Senior Academic Half Day Senior Academic Half Day

Dr S W BokhariDr S W Bokhari

Consultant HaematologistConsultant Haematologist

UHCWUHCW

Topics to coverTopics to cover

Low blood counts Low blood counts

- Anaemia due to haematinic deficiency- Anaemia due to haematinic deficiency

- Some other causes of anaemia- Some other causes of anaemia

- Thrombocytopenia- Thrombocytopenia

AnaemiasAnaemias

MCVMCV B12/folate defB12/folate def Haemolytic anaemia with reticulocytosisHaemolytic anaemia with reticulocytosis Liver diseaseLiver disease HypothyroidismHypothyroidism AlcoholAlcohol MyelodysplasiaMyelodysplasia DrugsDrugs

MCV MCV Iron deficiencyIron deficiency ThalassemiasThalassemias

Normal MCVNormal MCV Anaemia of chronic diseaseAnaemia of chronic disease Aplastic anaemiaAplastic anaemia

Anaemias due to haematinic Anaemias due to haematinic deficiencydeficiency

AimAim

Outline practical overview of B12, folate Outline practical overview of B12, folate and Iron deficiencyand Iron deficiency

Megaloblastic anaemiaMegaloblastic anaemia

Group of disorders characterised by Group of disorders characterised by presence of distinctive morphological presence of distinctive morphological appearances of red cells in the marrowappearances of red cells in the marrow

CausesCauses-B12 deficiency-B12 deficiency-Folate deficiency-Folate deficiency-Abnormal metabolism of these vitamins-Abnormal metabolism of these vitamins-Faults in DNA synthesis not related to B12 -Faults in DNA synthesis not related to B12

and folateand folate

Vitamin B12 deficiency-CausesVitamin B12 deficiency-Causes

Nutritional Nutritional (vegans)(vegans)MalabsorptionMalabsorption

- Gastric causes 1.pernicious anaemiaGastric causes 1.pernicious anaemia 2.Total or partial 2.Total or partial

gastrectomy gastrectomy- Intestinal causesIntestinal causes 1. Intestinal stagnant loop syndrome (jej diverticulosis, 1. Intestinal stagnant loop syndrome (jej diverticulosis,

ileocolic fistula, anatomical blind loop, intestinal ileocolic fistula, anatomical blind loop, intestinal stricture)stricture)

2. Ileal resection and chron’s disease2. Ileal resection and chron’s disease 3. Tropical sprue3. Tropical sprue 4. TCII deficiency4. TCII deficiency 5. Fish tapeworm (Diphyllobothrium latum)5. Fish tapeworm (Diphyllobothrium latum)

Vitamin B12Vitamin B12

2 main natural forms (Deoxyadenosyl 2 main natural forms (Deoxyadenosyl cobalamin, Methyl cobalamin)cobalamin, Methyl cobalamin)

2 main pharmaceutical forms 2 main pharmaceutical forms (Cyanocobalamin, Hydroxycobalamin)(Cyanocobalamin, Hydroxycobalamin)

Dietry source: animal products onlyDietry source: animal products only

Body stores: 2-3 mgBody stores: 2-3 mg

50% in liver50% in liver

Sufficient for 2-4 yearsSufficient for 2-4 years

BiochemistryBiochemistry

Homocysteine MethionineHomocysteine Methionine

(Methyl B12)(Methyl B12) DNA DNA

Methyl THF THF Methyl THF THF

dTMPdTMP

CYTOSOLCYTOSOL dUMP dUMP

AbsorptionAbsorption

B12 in average diet 5 -7 ug/dayB12 in average diet 5 -7 ug/dayDoses >1 mg: 1% absorbed passivelyDoses >1 mg: 1% absorbed passivelyR-binder: high level in saliva/gastric juiceR-binder: high level in saliva/gastric juice

ph2 – R:IF ~ 50:1ph2 – R:IF ~ 50:1 ph8 – R:IF ~ 3:1ph8 – R:IF ~ 3:1

IF: when present >70% B12 absorbedIF: when present >70% B12 absorbed if absent <1%if absent <1%

Enterohepatic circulation: 5-10 ug/day B12 analogues Enterohepatic circulation: 5-10 ug/day B12 analogues bind to R binderbind to R binderAbsorption in terminal ileum. Absorption in terminal ileum. Transportation: 75% TCITransportation: 75% TCI

10-20 % TCII10-20 % TCII

Mrs KCMrs KC

55 years55 years

Shortness of breath, sore mouth, tingling and Shortness of breath, sore mouth, tingling and numbness in hands and feetnumbness in hands and feet

Good diet, no GI symptoms, No drugs.Good diet, no GI symptoms, No drugs.

Hb: 4.1 Platelets:85 WCC: 3.1Hb: 4.1 Platelets:85 WCC: 3.1

MCV: 109MCV: 109

LFT: normal; Reticulocytes: 20 LDH: 1100LFT: normal; Reticulocytes: 20 LDH: 1100

Blood film:----------------------------------Blood film:----------------------------------

Blood Film----diagnosis?Blood Film----diagnosis?

Diagnosis?Diagnosis?

