deficiency of vit-B12(cobalamine) & / or folic acid

Impaired DNA synthesis

Delayed maturity of nucleus of RBC precursor

Slow division of cell.

(the cytoplasmic development progress normally)

• It leads to formation of large nucleated RBC precursor : Megalobasts.

• Megaloblastas are morphologically & functionally abnormal so that RBCs are formed from them released into the peripheral blood is also abnormal in size(macrocyte ).

Cause

B-12 deficiency.

due to:

1. inadequate dietary intake- more common in vegetarian and breast feed baby.

2. Malabsorption – due to lack of intrinsic factor , gastractomy , disease of small intestine like Clohn’s disease.

3. Increase demand – eg.pregnancy , lactation , infancy etc…

source

• Non-veg food like kidney, liver, heart , muscle meat etc are rich in B12.

• Fish , egg , cheese & milk also rich in B12.• Vegetable are poor in source(B12)

Daily requirement : 2-4µg Absorption : in distal Ilium. Storage : Mainly in liver -> 2mgm Kidney Heart 2mgm Brain

function

• DNA synthesis.

• Myelination of peripheral nerves , spinal cord and cerebrum.

(same as B-12 deficiency)

due to:

1. inadequate dietary intake- more common in vegetarian and breast feed baby.

2. Malabsorption – due to lack of intrinsic factor , gastractomy , disease of small intestine like Clohn’s disease.

3. Increase demand – eg.pregnancy , lactation , infancy etc…

Folic acid deficiency

Diet : Non-veg food is rich in folic acid than vegetarian food .

Daily requirement :100 – 200 mg/ day

Absorption :whole of small intestine

Nervous manifestation : numbness , weakness , ataxia , diminished reflexes

Atrophic gastritis in stomach is seen.

Lab diagnosis

RBC count : decreased

PCV : decreased

Absolute indices :-

• M.C.V → increased

• M.C.H → increased

• M.C.H.C → normal or slightly decreased

Reticulocyte count → decreased

P.S → anisocytosis & poikilocytosis.

• RBCs shows 2 characteristic changes

a) Macrosytosis

b) Ovalocytosis

e• Tear drop cells may be seen.

• Basophilic stipping of RBC.

WBC count : TLC ( total leukocyte count) slightly decrease

D.C ( differential count)

• Neutrophils → hyper segmented nucleus )

(lobes more than 5)

Platelet : slight thrombocytopenia with

Megathrombocytes.

Pancytopaenia is characteristic feature.

Biochemical findings :

• Serum B-12 level are decreased : >100 ng/litter

(normal 200-900 ng/litter )

• Serum iodate : >4 µg/litter

(normal 6-12 µg/litter)

• Megaloblastic erythroid hyperplasia.

• This abnormality of RBC , destroy in bone marrow and seen in 2 forms

a) Abnormal mitosis

b) Degenerated giant mitocyte(wbc)

Bone marrow finding

• Bone marrow is hypercellular due to megaloblastic erythroid hyperplasia.

• They may shows abnormal mitosis.

• Giant metamylocytes are also seen

• Also known as Addison’s megaloblastic

anaemia.

• Uncommon in India

• Age incidence :- middle and old age people

• When occur in children called - juvenile

pernicious anaemia.

• Both sex are similarly affected.

aetiology• Deficiency of intrinitsic factor.• Atrophy of gastric mucosa due to

prodenetion of autoimmune antibodies against parietal cell and intrinsic fator

• Antibodies are found in serum and gastric juice of the patient

Pathological changes in gastric mucos :

Certain mucosal atrophy affecting acid and pepsin secreting cells of stomach.

Result : deficiency of intrinsic factors leads to megaloblastic anaemia and subsentcombined degeneration of spinal cord and peripheral neuropathy.

Classification ( according to cause)

Haemolytic anaemia

Intracorpuscular Extracorpuscul- thalassaemia - Infection- enzymatic deficiency - drugs & chemical

in RBC -miscellaneou-Defect in cell mambrane

Aetiology – pathogenesis Increase haemolysis of RBCs

Decrease life span of RBC

Increased destruction of RBC

Increased release of haem

Increased formation of bilirubin(uncongugated)

goes to liverCongugated bilirubin

Goes to intestine

CAUSES :

1. Intracorpuscular cause

Mainly three intacorpuscular causesA. Thalassaemia and haemoglobinopathyB. Enzymatic deficiency in RBCs . Eg -> G-6PD deficiency &

P.K deficiency & haemoglobinopthisisC. Defect in cell-membrane eg. Hereditory sperocytosis & hereditory

eliptocytosis. It is a qualitative disorder of HB . Decreased of HB

synthesis leads to abnormal HB.

• Defect in the popypeptide chain of HB.

• over 100 abnormal Hbs are known. Hb-S, Hb-C Hb-D, Hb-E etc..

• Out of all this Hb-s is most common. Which cause sickle cell anaemia.

THALASSAEMIA

Quontative defect of haemoglobin.

Hereditary disorder.

Defect : reduced ret of synthesis of one or more of globin peptide chains.

Two types: α & β

Lab diagnosis• Hb : decreased • RBC :decreased • PCV : decreased• MCV• MCH normal• MCHC • Peripheral blood smear :• normocytic normochromic.• Polychorm cell is may seen.• RBC lies much apart from each other WBC : normal Platelets : normal

• Reticulocyte : increased up to 20-30 %

• Bone marrow : hyper cellular of erythroidhyparplasia

• Electrophoresis : separation of Hbs. Abnormal Hbs may be detected (Hb-s)

• Osmotic fragility of RBC – increased

• Sickle cell for Hb-S may be positive.

• G-6PD deficiency may be seen.

• Blood bilirubin level : increased.

• Urobilinogen in urine : increased

• Sterkobilirogen in stool : increased.

Characterised by pancytopaenia

Anaemia

Leucopaenia

Thrombocytopaenia

Cause atrophy of bone marrow

classification

-

chemical - infection drugsinsect killer - AIDS Eg.cytotoxic drugs

- aersenic cals - hepatitis -Like methotexaticChloramphenico ;

Aplastic Anaemia

PRIMARY SECONDARY

Clinical featurs• Anemia

• Haenmorrhages : of thrombocytopaeniableeding from gums , vagina ,bowels etc..

• Infections of leukopaenia

Lab diagnosisHb : decreased

P.S : normocytic normochromic .

RBC : decreased

PCV : decreased

MCV : increased

MCH : normal

MCHC : increased

Rticulocyte : nil

Leukopaenia : neutrophils decreased, relative lymphocytosis

• Platelet : increased (thrombocytopaenia)• Bone marrow : dry tap• Tryphling biopsy : hypocellular

Bone marrow is aplastic . Replaced by fat with patchy areas of cell

Sever decreased f myeloid cellsMegakareyocyte and erythroid cells.Pancytopaenia : marrow consist chiefly of

lymphocytes and plasma cells….