ANEMIA
(metabolic dysfunction and nutritional deficiencies)
(also see blood loss)
Etiology:
1.
2.
3.
hypochromic microcytic anemias:
a. iron deficiency anemia (chronic post-hemorrhage anemia)
1. most common type of anemia
2. hemorrhage must be ruled out in any adult presenting with iron deficiency anemia
3. can also cause anemia in pregnant women along with prolonged heavy menses
4. in men, slow GI absorption of iron is the primary cause
5. stages of iron deficiency anemia
1. iron depletion from body stores
2. decreased plasma iron levels with increase transferrin levels
3. anemia with RBCs and indices which appear normal
4. microcytosis, then hypochromia
5. signs and symptoms of anemia
b. atransferrinemic anemia (iron transport deficiency)
c. sideroblastic anemia (iron utilization anemia)
d. anemia of chronic disease (iron reutilization anemia)
normachromic normacytic anemias:
a. hypoproliferative anemia
b. anemia of renal disease
c. anemia of endocrine failure (myxedema and hypopituitarism)
d. anemia of protein depletion
e. hypoplastic (aplastic) anemia
f.
myelophthisic anemia
g. blood loss
1. sudden blood loss of a 1/3 of the blood volume can be fatal, as much as 2/3 of the blood may
be slowly lost over 24 hours with out death occurring
2. symptoms follow a sudden decrease in the blood volume due to compensatory hemodilution, as
well as a diminished oxygen-carrying capacity of the blood
macrocytic anemia:
a. anemia due to B12 deficiency (pernicious anemia)
1. absorption of vitamin B12 occurs in the terminal ileum and requires the presence of gastric HCl
and intrinsic factor
2. B12 is stored in the liver in sufficient quantities to sustain an individual for 3-5 years on a
B12-deficient diet
3. it typically develops insidiously as the liver stores are diminished
4. vegans: greater risk for B12 deficiency since most significant sources of B12 are in animal
products
b. anemia due to folic acid deficiency
1. most folic acid anemia is due to poor dietary intake
2. liver stores are good for only 2-4 months of a deficient intake
3. absorption of folic acid is decreased by alcohol, intestinal absorption diseases, oral
contraceptives and anticonvulsants
c. anemia due to copper deficiency
1. most often seen in infants and children
2. in adults may be associated with sprue, nephrotic syndrome, Wilson’s disease and kwashiorkor
d. anemia due to vitamin C deficiency
1. often associated with anemia
2. normally hypochromic but may be normocytic, microcytic or macrocytic
3. when macrocytic: further investigation may reveal concurrent
Signs and Symptoms:
1. anemia is a clinical sign or symptom itself
2. anemia is used as a diagnostic term requiring an understanding of its mechanism
3. anemia’s clinical expression is tissue hypoxia and its specific signs represent compensatory responses
4. severe anemia can produce:
a. weakness
b. vertigo
c. headache
d. tinnitus
e. spots before the eyes
f.
drowsiness
g. irritability
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ANEMIA
5.
6.
(metabolic dysfunction and nutritional deficiencies)
(also see blood loss)
less often:
a. amenorrhea
b. loss of libido
c. GI complaints
d. jaundice
e. splenomegaly
finally:
a. CHF
b. Shock
Blood Loss:
1.
