A Practical
Approach to Anemia
How to efficiently and accurately
work up an anemic patient ?
Dr.R.V.S.N.Sarma., M.D., M.Sc., (Canada)
Consultant Physician & Chest Specialist
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What is Anaemia ?
Important to remember
• Anemia is a clinical sign of disease
• It is not a single disease by itself
• Need to look for the underlying cause !
• Will we ignore a fever with out investigation ?
• Its diagnosis is not that simple !! We’ll make it
• Its very common and imp. in our practice
• Drug Rx. depends on the cause
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Definition of Anaemia
• Decrease in the number of circulating red blood
cell mass and there by O2 carrying capacity
• Most common hematological disorder by far
• Almost always a secondary disorder
• As such, critical for all practitioners to know
how to evaluate / determine its cause / treat
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Erythron
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Erythron is the machinery of RBC production
EPO, IL, Growth factors, Cytokines – stimulate it
Hypoxia is strong stimulus for the Erythron
Its functioning is influenced by
Normal renal production of EPO
A functioning Erythroid marrow
An adequate supply of substrates for Hb production
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The RBC Lineage
Let us meet the Grand Parents !
Haemopoesis in Bone Marrow
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Pro Erythroblast
Large purple nucleus
Thin rim of cytoplasm
Basophilic in stain
Cell > 35 µ
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Early Normoblast
Large purple nucleus
Denser nucleus
Thin rim of cytoplasm
Basophilic in stain
Cell > 25 µ
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Intermediate Normoblast
Medium sized nucleus
Reticulated nucleus
More cytoplasm
Neutral in stain
Cell > 20 µ
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Late Normoblast
Small dense nucleus
Darkly staining
Increased cytoplasm
Pink in stain
Cell > 15 µ
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Reticulocyte
No definite nucleus
Reticulum of RNA
Deep blue staining
Light blue cytoplasm
Cell size about 10 µ
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Normal Red Cells
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Normal Red Cells
No nucleus, Enzyme packets
Biconcave discs – Haem + Gl
Center 1/3 pallor
Pink cytoplasm (Hb filled)
Cell size 7 - 8 µ - capill. 2 µ
EM pathway, HMP
Negative charge – no phago
Na less, K more inside
100-120 days life span
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The Factory – Bone Marrow
Sternum, pelvis, vertebrae, long
bones, skull bones, Tibia (paed)
From stem cells (pleuripotent)
75% of marrow for WBC
25% of BM for Red cells
Erythrod / Granulocyte Ratio 1:3
E:G ratio increased in Anaemia
Large white areas are marrow fat
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Normal BM High Power
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Hemoglobin (Hb)
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First Question
• The onset of Anaemia
• Acute versus chronic
• Clues
– Hemodynamic stability
– Previous CBC
– Overt blood loss
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Types of Anaemia
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Screening Tests – Anaemia
• Clinical Signs and symptoms of Anaemia
• Look for bleeding – all possible sites
• Look for the causes for anemia
• Routine Hemoglobin examination
• Cut off marks for Hb –
– US < 13.5 g
WHO < 12.5 g
– India
Less than 12 g%
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Clinical Signs to be looked for
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Skin / mucosal pallor,
Skin dryness, palmar creases
Bald tongue, Glossitis
Mouth ulcers, Rectal exam
Jaundice, Purpura
Lymph adenopathy
Hepato-splenomegaly
Breathlessness
Tachycardia, CHF
Bleeding, Occult Blood
PCV or Hematocrit
• 57% Plasma
• 1% Buffy coat – WBC
• 42% Hct (PCV)
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The Three Basic Measures
Measurement
Normal
Range
A. RBC count
5 million
4 to 6
B. Hemoglobin
15 g%
12 to 17
C. Hematocrit
45
38 to 50
A x 3 = B x 3 = C - This is the rule of thumb
Check whether this holds good in given results
If not -indicates micro or macrocytosis or hypochro.
