Mayo Clin Proc. • July 2004;79(7):945-956 • www.mayo.edu/proceedings LETTERS TO THE EDITOR Practical Algorithms in Anemia Diagnosis To the Editor: In the October 2003 issue of Mayo Clinic Proceedings, I authored a concise review article on a contem- porary approach to the evaluation and diagnosis of anemia in adults. 1 In that article, I classified anemia into macrocytic, normocytic, and microcytic categories based on the mean corpuscular volume (MCV)—MCV >100 fL, 80-100 fL, and <80 fL, respectively. I also provided a stepwise approach to a specific diagnosis in each of these categories. I have since received numerous requests from readers of the Proceedings to complement the concise review with practical algorithms that correspond to each of the 3 categories of anemia. I am happy to accommodate that request (Figures 1, 2, and 3). However, I remind readers that such algorithms should serve only as guidelines and that an in-depth review of the clinical and laboratory data is essential before making a specific diag- nosis in an individual patient. Ayalew Tefferi, MD Mayo Clinic College of Medicine Rochester, Minn 1. Tefferi A. Anemia in adults: a contemporary approach to diagnosis. Mayo Clin Proc. 2003;78:1274-1280. FIGURE 1. Evaluation of macrocytic anemia. AZT = zidovudine; MCV = mean corpuscular volume; MMA = methylmalonic acid. Evaluation of macrocytic anemia Step 1: Rule out drug causes including hydroxyurea and AZT use Step 2: Check serum vitamin B 12 and homocysteine Both normal Nutritional cause unlikely Moderately macrocytic (MCV, 100-110 fL) Blood smear shows round macrocytes, target cells, or reticulocytosis Blood smear shows oval macrocytes, anisocytosis, or pseudo–Pelger-Huët nuclear anomaly Consider: (1) Hemolysis (2) Excess alcohol use (3) Liver disease Markedly macrocytic (MCV, >110 fL) One or both abnormal Check serum MMA Normal Check serum folate Consider vitamin B 12 deficiency Increased Consider: (1) Myelodysplastic syndrome (2) Other marrow disease 955 For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Practical Algorithms in Anemia Diagnosis
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Practical Algorithms in Anemia DiagnosisLETTERS TO THE EDITOR
Practical Algorithms in Anemia Diagnosis
To the Editor: In the October 2003 issue of Mayo Clinic Proceedings, I authored a concise review article on a contem- porary approach to the evaluation and diagnosis of anemia in adults.1 In that article, I classified anemia into macrocytic, normocytic, and microcytic categories based on the mean corpuscular volume (MCV)—MCV >100 fL, 80-100 fL, and <80 fL, respectively. I also provided a stepwise approach to a specific diagnosis in each of these categories. I have since received numerous requests from readers of the Proceedings to complement the concise review with practical algorithms
that correspond to each of the 3 categories of anemia. I am happy to accommodate that request (Figures 1, 2, and 3). However, I remind readers that such algorithms should serve only as guidelines and that an in-depth review of the clinical and laboratory data is essential before making a specific diag- nosis in an individual patient.
Ayalew Tefferi, MD Mayo Clinic College of Medicine Rochester, Minn
1. Tefferi A. Anemia in adults: a contemporary approach to diagnosis. Mayo Clin Proc. 2003;78:1274-1280.
FIGURE 1. Evaluation of macrocytic anemia. AZT = zidovudine; MCV = mean corpuscular volume; MMA = methylmalonic acid.
Evaluation of macrocytic anemia
Step 1: Rule out drug causes including hydroxyurea and AZT use
Step 2: Check serum vitamin B12 and homocysteine
Both normal
Blood smear shows round macrocytes, target cells, or reticulocytosis
Blood smear shows oval macrocytes, anisocytosis, or pseudo–Pelger-Huët nuclear anomaly
Consider: (1) Hemolysis (2) Excess alcohol use (3) Liver disease
Markedly macrocytic (MCV, >110 fL)
One or both abnormal
955
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clin Proc. • July 2004;79(7):945-956 • www.mayo.edu/proceedings 953
LETTERS TO THE EDITOR
Evaluation of normocytic anemia
Check history Perform FOBT
Check serum creatinine
Check haptoglobin, LDH, bilirubin, and reticulocyte count
Step 2: If all the above are unrevealing, consider: Anemia of chronic disease or Primary bone marrow disorder
Step 3: Perform bone marrow biopsy only if: (1) Information will influence treatment or (2) Anemia is symptomatic or (3) Blood smear suggests a primary bone marrow disease
FIGURE 3. Evaluation of microcytic anemia.
Evaluation of microcytic anemia
Low = iron-depleted state Normal or elevated
Step 2: Is the microcytosis new?
Consider anemia of chronic disease
Consider thalassemia
Yes No
FIGURE 2. Evaluation of normocytic anemia. FOBT = fecal occult blood test; LDH = lactate dehydrogenase.
956
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Practical Algorithms in Anemia Diagnosis
Reference
Practical Algorithms in Anemia Diagnosis
To the Editor: In the October 2003 issue of Mayo Clinic Proceedings, I authored a concise review article on a contem- porary approach to the evaluation and diagnosis of anemia in adults.1 In that article, I classified anemia into macrocytic, normocytic, and microcytic categories based on the mean corpuscular volume (MCV)—MCV >100 fL, 80-100 fL, and <80 fL, respectively. I also provided a stepwise approach to a specific diagnosis in each of these categories. I have since received numerous requests from readers of the Proceedings to complement the concise review with practical algorithms
that correspond to each of the 3 categories of anemia. I am happy to accommodate that request (Figures 1, 2, and 3). However, I remind readers that such algorithms should serve only as guidelines and that an in-depth review of the clinical and laboratory data is essential before making a specific diag- nosis in an individual patient.
Ayalew Tefferi, MD Mayo Clinic College of Medicine Rochester, Minn
1. Tefferi A. Anemia in adults: a contemporary approach to diagnosis. Mayo Clin Proc. 2003;78:1274-1280.
FIGURE 1. Evaluation of macrocytic anemia. AZT = zidovudine; MCV = mean corpuscular volume; MMA = methylmalonic acid.
Evaluation of macrocytic anemia
Step 1: Rule out drug causes including hydroxyurea and AZT use
Step 2: Check serum vitamin B12 and homocysteine
Both normal
Blood smear shows round macrocytes, target cells, or reticulocytosis
Blood smear shows oval macrocytes, anisocytosis, or pseudo–Pelger-Huët nuclear anomaly
Consider: (1) Hemolysis (2) Excess alcohol use (3) Liver disease
Markedly macrocytic (MCV, >110 fL)
One or both abnormal
955
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clin Proc. • July 2004;79(7):945-956 • www.mayo.edu/proceedings 953
LETTERS TO THE EDITOR
Evaluation of normocytic anemia
Check history Perform FOBT
Check serum creatinine
Check haptoglobin, LDH, bilirubin, and reticulocyte count
Step 2: If all the above are unrevealing, consider: Anemia of chronic disease or Primary bone marrow disorder
Step 3: Perform bone marrow biopsy only if: (1) Information will influence treatment or (2) Anemia is symptomatic or (3) Blood smear suggests a primary bone marrow disease
FIGURE 3. Evaluation of microcytic anemia.
Evaluation of microcytic anemia
Low = iron-depleted state Normal or elevated
Step 2: Is the microcytosis new?
Consider anemia of chronic disease
Consider thalassemia
Yes No
FIGURE 2. Evaluation of normocytic anemia. FOBT = fecal occult blood test; LDH = lactate dehydrogenase.
956
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Practical Algorithms in Anemia Diagnosis
Reference
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