faintness, dizziness, thirst, cold sweat, tachycardia, tachypnea and shortness of breath with exertion,
orthostatic hypotension, shock and death if the blood loss is severe and untreated
Iron Deficiency Anemia:
1. as reported above in blood loss, pica (craving dirt or paint) or pagophagia (craving ice), Plummer-Vinson
syndrome with dysphagia
2. late stages: glossitis, cheilosis, koilonychia
Vitamin B12 Deficiency Anemia:
1. splenomegaly and hepatomegaly; anorexia; occasional constipation and diarrhea; vague abdominal pain;
glossitis (burning of tongue); neurological involvement (even if there is no clear anemia), esp. peripheral
nerves although spinal cord conditions are also seen
Folic Acid Deficiency Anemia:
1. includes those found in vitamin B12 deficiency anemia but no neurological symptoms as in B12 deficiency
anemia
Vitamin C Deficiency Anemia:
1. scurvy (bleeding gums, easy bruising, frequent illness, nosebleeds, slow healing); anemia
Lab Findings:
1. lab work is essential for determining extent and cause of the anemia
2. requires:
a. CBC (with RBC indices, reticulocyte count, platelet count and cellular morphology)
b. see nutritional deficiency/blood loss for specific lab results
Blood loss:
1. early: RBC count, hemoglobin, hematocrit are deceptively high (due to the compensation vasoconstriction)
2. after some hours: decreased RBCs and hemoglobin in proportion to the severity of the anemia
3. anemia is normachromic normacytic
Iron Deficiency Anemia (dependent on the degree of iron deficiency):
1. increased serum transferrin and TIBC
2. decreased serum ferritin, serum iron, hemoglobin (6-12 mg/dl), RBC (3.5-5.0 million/cu.mm), MCV, MCHC
and MCH
3. anemia is hypochromic microcytic
Vitamin B12 Deficiency Anemia:
1. basophilic stippling of RBCs
2. anisocytosis, poikilocytosis
3. hypersegementation of granular leukocytes
4. (+) Schilling test with pernicious anemia only (not with dietary deficiency)
5. macrocytic anemia
6. MCV > 100
Folic Acid Deficiency Anemia:
1. (+) folate depletion (otherwise the peripheral blood and bone marrow findings are identical to B12
anemia)
2. decreased serum folic acid levels (< 5ng/ml) and erythrocyte folate levels
Copper Deficiency Anemia:
1. megaloblastic anemia with significant vascularization in the cytoplasm of developing RBCs
Vitamin C Deficiency Anemia:
1. decreased plasma levels of ascorbic acid (can be down to 0 in overt scurvy),serum alkaline phosphatase
and ascorbic acid in buffy coat
2. (+) Rumpel-Leede test
3. (+) microscopic hematuria
4. (+) associated lab findings (i.e. FA deficiency)
Course/Prognosis:
1. depends on the etiology
2
ANEMIA
(metabolic dysfunction and nutritional deficiencies)
(also see blood loss)
Conventional treatment:
1. Blood Loss: stop the bleed, plasma or blood transfusion, chemical agents capable of transporting oxygen,
rest, fluids and iron replacement
2. Iron Deficiency Anemia: a slow bleed must be ruled out, treatment in uncomplicated iron deficiency is iron
replacement therapy for at least 6 months
3. Vitamin B12 Deficiency Anemia: B12 (1000 ug IM 2-4/week) until the indices are normalized then monthly
4. Folic Acid Deficiency Anemia: folic acid (1 mg/day orally)
5. Copper Deficiency Anemia: copper sulfate replacement therapy completely reverses the anemia
6. Vitamin C Deficiency Anemia: vitamin C (500 mg/day orally), if there is macrocytemia, then replace folic
acid also as above
Differential Diagnosis:
1. since anemia is a symptom than a specific disease, it is important to probe the cause
a. initial direction may be obtained from thorough history and pertinent physical examination, along with the
morphologic evidence gathered from blood work
b. determine whether the anemia is from blood loss, decreased production or increased destruction
c. differential is systematic and widely described in standard reference texts
Nutrition:
1.
2.
3.
Avoid:
1.
2.