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The Three Derived Indicies
Measurement
Normal
Range
A. RBC count
5 million
B. Hemoglobin
15 g%
12 to 17
C. Hematocrit
45
38 to 50
MCV
MCH
MCHC
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C ÷ A x 10
B ÷ A x 10
B ÷ C x 100
4 to 6
=
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90 fl
30 pg
33%
Causes of Anaemia
1. Decreased production of Red Cells
- Hypo proliferative, marrow failure
2. Increased destruction of Red Cells
- Hemolysis (decreased survival of RBC)
3. Loss of Red Cells due to bleeding
- Acute / chronic blood loss (hemorrhagic)
M = P x S ( L)
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Hypoproliferative Anaemias
Nuclear
breakdown
Failure of cell
maturation
Cytoplasmic
breakdown
Folate or B12 deficiency
Haem defect
Globin defect
Defective DNA synthesis
Fe
Sickle cell A
Megaloblastic Anaemia
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Phorph
IDA, SA
Thalassemia
Anaemia – First Test
RETICULOCYTE COUNT %
• ‘RBC to be’ or Apprentice RBC
• Fragments of nuclear material
• RNA strands which stain blue
Normal
Less than 2%
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Reticulocytes
Supravital
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Leishman’s
Reticulocyte Production Index
For example the RPI is calculated as follows
Reticulocyte count
9%
Hb content
7.5 g%
1. Correction for Anaemia
= 9 x (7.5 ÷ 15) = 9 x 0.5 = 4.5 %
2. Correction for increased life span
4.5 ÷ 2 = 2.25 %
3. Thus, the RPI is 2.25
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Anaemia
Hb% < 12, Hct < 38%
Hypoproliferative
Hemolytic
RPI < 2
RPI > 2
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Normal CBC
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Workup – Second Test
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The next step is ‘What is the size of RBC’ ?
MCV indicates the Red cell volume (size)
Both the MCH & MCHC tell Hb content of RBC
If the RPI is 2 or less
We are dealing with either
– Hypoproliferative anaemia (lack of raw material)
– Maturation defect with less production
– Bone marrow suppression (primary/ secondary)
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Red Cell Size
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Mean Cell Volume (MCV)
• RBC volume (rather) is measured by
• The Mean Cell Volume or MCV and RDW
MCV
Microcytic
Normocytic
Macrocytic
< 80 fl
80 -100 fl
> 100 fl
< 6.5 µ
6.5 - 9 µ
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>9µ
Anaemia Workup - MCV
MCV
Microcytic
Normocytic
Macrocytic
Iron Deficiency IDA
Chronic disease
Megaloblastic anemias
Chronic Infections
Early IDA
Liver disease/alcohol
Thalassemias
Hemoglobinopathies
Hemoglobinopathies
Hemoglobinopathies
Primary marrow disorders Metabolic disorders
Sideroblastic Anemia
Combined deficiencies
Marrow disorders
Increased destruction
Increased destruction
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Anaemia Workup – 3rd Test
Red cell Distribution Width – RDW
RDW
< 13
RDW is 13
Mean
MCV90
90 fl
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Red cell Distribution Width - RDW
MCV
Microcytic
Normocytic
Macrocytic
Left
Mean 90
Right
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Anaemia Workup - 4th Test
Peripheral Smear Study
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Are all RBC of the same size ?
Are all RBC of the same normal discoid shape ?
How is the colour (Hb content) saturation ?
Are all the RBC of same colour/ multi coloured ?
Are there any RBC inclusions ?
Are intra RBC there any hemo-parasites ?
Are leucocytes normal in number and D.C ?
Is platelet distribution adequate ?
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IDA -CBC
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Severe Hypochromia
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Microcytic Hypochromic - IDA
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Microcytic Hypochromic Anaemia
Serum Ferritin
< 33 pmol / l
> 270pmol / l
33-270 pmol / l
TIBC
N or ↓
HIGH
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BM Fe
Iron Deficiency Anaemia IDA
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+
Not IDA, Other Mi A
IDA – Special Tests
Iron related tests
Normal
IDA
Serum Ferritin (pmo/L)
33-270
< 33
TIBC (µg/dL)
300-340
> 400
Serum Iron (µg/dL)
50-150
< 30
Saturation %
30-50
< 10
++
Absent
Bone marrow Iron
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IDA Summary
• Microcytic
MCV < 80 fl, RBC < 6 µ
• RDW
Widened and shift to left
• Hypochromic
MCH < 27 pg, MCHC < 30%
• RPI
<2
• Retic. count
May be > 2 %
• Serum ferritin
Very low < 30 (p mols/L)
• TIBC
Increased > 400 (µg/dL)
• Serum Iron
Very low < 30 (µg/dL)
• BM Fe Stain
Absent Fe
• Response to Fe Rx.
Excellent
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IDA- Some Nuggets
• Look for occult blood loss – 2 days non veg. free
• Pica and Pagophagia – Ice sucking
• Absorption of Haem Iron > Fe ++ > Fe+++
• Food, Phytates, Ca, Phosphate, antacids ↓absorption
• Ascorbic acid ↑absorption
• Oral iron Rx. always is the best, ? Carbonyl Fe
• FeSO4 is the best. Reserve parenteral Rx.
