Dr.T.M.J.K.Tennakoon
Red cell indicies
 RBC number
 Hb%
 PCV- Red cell Mass
 MCV-Volume of a red cell
 MCH-Amount of haemoglobin in a red cell
 MCHC-Amount of haemoglobin in unit of red
cell mass
 RDW-Indicates the different sizes of red cells
Total WBC count
Neutrophils
Lymphocytes
Eosinophils
Monocytes
Basophils



Platelet count
MPV
PDW
Definition : Low haemoglobin level compare
to the age and sex of the normal population.
In Sri Lanka
Adult Male – 12g%
Adult Female- 11g%
Children – 11g%
2nd and 3rd trimesters of the pregnancy10.5g%
Depends on the red cell size (MCV)
Low MCVHypochromic microcytic anaemia.
Normal MCVNormocytic Normochromic Anaemia.
High MCVMacrocytic Anaemia.




Iron deficiency Anaemia
Thalassemia Trait
Sideroblastic Anaemia (Including Lead
poisoning)
Long standing Anaemia of Chronic disorder




Acute blood loss / Haemolysis
Anaemia of chronic disorder
Chronic Renal Failure
Endocrine Disorders








Vit.B12 /Folate Deficiency
Alcohol Excess
Liver Disease
Retculocytosis with blood loss or Haemolysis
Cytoreductive treatment
MDS /Aplastic Anaemia
Hypothyroidism
Anti Folate treatment
RBC
MCV
MCH
MCHC
RDW
IDA
Thal Trait
or
In real life, both co-exisists
Place for blood picture and iron studies
 S.ferritin level
 S.Iron
 TIBC
 Iron saturation%
 For confirmation of thalasemia- HPLC


ML is a 64-year old male who has not had
any primary care for several years. When he
tried to donate blood last week, he was told
that he was anemic. He presents to your
clinic for evaluation.
What would you do??

HISTORY
◦ Is the patient bleeding?
 Actively? In past?
◦
◦
◦
◦
Is there evidence for increased RBC destruction?
Is the bone marrow suppressed?
Is the patient nutritionally deficient? Pica?
PMH including medication review, toxin exposure
REVIW OF SYMPTOMS
 Decreased oxygen delivery to tissues
◦
◦
◦
◦
Exertional dyspnea
Dyspnea at rest
Fatigue
Signs and symptoms of hyperdynamic state
 Bounding pulses
 Palpitations
◦ Life threatening: heart failure, angina, myocardial
infarction

Hypovolemia
◦ Fatiguablitiy, postural dizziness, lethargy,
hypotension, shock and death
PHYSICAL EXAM
•Stable or Unstable?
-ABCs
-Vitals
•Pallor
•Jaundice
-hemolysis
•Lymphadenopathy
•Hepatosplenomegally
•Bone Pain
•Petechiae
•Rectal-? Occult blood

Initial Testing
◦ FBC (includes RBC indices)
◦ Reticulocyte count
◦ Peripheral blood smear



Iron Studies
◦ Ferritin
◦ TIBC
◦ % Saturation
Urinalysis
Upper and lower GI endoscopy referral

Blood loss?
◦ Age places him at risk for colon CA

Decreased Production?
◦ Alcohol use, Iron deficiency

Increased Destruction?
◦ “Darker urine” lately





FBC, Hb-9.5g%,MCV-72fl, MCH-25pg
WBC-8200/ml , Plt- 221000/ml
Smear reveals microcytic, hypocrochromic
RBCs
Retic count is normal
Urinalysis -normal
Iron Studies
◦ Ferritin: 10
◦ TIBC: 350
◦ % Sat: 15



Rule out Sources of Bleeding
◦ FOB
◦ Upper and lower GI endoscopies
Consider oral iron therapy
Dietary counseling (iron sources, limiting
alcohole, etc)



Colonoscopy revealed small suspicious
lesion in sigmoid colon.
Histo- adenocarcinoma.
Excised surgically, no mets.


Routine FBC, one year later, reveal Hb of
12g%.
He feels “better than ever”!




Anemia is a sign, not a disease.
Anemias are a dynamic process.
Its never normal to be anemic.
The diagnosis of iron deficiency anemia
mandates further work-up.

A 21-year-old married woman was referred for
evaluation of anemia.

History- recently married and wants to have a family.

Feels lethargic. No history of melena or bleeding PR.

Menstrual history- normal.

Family history - anaemia

O/E – pale. No icterus. CVS and RS are normal.
Spleen-palpable . No edema.


FBC: WBC= 4600, platelets 421,000/ul,
Hb- 8.1g%, RBC- 5.2M/ul, MCV 59, (MCH) 17,
MCHC- 32.
Retic 3.1%,
Ferritin 482 ng/ml, serum iron 149, transferrin 193,
Iron sat 77%.

