Anemia
• WHO definition: a hemoglobin level <130g/L (13g/dL) in men and <120g/L (12g/dL) in women
• Reduction in below normal in the concentration of hemoglobin or RBC’s in the blood
Clinical Presentation: Acute anemia due to blood loss
• Acute blood loss – hypovolemia, hematocrit and hemoglobin level do not reflect volume loss, compensation due to Bohr effect
• Blood loss of 10-15% of total blood volume – signs of vascular instability
• Blood loss of >30% - remains supine, postural hypotension and tachycardia
• Blood loss >40% (>2L in average sized adult) – hypovolemic shock (confusion, dyspnea, diaphoresis, hypotension and tachycardia)
Clinical Presentation: Anemia due to Hemolysis
• Signs and symptoms dpend on the mechanism that led to the red cell destruction
• Intravascular hemolysis w/ release of free hemoglobin – associated with acute back pain, free hemoglobin in the plasma and urine, and renal failure
Clinical Presentation: Moderate anemia
• Fatigue, loss of stamina, breathlessness and tachycardia (with physical exertion)
Clinical Presentation: Chronic or Progressive anemia
• Depends on the age of the patient and the adequacy of blood supply to critical organs
Disorders commonly associated with anemia
• Chronic inflammatory states
• Lymphoproliferative disorders
3 Functional Categories
• Disorders of Proliferation
• Disorders in Erythrocyte Maturation
• Disorders due Primarily to Erythrocyte Destruction or Red Cell Loss
Approach to the Patient
• Do a careful and thorough history and physical examination
• Determine the Subjective and Objective data pertinent to anemia
Subjective Data
• Severity of the anemia
• Rapidity of onset
• Patient’s age and CV status
• Associated manifestations of the underlying disorder- Endocrine disorder- Renal disorder- Hepatic disorder
• Onset & Duration of symptoms insiduous or acute
• Previous prescription for hematinics & response• Medication history• Occupation, household customs & hobbies• Symptoms of hemolysis- jaundice, changes in
urine color• Symptoms of blood loss - melena,
hematochezia, epigastirc pain
• Geographic backgrounds and ethnic origin
• Obstetric & Gynecologic history – # of pads/day– duration– # of pregnancies, abortions - interval
• Concomitant bleeding manifestations
• Dietary history
• Fever, Weight loss
Objective Data
• Cardiac Signs– Hemic murmurs - mid or holosystolic often in
the pulmonic or apical area, due to increased blood flow and turbulence
– Gallop rhythms– Tachycardia/Cardiomegaly– Strong peripheral pulses with wide pulse
pressure
• Integumentary Manifestation– Pallor: <8 to 10 mg/dL hemoglobin– Affected by:
• state of vasoconstriction/vasodilatation• degree & nature of pigmentation• nature & fluid content of the subcutaneous tissues
– Most constantly detected in:• mucous membranes of the mouth, pharynx, conjunctivae,
lips• Nailbeds• Palamar creases
• Neuromuscular Sign– Headache– Vertigo– Tinnitus– Faintness– Retinal hemorrhage– Paresthesias– Scotomas– Lack of mental concentration– Drowsiness– Restlessness
• GI Manifestations– Glossitis– Atrophy of the papillae of the tongue– Dysphagia– Oral ulcers– Gingival hyperplasia– Hepatosplenomegaly
• Sternal Tenderness– lymphadenopathy
• Genitourinary Sign– Slight proteinuria– Changes in urine color
• Laboratory Evaluation – Complete Blood Count:– Red cell count- hgb, hct, reticulocyte count– RBC indices – MCV, MCH, MCHC, RDW– White Blood cell count- cell differential, nuclear
segmentation of neutrophils– Platelet count– Peripheral smear morphology – cell size, hemoglobin
content, anisocytosis, poikilocytosis, polychromasia– Iron Supply Studies – serum iron, total iron-binding
capacity, serum ferritin– Bone marrow examination – Aspirate: M/E ratio, Cell
Morphology, iron stain; Biopsy: cellularity, morphology
• Physiologic factors affecting CBC– Age– Sex– Pregnancy– Smoking– Altitude
Red Blood Cell IndicesIndex Normal Value
• Mean Cell Volume(MCV):(hematocrit x 10)/(red cell ct. x 106) 90 + 8 fL
• Mean Cell Hemoglobin (MCH):(hemoglobin x 10)/ (red cell ct. x 106) 30 + 3 pg
• Mean Cell Hemoglobin Concentration:(hemoglobin x 10)/ hematocrit, 33 + 2% or MCH/MCV
• MCV – reflects microcytosis and macrocytosis
• MCH and MCHC – reflectsdefects in hemoglobin synthesis
Changes in Normal Hemoglobin/Hematocrit Values with Age and Pregnancy
Age/Sex Hemoglobin g/dl Hematocrit %– At birth 17 52
– Childhood 12 36
– Adolescence 13 40
– Adult man 16(+2) 47(+6)
– Adult woman 13(+2) 40(+6)
– (menstruating)
– Adult woman 14(+2) 42(+6)
– (postmenopausal)
– During pregnancy 12(+2) 37(+6)
Peripheral Blood Smear
• Provides important information about defects in red cell production
• It reveals:– Anisocytosis – variations in cell size; correlates w/
increases in RDW or range of cell sizes– Poikilocytosis – variations in cell shape; suggests a
defect in maturation of red cell precursors in the bone marrow or fragmentation of circulating red cells
– Polychromasia – rbc that are slightly larger than normal and grayish-blue in color on the right-Giemsa stain
Normal Peripheral Smear
Microcytic Hypochromic RBC’s with anisocystosis and poikilocytosis
Macrocytosis
Howell-Jolly Bodies
Tear-drop shape cell and Nucleated RBC
Target Cell
RBC Fragmentation
Burr cell or Echinocytes
Spur Cell