• Packed cell transfusion in emergency
• Continue Fe Rx at least 2 months after normal Hb
• 1 gram ↑in Hb every week can be expected
• Always supplement protein for the Globin component
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Microcytic Anaemias
MCV < 80 fl
Serum Iron
TIBC
BM Perls stain
↓↓
↓↓
↑↑
↑↑
↓↓
0
++
N
++++
Hemoglobinopathy
N
N
Lead poisoning
N
N
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↑↑
N
++++
Iron Def. Anemia
Chronic Infection
Thalassemia
Sideroblastic
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Ringed Sideroblasts in BM
Prussian Blue Stain
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Macrocytic Anaemias
A. Megaloblastic Macrocytic – B12 and Folate↓
B. Non Megaloblastic Macrocytic Anaemias
1. Liver disease/alcohol
2. Hemoglobinopathies
3. Metabolic disorders, Hypothyroidism
4. Myelodystrophy, BM infiltration
5. Accelerated Erythropoesis -↑destruction
6. Drugs (cytotoxics, immunosuppressants,
AZT, anticonvulsants)
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Anemia - Macrocytic (MCV > 100)
Premature gray hair – consider MBA
Macrocytic anemias may be asymptomatic until
the Hb is as low as 6 grams
MCV 100-110 fl
must look for other causes of macrocytosis
MCV > 110 fl
almost always folate or B12 deficiency
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Macrocytosis of Alcoholism
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25-96% of alcoholics
MCV elevation usually slight (100-110 fl)
Minimal or no anemia
Macrocytes round (not oval)
Neutrophil hyper segmentation absent
Folate stores normal
Smoking increases the Red Cell Mass
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Megaloblastic Hematopoiesis
Marrow failure due to
• Disrupted DNA synth. & ineffective erythropoesis
• Giant precursors (Megaloblasts)
• Nuclear : Cytoplasmic dyssynchrony in marrow
• Neutrophil hyper segmentation & macro ovalocytes
• Anemia (and often leukopenia & thrombocytopenia)
• Almost always due to B12 or folate deficiency
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MBA
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Macrocytosis -MBA
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Anisocytosis - Macrocytic Anaemia
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HSN - MBA
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HSN - MBA
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Basophilic Stippling - MBA
BS occurs in Lead poisoning also
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Megalocyte in PS
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MBA - BM
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MBA - BM
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Megaloblast – FA deficiency
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Pernicious Anaemia - Tongue
Bald, smooth, lemon
yellowish red tongue
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Normocytic Anaemias
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Chronic disease
Early IDA
Hemoglobinopathies
Primary marrow disorders
Combined deficiencies
Increased destruction
Anaemia of investigations -ICU
Anaemia of Chronic Disease
• Thyroid diseases
• Malignancy
• Collagen Vascular Disease
– Rheumatoid Arthritis
– SLE
– Polymyositis
– Polyarteritis Nodosa
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• IBD
– Ulcerative Colitis
– Crohn’s Disease
• Chronic Infections
– HIV, Osteomyelitis
– Tuberculosis
• Renal Failure
‘Dimorphic’ Anaemia
• Folate & Fe deficiency (pregnancy, alcoholism)
• B12 & Fe deficiency (PA with atrophic gastritis)
• Thalassemia minor & B12 or folate deficiency
• Fe deficiency & hemolysis (prosthetic valve)
• Folate deficiency & hemolysis (Hb SS disease)
• Peripheral smear exam is critical to assess these
• RDW is increased very much
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RBC Size – Anisocytosis
Different sizes of RBC
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Poikilocytosis
Different Shapes of RBC
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Polychromasia - Spherocytosis
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Target Cells
1. Liver Disease
2. Thalassemia
3. Hb D Disease
4. Post splenectomy
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Tear Drop Cells
1. Myelofibosis
2. Infiltration of BM
3. Tumours of BM
4. Thalassemia
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Hair on end - Thalassemia Major
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Drepanocytes - SS
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Sickle Cell Anaemia
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Autosplenectomy - SS
Normal spleen is 8 to 12 cm
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Hemolytic Anaemia
Anemia of increased RBC destruction
