Anaemia

1. BASIC ASPECTS OF ANAEMIA Prabin Shah BScMLT,MSc(Biochemistry)

2. OBJECTIVES. Definition. Pathophysiology. Classification. Clinical features. Investigation.

3. Definition. Anaemia is present when the haemoglobin level in the blood is below the lower extreme of the normal range for the age and sex of the individual. Classification of Anaemia. 1. Morphological 2. Etiological (causes)

4. Based on morphology of red cell on stained blood films and red cell size. 1. Macrocytic 2. Microcytic 3. Normocytic

5. a)Macrocytic (Megaloblastic Anaemia) Vit B12 deficiency Folic acid deficiency Drug induced disorder of DNA synthesis

6. Microcytic Iron deficiency anaemia Deficiency of globin synthesis

7. Normocytic Recent blood loss Endocrine abnormality Hemolytic disease Renal disease Liver disease

8. Based on etiological classification. I. Anaemia due to impaired red cell production. II. Based on increased destruction of RBCs

9. a) Deficiency of essential nutrients. 1) Fe 2) Vit B12 3) Folic acid 4) Vit C I. Anaemia due to impaired red cell production.

10. b) Defect in stem cell / erythroid precursor. 1) Aplastic anaemia 2) Red cell aplasia c) Infiltration of bone marrow. 1) Leukemia 2) Multiple myeloma 3) Carcinoma

11. d) Endocrine abnormalities. 1) Myxedema 2) Addisons disease 3) Pituitary insufficiency e) Chronic liver diseases. f) Cirrhosis of liver.

12. II. Based on increased destruction of RBCs. A) Intra corpuscular disease. B) Extra corpuscular disease. Intra corpuscular disease 1) Hereditary. a) Enzyme deficiency # G6PD deficiency. # Pyruvate kinase.

13. b) Membrane defect. # Hereditary spherocytosis. # Hereditary ovalocytosis. c) Hb abnormalities. # Haemoglobinopathies. # Sickle syndrome. # Thalassemia.

14. B) Extracorpuscular disease. 1) Acquired. # Hypersplenism. # Fragmentation syndromes. # Immune haemolytic anaemia.

15. PATHOPHYSIOLOGY. Loss of blood. Excessive mature red cell destruction. Impaired red cell production.

16. Clinical features Depending upon the Hb level the signs and symptoms of anaemia is of 4 main factors; The speed of onset of anaemia: Rapidly progressive anaemia causes more symptoms than anaemia of slow- onset as there is less time for physiologic adaptation. The severity of anaemia: Mild anaemia produces no symptoms or signs but a rapidly developing severe anaemia (Hb below 6.0 g/dl ) may produce significant clinical features. The age of the patient: The young patients due to good cardiovascular compensation tolerate anaemia quite well as compared to the elderly, due to associated cardio vascular disease.

17. The Hb dissociation : In anaemia the affinity of Hb for O2 is depressed. As a result, oxyhaemoglobin is dissociated more readily to release free O2 for cellular use. SYMPTOMS: Tiredness, easy fatigability, generalised muscular weakness, lethargy and headache. In older patients: Cardiac failure, angina pectoris, confusion and visual disturbances.

18. Signs 1. Pallor: Pallor is the most common and characteristic sign which may be seen in the mucous membranes, conjunctiva, nail & skin. 2. Cardiovascular system: A hyper dynamic circulation may be present with tachycardia, collapsing pulse, cardiomegaly, dyspnoea on exertion and in the case of elderly congestive heart failure. 3. Central nervous system: The older patients may develop symptoms referable to the CNS such as attacks of faintness, giddiness, headache, drowsiness, numbness and tingling sensations of the hands and feet.

19. 4) Ocular manifestations: Retinal haemorrhages may occur if there is associated vascular disease or bleeding diathesis. 5) Reproductive system: Menstrual disturbances such as amenorrhea and menorrhagia 6) Renal system: Mild proteinuria and impaired concentrating capacity of the kidney may occur in severe anaemia 7) Gastrointestinal system: Anorexia, flatulence, nausea, constipation and weight loss may occur.

20. Investigations Full medical history, signs and symptoms is examined for evidence of anaemia. Colour of skin, conjunctivae, scleral and nails. Changes in retina. Atrophy of the papillae of tongue, rectal examination for evidence of bleeding. Presence of hepatomegaly, splenomegaly, lymphadenopathy and bony tenderness are looked for.

