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ANEMIA

Department of Clinical Microscopy

Faculty of Associated Medical Sciences, Chiang Mai University

PRASIT CHANARAT, M.S.(Clin.Path)

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ANEMIASymptoms : Pallor Jaundice Fatique Palpitation Dyspnea Virtigo Peptic ulcer Glossitis Dysphagia etc

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Classification of Anemia I. Etiologic Classification 1. Impaired RBC production 2. Excessive destruction 3. Blood lossII. Morphologic Classification 1. Macrocytic anemia 2. Microcytic hypochromic anemia 3. Normochromic normocytic anemiaIII. Kinetic ClassificationIV. Physiologic Classification PC

Impaired RBC Production1. Abnormal bone marrow 1.1 Aplastic anemia 1.2 Myelophthisis : Myeloficrosis, Leukemia, Cancer metastasis 2. Essential factors deficiency 2.1 Deficiency anemia : Fe, Vit. B12, Folic acid, etc 2.2 Anemia in renal disease : Erythropoietin3. Stimulation factor deficiency 3.1 Anemia in chronic disease 3.2 Anemia in hypopituitarism 3.3 Anemia in hypothyroidism

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Excessive Destruction of RBC(cont.)

Hemolytic anemia

1. Intracorpuscular defect

1.1 Membrane : Hereditary spherocytosis

Hereditary ovalocytosis, etc.

1.2 Enzyme : G-6PD deficiency, PK def., etc.

1.3 Hemoglobin : Thalassemia, Hemoglobino- pathies

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Excessive Destruction of RBC

2. Extracorpuscular defect

2.1 Mechanical : March hemolytic anemia

MAHA (Microangiopathic HA)

2.2 Chemical/Physical

2.3 Infection : Clostridium tetani

2.4 Antibodies : HTR, SLE

2.5 Hypersplenism

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Blood Loss

1. Acute blood loss : Accident, GI bleeding

2. Chronic blood loss : Hypermenorrhea

Parasitic infestation

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Macrocytic Anemia MCV > 94 MCHC > 311. Megaloblastic dyspoiesis 1.1 Vit. B12 deficiency : Pernicious anemia 1.2 Folic acid deficiency : Nutritional megaloblas- tic anemia, Sprue, Other malabsorption 1.3 Inborn errors of metabolism : Orotic aciduria, etc. 1.4 Abnormal DNA synthesis : Chemotherapy, Anticonvulsant, Oral contraceptives

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Macrocytic Anemia MCV > 94 MCHC > 312. Non-Megaloblastic dyspoiesis 2.1 Increased erythropoiesis : Hemolytic anemia response to hemorrhage 2.2 Increased membrane surface area : Hepatic disease, Obstructive jaundice, Post-

splenectomy 2.3 Idiopathic : Hypothyroidism, Hypoplastic and Aplastic anemia

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Microcytic Hypochromic Anemia MCV < 80 MCHC < 311. Fe deficiency anemia : Chronic blood loss, Inadequate diet, Malabsorption, Increased demand, etc.2. Abnormal globin synthesis : Thalassemia with or without Hemoglobinopathies3. Abnormal porphyrin and heme synthesis : Pyridoxine responsive anemia, etc.4. Other abnormal Fe metabolism :

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Normocytic Normochromic Anemia MCV 82 - 92 MCHC > 301. Blood loss2. Increased plasma volume : Pregnancy, Overhydration3. Hemolytic anemia : depend on each cause4. Hypoplastic marrow : Aplastic anemia, RBC aplasia5. Infiltrate BM : Leukemia, Multiple myeloma, Myelofibrosis, etc.6. Abnormal endocrine : Hypothyroidism, Adrenal insufficiency, etc.7. Kidney disease / Liver disease / Cirrhosis

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Kinetic Classification of Anemia

1. Insufficient erythropoiesis

Stem cells , Hypoplastic marrow, Infiltrated BM

2. Ineffective erythropoiesis

- Megaloblastic anemia

- Thalassemia

- Sideroblastic anemia

3. Uncompensated hemolytic disease with continued

bleeding

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Physiologic Classification of Anemia

1. RPI (Reticulocyte Production Index) < 2

(Ineffective erythropoiesis)

