ANEMIA - PART I
Overall Approach and
Iron Deficiency Anemia
BY: Zorawar Noor
4/21/2014
Objectives
 Understand signs and symptoms of anemia
 Use 4 simple steps to classify anemia
 Learn about the causes of iron deficiency
anemia
 Learn the lab findings in iron deficiency anemia
MKSAP Case 1
 A 77-yo man is evaluated for a 1-year history of
extreme fatigue and SOB on exertion and 8
weeks of substernal CP with exertion.
 On Physical Exam, T 36.7C, BP 137/78, HR 118, BMI
27, Patient has pale conjunctiva, cardiopulmonary
examination with summation gallop and crackles
at lung bases.
 Laboratory studies: Hgb 5.4, WBC 6400, MCV 58, Plt
154,000, RDW 25
 Echocardiogram is normal.
 Peripheral blood smear …
… MKSAP Case 1
… MKSAP Case 1
 Which of the following is the most likely diagnosis?
 (A) G6PD deficiency
 (B) Iron Deficiency
 (C) Myelofibrosis
 (D) TTP
What is Anemia?
 Reduction of Hgb, Hct, or RBC count
 Or 2 standard deviations below the mean
 Or in Men Hg < 13 in men and Hg < 12 in women
 (WHO criteria)
Signs and Symptoms
 Asymptomatic
 Tachycardia
 Dyspnea on Exertion
 Pallor of nails and conjunctivae
 Nail spooning
 Fatigue
 Decreased exercise tolerance
 Pica
Physical Manifestation : “Spoon
Nails” in Iron Deficiency
Reasons for Anemia
 1) Blood Loss
 2) Underproduction of Erythrocytes
 3) Destruction of Erythrocytes (hemolysis)
4 Steps to Classify Anemia
 Step 1 – Characterize by MCV
 Step 2 - Identify Morphologies on Peripheral Smear
 Step 3 – Calculate Reticulocyte Index
 Step 4 – Use iron studies, bone marrow biopsy, etc.
Step 1
 Step 1- Characterize by MCV:
 Microcytic (MCV < 80)
 Reduced iron availability, heme synthesis, or globin
production
 Normocytic ( 80 < MCV < 100)
 Anemia of chronic disease
 Macrocytic (MCV > 100)
 Liver disease, B12, folate
Step 2
 Step 2-Identify Morphologies on Peripheral Smear

Examples:
 Microcytosis, anisocytosis = Iron deficiency
 Spherocytes = hereditary spherocytosis, warm AIHA
 Macrocytes = B12 or folate def, myelodysplasia
 Target cells = Hgb-opathy, liver dz, splenectomy
 Schistocytes = microangiopathy (TTP/HUS, DIC)
 Nucleated erythrocytes = hemolysis/hypoxia
 Teardrop cells = fibrosis/infiltration, BM granuloma
 Bite cells = G6PD
 Sickle cells = Sickle cell disease
 Rouleaux = IgM myeloma (Waldenstrom)
 Burr cell = kidney dz (uremia), spur cell = severe liver dz
Step 3
 Step 3- Calculate the Reticulocyte Index:
 Reticulocyte = Immature RBC, suggests marrow
response
 Reticulocyte Index (RI) = ReticCount * 0.5(Hct/45)
 In general, RI <2% with anemia suggests
hypoproliferation
Step 4
 Step 4: Iron studies, BM biopsy and other:
 Iron Studies:
 Iron Deficiency: Low Fe, high TIBC, low ferritin, low %sat
 Inflammatory Anemia: nl/Low Fe, low TIBC, high ferritin
 Other: Bone Marrow Biopsy (often the gold
standard), EPO levels, Hgb electrophoresis, Coombs’
test, NADPH testing, etc.
Iron Deficiency Anemia
 History: bleeding, pregnancy, malabsorption..
 Step 1) Microcytosis
 Step 2) Anisocytosis (high RDW)
 Step 3) Low Retic Count
 Step 4) low iron level, HIGH TIBC, low ferritin
Who needs a GI work-up?
 All men, all women without menorrhagia,
women greater than 50 with menorrhagia
 If UGI symptoms, EGD
 If asymptomatic, colonoscopy
 Women less than 50 plus menorrhagia: consider
GI workup based upon symptoms
Iron Studies in Iron Deficiency
Finding
Fe
low
TIBC
High
% Sat
low
Ferritin
low
Treatment of Anemia
 Treat the underlying cause
 Treat the underlying cause
 Oral Iron usually the correct answer
 Consider co-existent iron deficiency as well
 If underlying disease state requires it, consider
EPO injection
Summary
 Just approach it one step at a time!
 Remember that in iron deficiency, iron is low, freeing
up your binding capacity, giving a high TIBC
 For all anemia, try and treat the underlying cause.
References

Harrison’s Principles of Internal Medicine

Adamson JW. Chapter 103. Iron Deficiency and Other Hypoproliferative
Anemias. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL,
Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New
York: McGraw-Hill; 2012.
http://www.accessmedicine.com/content.aspx?aID=9117223. Accessed
December 7, 2011

Wians, F.H. and Urban JE. “Discriminating between Anemia of Chronic
disease Using Traditional Indices of Iron Status v. Transferring Receptor
Concentration”. 2001. American Journal of Clinical Pathology. Volume
115.

UptoDate


Schrier, SL. Approach to the adult patient with anemia. In: UpToDate,
Landaw, SA(ED). UptoDate, Waltham, MA. 2012.
Schrier, SL. Causes and diagnosis of anemia due to iron deficiency. In:
UpToDate. Landaw, SA.(ED). Uptodate, Waltham, MA. 2012.