21. A. Hb estimation: Hb value below the lower limit of the normal range for particular age and sex the patient is said to be anaemic. In pregnancy, there is haemodilution and the lower limit in normal pregnant women is less ( 10.5 g/dl ) than in the non pregnant state. B. Peripheral blood film examination: Romanowsky dyes. The blood smear is examined for

22. 1) Variation in size (Anisocytosis ) Normal 6.7 7.7 m ( mean value 7.2 m ) Increased variation in size of red cell anisocytosis. Macrocytosis cells larger than normal. Microcytosis cells smaller than normal. Dimorphic both microcytosis and macrocytosis.

23. 2. Variation in shape (Poikilocytosis) - Increased variation in shape of the red cells. - Abnormal shape determines the cause of anaemia. 3. Inadequate haemoglobin formation.(Hypochromasia) - Normally the intensity of pink staining of Hb in a Romanowsky stained blood smear gradually decreases from the periphery to the centre of the cell.

24. Increased central pallor - Hypochromasia. - lowered Hb content. [ Eg: IDA, Chronic infections] - due to thinness of red cells. [ Eg: Thalassemia ] Deep pink staining of red cells due to increased Hb concentration. - Hyperchromasia. - Eg: Megaloblastic anaemia. Spherocytosis.

25. 4. Compensatory erythropoiesis : Changes are associated with compensatory increase in erythropoietic activity. a) Polychromasia - Red cells having more than one type of colour. Polychromatic red cells are slightly larger, stained bluish- grey. b) Erythroblastaemia Presence of nucleated red cells in the peripheral blood film. This appears in various types of severe anaemias except in aplastic anaemia.

26. c) Basophilic stippling. Is diffuse and uniform basophilic granularity in the cells. Classical punctate basophilia is seen in : - Aplastic Anaemia. - Thalassemia. - Myelodysplasia. - Infections & Lead poisoning. d) Howell Jolly bodies. Purple nuclear remnants usually found singly and are larger than basophilic stippling. Eg: Megaloblastic Anaemia.

27. 5) Miscellaneous changes. a) Spherocytosis : Presence of spheroidal rather than biconcave disc-shaped red cells. Seen in - Hereditary spherocytosis. Autoimmune Haemolytic anaemia. ABO Haemolytic disease of newborn. b) Schistocytosis : Fragments of erythrocytes. Seen in - Thalassemia. Megaloblastic anaemia. Iron deficiency anaemia. Haemolytic anaemia.

28. c) Irregularily contracted red cells. - Found in drug and chemical induced haemolytic anaemia. d) Leptocytosis. - Presence of unusually thin red cells. Eg: Iron deficiency anaemia,Thalassemia. Target cell : Form of leptocyte. - There will be a central round stained area & a peripheral rim of Hb. Eg: Iron deficiency anaemia. Thalassemia.

29. e) Sickle cells / Drepanocytes. Sickle - shaped red cells found in sickle cell disease. f) Crenated red cells. Erythrocytes which develop numerous projections from the surface. g) Acanthocytosis. Presence of coarsely crenated red cells. Eg: Splenectomised subject. Chronic liver disease. h) Burr cells. Cell fragments having one/ more spines.

30. BURR CELLS ACANTHOCYTES CRENATED CELLS SICKLE CELLS

31. i) Stomatocyctosis. Central area having slit-like or mouth like appearance. - Chronic alcoholism. - Hereditary stomatocytosis. j) Ovalocytosis or elliptocytosis: Oval or elliptical shape of red cells. - Megaloblastic anaemia - Hypochromic anaemia.

32. C) Red cell indices. Iron deficiency & Thalassemia - MCV, MCH, & MCHC are reduced. In anaemia due to acute blood loss & haemolytic anaemia - MCV, MCH & MCHC are all within normal range. In megaloblastic anaemias - MCV is raised above the normal range.

33. D) Leucocytes and platelet count. This helps to distinguish pure anaemia from pancytopenia in which red cells, granulocytes and platelets are all reduced. In anaemia due to haemolysis or haemorrhage - neutrophil , platelet counts are elevated. In infection and leukemias leukocytes are high and immature leukocytes appears in the blood.

34. E) Reticulocyte count. Normal : 0.5 2.5 % It is done to assess the marrow erythropoietic activity. In acute haemorrhage & haemolysis the reticulocyte response is indicative of impaired marrow function. F) Bone marrow examination.

35. G) Erythrocyte sedimentation rate. ESR is a non specific test. Screening test for anaemia. Anaemia cause rise in ESR level.

Anaemia

Health & Medicine

symptoms of anaemia

classification of anaemia

mild anaemia

aplastic anaemia

progressive anaemia

anaemia of slow

severity of anaemia

severe anaemia hb