1.1 Hypoproliferative anemia

1.2 Maturation disorder

2. RPI > 3 (Effective erythropoiesis

2.1 Hemolytic anemia

2.2 Blood loss anemia

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Physiologic Classification of Anemia

1. RPI (Reticulocyte Production Index) < 2

(Ineffective erythropoiesis)

1.1 Hypoproliferative anemia

(normocytic normochromic, N/N)

- Hypoplastic anemia - Idiopathic/ Chemical/ Infectious / Drug --> Maturation arrest

- Myelophthisic anemia (Marrow infiltration)

- Refractory anemia (Dysmyelopoietic syndrome)

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1.1.1 N/N and normal RDW

a) BM failure

b) Decrease marrow stimulation

- Endocrine disease

- Anemia of chronic disease

- Renal disease

1.1.2 Abnormal RBC morphology & RDW

a) Oval macrocyte :- Refractory dysmyelo- poietic

b) Dacrocytes/ tear drops :- Myelophthisic

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Physiologic Class. of Anemia RPI < 2

1.2 Maturation disorder 1.2.1 Microcytic, high RDW a) Siderblastic (Microcytic dimorphic RBC) b) Fe def. (Microcytic hypochromic RBC) 1.2.2 Microcytic, normal RDW a) Heterozygous, thalassemia syndrome

b) Anemia of chronic disease 1.2.3 Macrocytic a) Liver disease b) Folate def. c) Vit. B12 def. d) Hemolytic anemia (Normocyte

polychromasia)PC

Physiologic Class. of Anemia RPI < 2

Physiologic Classification of Anemia

2. RPI > 3

(Effective erythropoiesis)

2.1 Hemolytic anemia

- Intrinsic hereditary disorder - Extrinsic acquired disorder

2.2 Blood loss

- Acute blood loss

- Chronic blood loss (without treatment --> micro-

cytic, hypochromic anemia)PC

Evaluation of AnemiaA. Hematologic

1. Hematocrit (VPRC preferred)

2. Hemoglobin concentration

3. RBC indices : MCV, MCH, MCHC

4. Leukocyte count

5. Reticulocyte count

6. Platelet count

7. ESR (Erythrocyte sedimentation rate)

8. Stained blood smear : RBC morphologyPC

Evaluation of AnemiaB. Urine analysis 1. Appearance : Color, pH, Clarity, sp gr 2. Test for protein, Bence Jones protein 3. Bilirubin, Uribilinogen 4. Occult blood 5. Microscopic examination C. Stool 1. Appearance : Color, consistency 2. Occult blood 3. Examination for ova, parasites

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Evaluation of AnemiaD. Serum or Plasma 1. BUN 2. Creatinine, if urea N is abnormal 3. Bilirubin : Direct, indirect 4. Protein 5. SI (Serum iron), TIBC (Total iron binding capacity)E. Special tests in hematology Hb typing / Ham acid test / Coombs’ test, G-6PD, Ferritin

, Sucrose test, Autohemolysis test, Haptoglobin, etc.

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DDx of Common Anemia in Thailand

1. Acute anemia

1.1 Acute blood loss

BP , Pulse --> Acute hemorrhage

1.2 No acute blood loss• Jaundice, hemoglobinuria --> G-6-PD def.• Jaundice, No hemoglobinuria --> AIHA (NCNC), HS

(Spherocycyte), hemoglobin H disease (HCMC) • Jaundice, fever --> Malaria• No jaundice --> G-6-PD def., Hb H, Acute leukemia

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Hb < 9-10 gm/dL

DDx of Common Anemia in Thailand

2. Chronic anemia

2.1 No hepatosplenomegaly • No petichiae and purpura --> Fe def. Anemia, anemia

of chronic disease, folate def.• Petichiae & purpura --> ITP + Fe def., Acute leukemia

(Blast cell), Aplastic anemia• Chronic disease --> Chronic renal failure, rheumatoid

arthritis, infective endocarditis, hypothyroidism, etc.