– Normochromic, normocytic anemia
– Shortened RBC survival
– Reticulocytosis – due to ↑ RBC destruction
Will not be symptomatic until the RBC life span is
reduced to 20 days – BM compensates 6 times
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Tests Used to Diagnose Hemolysis
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Reticulocyte count
Combined with serial Hb
Serum LDH
Serum bilirubin
Haptoglobin
Urine hemosiderin
Hemoglobinuria
Findings in Hemolytic Anaemia
Reticulocyte count and RPI
Increased
Serum Unconjugated Bilirubin
Increased
Serum LDH 1: LDH 2
Increased
Serum Haptoglobin
Decreased
Urine Hemoglobin
Present
Urine Hemosiderin
Present
Urine Urobilinogen
Increased
Cr 51 labeled RBC life span
Decreased
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Tests to define
the cause of hemolysis
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Hemoglobin electrophoresis
Hemoglobin A2 (βeta-Thalassemia trait)
RBC enzymes (G6PD, PK, etc)
Direct & indirect antiglobulin tests (immune)
Cold agglutinins
Osmotic fragility (spherocytosis)
Acid hemolysis test (PNH)
Clotting profile (DIC)
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MAHA
Micro Angiopathic Hemolytic Anaemia
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MAHA
Micro Angiopathic Hemolytic Anaemia
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Hyperactive BM – Skull
Hemolytic Anaemia
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Spherocytosis
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Spherocytosis
Hereditary Spherocytosis
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Spherocytosis
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Elliptocytes
Hereditary Elliptocytosis, B12 or Folate↓
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Stomatocytes
Slit like central pallor in RBC
1. Liver Disease
2. Acute Alcoholism
3. H Stomatocyosis
4. Malignancies
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Echinocytes
Evenly distributed spicules > 10
1. Uremia
2. Peptic ulcer
3. Gastric Ca
4. PK-D
Called Burr Cells
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Acanthocytes
5-8 spikes of varying length, irregular intervals
Called Spur Cells, Occur in A H A
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Shistocytes
Fragmented, Helmet or triangle shaped RBC
1. MAHA
2. Prosthetic valves
3. Uremia
4. Malignant HT
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Leukoplakia - Aplastic Anaemia
1. Chloramphenicol
2. Neomercazole
3. Sulfonamides
4. Analgin
5. Phenytoin
6. Butazolidin group
7. Anti Ca drugs
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Normal BM High Power
E:G=1:3
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Shift in E : G Ratio
E:G=2:1
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BM - Aplastic Anaemia
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Myelofibrosis
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Post transfusion - CBC
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Howell-Jolly Bodies
Absence of Splenic function; Nuclear chromatin in RBC
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Pelger-Huet Anomaly
• Inherited condition
• PMN - Spectacles
• Heterozygous
• Homozygous fatal
• Neutrophil Bands ↑
• Normal WCC
• No e/o infection
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Anaemia Diagnosis -Algorithm
Anaemia Suspected
Thorough Clin, Bleed
Hb%, RCC, Hct Decreased
Ca, Leukemia, Ulcer
Identify the cause
Microcytic hypochromic
RPI, Retic count <2
RPI, Retic count >2
MCV, MCH, MCHC, PSE
Hemolytic Anaemia
Macrocytic hypo/normo
Coombs DAT, IDAT
Iron Def. Anaemia
Megaloblastic
Normoblastic
Hb electrophoresis
Ferritin, TIBC, BM Fe
Folate defici.
ALD, CLD, Drug
Osmotic fragility
Thalassemia, Hb pathy
B12 def., PA
Chr. Renal dis.
Acid hemolysis
Sederoblastic Anaem.
Hypothyroid
Cold agglutinins
Chr. Infection, Lead
BM infiltration
Coagulopathy, DIC
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Anaemia - Summary
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If Hb% is low – Do not start on Iron straight away
Ask for RCC, Hematocrit – Derive MCV, MCH, MCHC
Order for Reticulocyte count – Is RPI < 2 % or > 2%
Thoroughly look for blood loss – acute / chronic / occult
Is it hypo-proliferative or hemolytic or hemorrhagic anaemia
If hypo proliferative – Microcytic or Macrocytic? (MCV, RDW)
If microcytic – IDA or others – Spl. Iron tests, BM Iron
If macrocytic – Megaloblastic (B12, FA) or Normoblastic BM
If normocytic – Anaemia of chr. Disease – Liver, MRD, Ca
Peripheral smear study for RBC size, shape, colouration etc.
If retic. count is ↑- HA work up; Hb EP, spl. tests
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Thank You ALL
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