3.
increase foods high in vitamin C and E, selenium and zinc and yams, cold water fish (salmon, mackeral, herring and
sardines), beets, green vegetables, bee pollen, apricots, blackberries, apples, currants, egg, kelp, lettuce, prunes,
green beans, spinach, tahini, lentils, peach, molasses, mustard greens, mulberries, parsley, liver, watercress, iron
rich foods (red meat)
Sickle cell anemia: high protein diet
Take 250 gm soybean sprouts, 15 gm Chinese dates and 250 gm pork bones, add water and simmer for several
hours, add salt to taste, eat tid
oils, butter, coffee, black tea and caffeine
avoid eating iron rich foods with dairy or with caffeine containing foods (decreases absorption)
EDTA additives
Supplements:
1. Sickle Cell Anemia:
a. vitamin C (3-4 gm qd)
b. vitamin E (400 IU qd)
c. selenium (200 mcg qd)
d. zinc (50 mg qd)
e. bioflavinoids (6 gm qd)
2. Iron Deficiency Anemia:
a. ferrous sulfate (100 mg qd, may use in drop form)
b. vitamin C (1000 mg qd, take with liver extract)
c. Cobaltum metallicum 3x (3 bid)
3. B12/Folate Deficiency Anemia:
a. folate (1-5 mg qd)
b. vitamin B12 (1000 mcg IM qd, for 1 week)
4. Copper or B6 Deficiency Anemia:
a. vitamin B6 (100 mg tid)
b. copper (5 mg qd)
Hydrotherapy:
1. wet sheet pack: stage 1
2. alternating warm and cool showers
3. constitutional hydrotherapy
4. cold applications (graduated)
5. cold mitten friction
Physiotherapy:
1. spondylotherapy: sinusoidal stimulation alternately to T10 then L2, followed by concussion to T3,4 and 5
2. galvanism: (-) pad to liver, inactive pad to back, 10-20 mA for 10 min
3. massage
4. for pernicious anemia (see gastroenteritis)
5. diathermy: to long bones, femur, over liver and spleen
Botanicals:
1.
Ceanothus americanus: hemolytic anemia; treats spleen
3
ANEMIA
2.
3.
4.
5.
6.
7.
(metabolic dysfunction and nutritional deficiencies)
(also see blood loss)
Chamaelirium luteum (Helonias): pernicious anemia
Cinchona spp. (toxic): patient is weak, pale; when a tonic effect is indicated after exhaustive bleeding
Cratagus Oxyacantha: marked anemia associated with heart irregularity
Gentiana lutea: increases ability to assimilate food
Hydrastis canadensis: pernicious anemia
Leonutus cardiaca (heart remedy): anemic nervousness and insomnia; with Senecio aureus (toxic) or Mitchella
repens
8. Medicage sativa: nutritive
9. Rumex crispus: as a bitter, the root theorized to aid the absorption of iron; of iron salts
10. Strophanthus hispidus: chronic persistent anemia, anemia with feeble imperfect heart action
11. Strychnos nux vomica (toxic): atony of the GI tract
12. Urtica urens: pernicious anemia
Formulas:
1.
pernicious anemia: Artemisia absinthium, Gentian lutea, equal parts, two “00” capsules before each meal
to increase HCl
Homeopathy:
1. Arsenicum album: excessive prostration, considerable edema; violent and irregular palpitation; rapid emaciation,
irritable stomach
2. Calcarea carbonica: since childhood, esp. girls, disposed to obesity, catarrh and diarrhea with great weakness;
swelling of abdomen, vertigo and palpitation on ascending (stairs)
3. Cinchona: loss of fluids, sight; fainting and ringing in ears; sour belching
4. Ferrum metallicum: appearance of bloatedness followed by paleness of face and puffiness of extremities; easily
exhausted, vomiting after meal
5. Helonias: prolonged hemorrhage in women; too tired to sleep; strained muscles burn and ache, > if attention is
engaged
6. Kali carbonicum: weak heart; sweats; backache esp. with female complaints
7. Natrum muriaticum: patient eats well yet remains emaciated and pale; throbbing headache, dyspnea, esp. going
upstairs; much palpitation; fluttering and intermittent action of heart
8. Picric acid: extreme prostration with heavy, tired feeling all over body; burning pains along spine,
<
excitement
9. Phosphorus: puffy eyes
10. Pulsatilla: similar to Ferrum metallicum, for antidoting previous dose of iron; patient chilly
11. Secale cornutum: progressive anemia with pale, bloodless, jaundice color
12. Valerian: hysteria and extreme nervousness
4