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Hb < 9-10 gm/dL

DDx of Common Anemia in Thailand

2. Chronic anemia

2.2 Hepatosplenomegaly• Mongoloid face --> Thalassemia• No Mongoloid face with lymphadenopathy --> DDx

Acute leukemia, lymphoma, TB lymph node• Liver disease

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Hb < 9-10 gm/dL

Mechanisms of Anemia

Production Disorders:Hematopoietic Cell Damage

-Drugs, Radiation, Infections, ToxinsFactor Deficiency

-Iron (Heme Synthesis)-Vitamin B12 (DNA Synthesis)

-Folate (DNA Synthesis)

Mechanisms of Anemia

Survival Disorders:Blood Loss - External or InternalRed blood Cell Destruction -Hemolytic Anemias

Anemia

Manifestations - Cause & ChronicityNonspecific Signs and Symptoms

Weakness, Malaise, FatigueCNS hypoxia - Headaches, Faintness,

Dimness of VisionSkin Pallor, Thinning and InelasticityNail BrittlenessAngina Pectoralis (if ASCVD)

Production Disorder - Iron Deficiency

Most Common Nutritional DeficiencyRequired in Hemoglobin Synthesis

Heme + Globin Chains = HemoglobinOccurs in RBC Cytoplasm

Hypochromic Microcytic Anemia

Iron Metabolism

Iron is Absorbed Primarily in Duodenum

- 25% of Heme-Bound Iron (Red Meat)

- 1-2% of Non-Heme IronBody Losses of Iron are Limited

- 1-2 mg/Day By Epithelial Cell SheddingMucosal Block - Maintains Balance

Transferrin

Transport Protein For Iron In Blood

Fully Saturated Transferrin = TIBC

300 - 350ug/dl Fe

Normal Transferrin - 1/3 Filled With Iron

100 - 120ug/dl Fe (Serum Iron)

Iron Storage

Ferritin - Protein Iron Complex *Found In All Tissues*BM, Liver (Transferrin)*Spleen (RBC Breakdown)

Hemosiderin - Breakdown Product ofFerritin

Development of Iron Deficiency

Depletion of Stores Serum Ferritin

Stainable BM Iron

Transferrin ( TIBC) Serum Fe

Transferrin Saturation Hemoglobin, Myoglobin, Fe Proteins

Iron Deficiency Anemia Laboratory Findings

Hypochromic Microcytic Anemia

( RBC Count, MCV)

Serum Ferritin Levels

Transferrin Saturation

( Serum Fe, Transferrin)

Causes of Iron Deficiency

External Blood Loss - Most CommonFemale Genital TractGastrointestinal Tract

Demand - Infancy, PregnancyDietary Deficiency - Rare

(Vegetarian Diets) Intestinal Malabsorption Syndrome

Iron DeficiencyClinical Manifestations

Anemia - Non-Specific FindingsKoilonychiaPlummer-Vinson Syndrome

-Hypochromic Microcytic Anemia-Atrophic Glossitis-Esophageal Webs (Dysphagia)

Koilonychia - Iron DeficiencyKoilonychia - Iron Deficiency

Hypochromic Microcytic Anemia (Iron Deficiency)Hypochromic Microcytic Anemia (Iron Deficiency)

Vitamin B12 Absorption

Parietal cells - produce IF

IF

B12

B12

B12

IF

Stomach

IF

Ileum -IF receptorsB12

B12

Vitamin B12 Deficiency

Western World - Pernicious Anemia

Autoantibodies (Serum and Gastric)

IF Function Gastric

Production

IF ParietalCell

IFB12

Production Disorder - Vitamin B12 or Folate Deficiency

Megaloblastic Anemias

Impaired DNA Synthesis (Nucleus)

Function - Transfer of Carbon Groups

Affects All Rapidly Dividing Cells

-Mouth - Atrophic Glossitis

-GI tract - Intestinal Malabsorption

Megaloblastic AnemiaPeripheral Blood

RBCs - Large Oval Macroovalocytes - MCV > 100u3

Anemia Due To Ineffective Hematopoiesis- Autohemolysis of Megaloblasts(Circulating Large RBCs Destroyed)

Hypersegmented Neutrophils Thrombocytopenia, Neutropenia (Severe)

Macroovalocytes and Hypersegmented NeutrophilMacroovalocytes and Hypersegmented Neutrophil

Vitamin B12 Deficiency - Cause

Western World - Pernicious AnemiaAutoimmune Disorder -Autoantibodies to IF and Parietal Cells