Ix:
◦ Smear: microcytic/hypochromic, misshapen RBCs



HPLC- elevated HbA2.
Dx- Thalassemia trait
Tx:
◦ Mild: None
◦ Severe: RBC transfusions + Fe chelation, Stem cell
transplants

Genetic defect in hemoglobin synthesis
◦  synthesis of one of the 2 globin chains ( or )
◦ Imbalance of globin chain synthesis leads to
depression of hemoglobin production and
precipitation of excess globin (toxic)
◦ “Ineffective erythropoiesis”
◦ Ranges in severity from asymptomatic to incompatible
with life (hydrops fetalis)




Heterogenous group of anemias
Defined by presence of ringed sideroblasts in the BM
Etiologies:
◦ Hereditary (rare),
◦ Some types of porphyria
◦ Myelodysplasia
◦ Ethanol
◦ Drugs (INH, Chloramphenicol)
Tx:
◦ Trial of pyridoxine for hereditary or INH induced SA



55 yr, Female with moderately severe Rheumatoid
Arthritis on Prednisolone , Celecoxib and MTX with
FA, is referred to you for evaluation of anemia.
FBC: Hb = 9g%, MCV = 82,
WBC = 5400/l, plt = 345 000/ l
Smear – Normochromic normocytic anaemia
Retic count = 2 %
Ferritin = 330 g/dL (20-160)




A-- Marrow Failure
B-- Iron Deficiency
C-- Thalassemia
D– Anaemia of chronic disorder.
Lab measure
ACD
Iron-def. anemia
Plasma Fe
Reduced (normal)
Reduced
Plasma transferrin
Reduced (normal)
Increased
Transferrin sat.
Reduced (normal)
Reduced
Plasma ferritin
Increased (normal)*
Reduced
Plasma TfR
Normal
Increased
TfR/log ferritin
Low (<1)
High (>4)
 Utility
of supraphysiologic doses
of erythropoietin in the setting of
Anaemia of chronic disorder.







•
•
•
•
•
A 69 yr old woman with progressive anemia with
macrocytosis.
FBC- leukopenia and thrombocytopenia.
BP- hypersegmented granulocytes.
Neurologic examination – normal
Serum folate - normal.
Erythrocyte folate level - below the normal range.
Which statement is true?
The patient has folic acid deficiency
The serum follate is normal because the patient has
taken a green salad in the past 24 hrs
These findings are not specific to folate def. and a
B12 level should be checked
A bone marrow test would be helpful
A serum epo level should be checked

Etiology:
◦ Anemia-- Vitamin B12 and folate are needed for
DNA synthesis deoxyuridate to thymidylate ,
including RBC precursors
◦ Causes for B12 deficiency  Dietary intake, acid-pepsin in the stomach, pancreatic
proteases, gastric secretion of intrinsic factor, an ileum with
Cbl-IF receptors
Causes for Foliate deficiency  Poor dietary intake  alcohol, malabsorption, increased
demand (pregnancy, hemolytic anemias),

Ix:
◦ Smear: Macrocytic (High MCV) RBCs, +/- hypersegmented
neutrophils, +/- modest neutropenia, but…
◦ B12
 Low serum B12, elevated serum methylmalonic acid levels
 Anti-IF Abs, Schilling test (?), PA accounts for 75%
◦ Folate
 Serum folate level-- can normalize with a single good meal

Tx:
◦ B12 deficiency: B12 1 mg IM. EOD for 6 doses
and repeat monthly.
◦ Folate deficiency: Improved diet, folate 1 mg/day
◦ Monitor the response.
◦ Pernicious Anemia – monitor for GI cancers.






A 32-year-old woman with Crohn’s disease for
15 years. A recent flare beginning 2 weeks ago
was treated with sulfasalazine and
corticosteroids. Despite improvement in diarrhea
and abdominal pain, she continues to feel ill and
experiences easy fatigability with dyspnea and
palpitations on mild exertion.
On physical examination, pallor, trace scleral
icterus, and active bowel sounds are noted.
Laboratory studies show:
Hb =8g%;
WBC= 14,000/ul. (90% neutrophils with left
shift )
reticulocyte count= 7%;
platelets =Normal







Hemolytic anemias are either acquired or congenital. The
laboratory signs of hemolytic anemias include:
1. Increased LDH (LDH1) - sensitive but not specific.
2. Increased indirect bilirubin - sensitive but not
specific*.
3. Increased reticulocyte count - specific but not
sensitive
4. Decreased haptoglobin - specific but not sensitive.
5. Urine hemosiderin - specific but not sensitive.
*The indirect bilirubin is proportional to the hematocrit,
so with a hematocrit of 45% the upper limit of normal is
1.00 mg/dl and with a hematocrit of 22.5% the upper
limit of normal for the indirect bilirubin is 0.5mg/dl. Since
tests for hemolysis suffer from a lack of sensitivity and
specificity, one needs a high index of suspicion for this
type of anemia
 Thank
you