ANEMIA

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

• Department of Clinical Microscopy
• Faculty of Associated Medical Sciences, Chiang
  Mai University

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ANEMIA
Symptoms 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 loss
• II. Morphologic Classification
• 1. Macrocytic anemia
• 2. Microcytic hypochromic anemia
• 3. Normochromic normocytic anemia
• III. Kinetic Classification
• IV. Physiologic Classification

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Impaired RBC Production

• 1. 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 Erythropoietin
• 3. 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 gt 94
• MCHC gt 31
• 1. 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 gt 94
• MCHC gt 31
• 2. 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 lt 80
• MCHC lt 31
• 1. Fe deficiency anemia Chronic blood loss,
• Inadequate diet, Malabsorption, Increased
• demand, etc.
• 2. Abnormal globin synthesis Thalassemia with
  or
• without Hemoglobinopathies
• 3. 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 gt 30
• 1. Blood loss
• 2. Increased plasma volume Pregnancy,
  Overhydration
• 3. Hemolytic anemia depend on each cause
• 4. Hypoplastic marrow Aplastic anemia, RBC
  aplasia
• 5. 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) lt 2
• (Ineffective erythropoiesis)
• 1.1 Hypoproliferative anemia
• 1.2 Maturation disorder
• 2. RPI gt 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) lt 2
• (Ineffective erythropoiesis)
• 1.1 Hypoproliferative anemia
• (normocytic normochromic, N/N)
• - Hypoplastic anemia - Idiopathic/
  Chemical/ Infectious / Drug --gt
  Maturation arrest
• - Myelophthisic anemia (Marrow
  infiltration)
• - Refractory anemia (Dysmyelopoietic
  syndrome)

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Physiologic Class. of Anemia RPI lt 2

• 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 lt 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)

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Physiologic Classification of Anemia

• 2. RPI gt 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
  --gt micro-
• cytic, hypochromic anemia)

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Evaluation of Anemia

• A. 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 morphology

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Evaluation of Anemia

• B. 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 Anemia

• D. 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
Hb lt 9-10 gm/dL

• 1. Acute anemia
• 1.1 Acute blood loss
• BP , Pulse --gt Acute hemorrhage
• 1.2 No acute blood loss
• Jaundice, hemoglobinuria --gt G-6-PD def.
• Jaundice, No hemoglobinuria --gt AIHA (NCNC), HS
  (Spherocycyte), hemoglobin H disease (HCMC)
• Jaundice, fever --gt Malaria
• No jaundice --gt G-6-PD def., Hb H, Acute leukemia

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DDx of Common Anemia in Thailand
Hb lt 9-10 gm/dL

• 2. Chronic anemia
• 2.1 No hepatosplenomegaly
• No petichiae and purpura --gt Fe def. Anemia,
  anemia of chronic disease, folate def.
• Petichiae purpura --gt ITP Fe def., Acute
  leukemia (Blast cell), Aplastic anemia
• Chronic disease --gt Chronic renal failure,
  rheumatoid arthritis, infective
  endocarditis, hypothyroidism, etc.

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DDx of Common Anemia in Thailand
Hb lt 9-10 gm/dL

• 2. Chronic anemia
• 2.2 Hepatosplenomegaly
• Mongoloid face --gt Thalassemia
• No Mongoloid face with lymphadenopathy --gt
  DDx Acute leukemia, lymphoma, TB lymph node
• Liver disease

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ANEMIA
The End
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