-Chronic Atrophic Gastritis -Achlorhydria - Absent HCL Incidence of Other Autoimmune

Disorders

Vitamin B12 Deficiency

Additional Causes: Inadequate Diet - Rare (>20yr Stores)

-Foods Containing Animal Protein-Microorganisms Synthesize-Stored in Liver, Reabsorbed in Bile

Gastrectomy, Ileal ResectionMalabsorption States, Gastric AtrophyDiphyllobothrium Latum - Fish Tapeworm

Megaloblastic Anemia - Bone Marrow

Nuclear- Cytoplasmic Asynchrony:Erythroid Series (Hallmark Changes)

-Megaloblasts

-Erythroid HyperplasiaMyeloid SeriesMegakaryocytic Series - (Infrequent)

Normal Erythroids (Left); Megaloblasts (Right)Normal Erythroids (Left); Megaloblasts (Right)

B12 and Folate in DNA Synthesis

ThymidylateSynthetase

DNA

FH4 (Folate)

dTMP

N5 - Methyl FH4

Methyl Cobalamin

Cobalamin (Vitamin B12)

dUMP

Vitamin B12 Deficiency

Clinical - Similar to Folate Deficiency But Demyelinating Neurologic Disorder- Affects Both Sensory and Motor Tracts- Lack of Correlation With Anemia

Parenteral B12 - Improves Anemia, +/- Resolution of Neurologic Symptoms

Caution! Anemia of B12 Deficiency Also Improves With Folate Supplementation

Vitamin B12 Deficiency

Laboratory Findings:Low Serum Vitamin B12 LevelsNormal RBC Folate LevelsAbnormal Schilling Test - Impaired

Absorption of Radioactive Vitamin B12 Correctable by Addition of IF

Anti-Intrinsic Factor Antibodies (Anti-Parietal Antibodies Less Sensitive)

Causes of Folate Deficiency

Dietary Deprivation - Widely Distributed in Foods (Uncooked Vegetables, Fruits, Liver)- Limited Body Stores (Wks-Months) - Chronic Alcoholics, Elderly, Indigent

Malabsorption (Upper 1/3 Intestine)- Intestinal Disease (Sprue, Celiac Dx)- Chronic Drugs (Dilantin)

Folate Deficiency

Increased Requirements - Pregnancy Impaired Utilization - Folic Acid

Antagonists (Chemotherapy Drugs)Laboratory Findings:Red Blood Cell Folate - Reflects Tissue

Content of Folate Throughout BodySerum Folate - Levels Fluctuate Based on

Recent Intake, Do Not Reflect Stores

Anemia of Chronic Disease

Normochromic Normocytic Anemia(or Hypochromic Microcytic)

Chronic Disorders (Inflammation or Tissue Necrosis)

-Chronic Microbial Illnesses-Chronic Immune Disorders-Neoplasms

Often TIBC, Ferritin

Anemia of Chronic Disease

Defect

Storage Iron

IL-1

TNF IFN

Erythroid Precursors

(Insufficient Erythropoietin)

Bone Marrow Storage Iron (Blue)Bone Marrow Storage Iron (Blue)

Hematopoietic Cell DamageAplastic Anemia

Bone Marrow Aplasia (Lack of Cells)Failure of Multipotent Stem Cell

- T-cell Mediated Suppression or- Genetic Damage

Bone Marrow - Markedly HypocellularPeripheral Blood - Pancytopenia

- Normochromic Normocytic RBCs

Markedly Hypocellular BM - Aplastic AnemiaMarkedly Hypocellular BM - Aplastic Anemia

Aplastic Anemia

Causes of Stem Cell Failure Idiopathic (>50%) - Poor Prognosis

Especially If < 40 Years OldWhole Body IrradiationViral Infections - Most Common

After Non-A/Non-B HepatitisChemical Agents and Drugs -

Reversible and Non-Reversible

Myelophthisic Anemia

BM Replacement BM failure:Metastatic Carcinoma Most CommonDestruction By Non-Neoplastic Process

is Less Common i.e. Fibrosis, InfectionPeripheral Blood Cytopenias, Immature

Circulating Cells

Breast Cancer Replacing BMBreast Cancer Replacing BM

ANEMIA

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