B12 level: 105B12 level: 105

IF antibodies: positiveIF antibodies: positive

Pernicious AnaemiaPernicious Anaemia

Severe lack of IF due to gastric atrophySevere lack of IF due to gastric atrophy

Incidence 25/100,000/year aged over 40yearsIncidence 25/100,000/year aged over 40years

10 female: 7 male10 female: 7 male

20% have positive family history20% have positive family history

Association with autoimmune disease (30% with Association with autoimmune disease (30% with Crohn’s disease)Crohn’s disease)

90% parietal cell antibody positive (~20% in 90% parietal cell antibody positive (~20% in normal population)normal population)

60% IF antibody positive60% IF antibody positive

Clinical featuresClinical features

Symptoms:Symptoms: Malaise, SOB, Paraesthesia, sore mouth, weight loss, Malaise, SOB, Paraesthesia, sore mouth, weight loss,

alopecia/grey hair, irritability, poor memory, depression, alopecia/grey hair, irritability, poor memory, depression, personality change, hallucinations, impotence, postural personality change, hallucinations, impotence, postural hypotensionhypotension

Signs: Signs: Smooth tongue, angular chellosis, vitiligo, PUO, LVF, Smooth tongue, angular chellosis, vitiligo, PUO, LVF,

sensory disturbance, subacute combined degenration, sensory disturbance, subacute combined degenration, optic atrophy, altered colour visionoptic atrophy, altered colour vision

Laboratory AbnormalitiesLaboratory Abnormalities

Upto 40% not anaemicUpto 40% not anaemic

Upto 30% not macrocytic (masked by Upto 30% not macrocytic (masked by IDA/thalassaemia)IDA/thalassaemia)

PancytopeniaPancytopenia

Neutrophil hypersegmentationNeutrophil hypersegmentation

HyposplenismHyposplenism

Howell Jolly bodiesHowell Jolly bodies

Laboratory Abnormalities - Laboratory Abnormalities - ChemistryChemistry

Increased serum IronIncreased serum Iron

Increased Iron storesIncreased Iron stores

Increased bilirubin and LDHIncreased bilirubin and LDH

Decreased immunoglobulinsDecreased immunoglobulins

Decreased cholesterolDecreased cholesterol

Presentation and ManagementPresentation and Management

Optic atrophy Urgent referralOptic atrophy Urgent referral

Subacute comb.deg.Subacute comb.deg.

Pancytopenia Check B12Pancytopenia Check B12

Treat blind with B12 & folate Treat blind with B12 & folate

Cont…Cont…

When to screenWhen to screen::

Unexplained macrocytic anaemiaUnexplained macrocytic anaemia

Unexplained normocytic anaemia (elderly, Unexplained normocytic anaemia (elderly, GI disease, autoimmune disease, family GI disease, autoimmune disease, family h/o of PA)h/o of PA)

Dimentia anaemic or Dimentia anaemic or

Unexplained psychiatric illness notUnexplained psychiatric illness not

Cont…Cont…

B12 <170 pg/mlB12 <170 pg/ml B12 170-200B12 170-200 normal FBC/well normal FBC/well

Treat Neurology or repeat 3-4 moTreat Neurology or repeat 3-4 mo

5 1mg injections >65/debilitated 5 1mg injections >65/debilitated

1mg every 3 months1mg every 3 months

<65: Treat Level normal/static<65: Treat Level normal/static

IF Abs ?improvedIF Abs ?improved

Schillings test ?B12 ^ probably spuriousSchillings test ?B12 ^ probably spurious

Assessment of megaloblastic Assessment of megaloblastic anaemiaanaemia

Confirmed megaloblastic BM: Confirmed megaloblastic BM: Plasma B12Plasma B12

90-95% B12 <20090-95% B12 <200

5-10% B12 200-3005-10% B12 200-300

1% B12 > 3001% B12 > 300

But 50% of patients with B12<200 are not But 50% of patients with B12<200 are not MegaloblasticMegaloblastic

Therefore B12 <100 usually B12 deficientTherefore B12 <100 usually B12 deficient

Only 50% of patients with a B12 100-200 will be Only 50% of patients with a B12 100-200 will be truly deficient; others spurious low B12 truly deficient; others spurious low B12

Causes of Spurious low B12Causes of Spurious low B12

Iron deficiency- 30% IDA have low B12 which corrects Iron deficiency- 30% IDA have low B12 which corrects with FeSO4 alonewith FeSO4 aloneFolate deficiency- 30% folate deficient patients have a Folate deficiency- 30% folate deficient patients have a low B12 which corrects with folate alonelow B12 which corrects with folate aloneMyelomaMyelomaMegadose Vit CMegadose Vit CVegetarian dietVegetarian dietPregnancyPregnancyTC I deficiencyTC I deficiencyPancreatic diseasePancreatic disease

Schilling TestSchilling Test

Low B12 (<100) + pos IF Ab +>60yrs = PALow B12 (<100) + pos IF Ab +>60yrs = PA

If <60yrs/ IF Ab negative Schilling testIf <60yrs/ IF Ab negative Schilling test

Requirements:Requirements:- Normal renal functionNormal renal function- B12 repleteB12 replete

Schilling Test- Part 1Schilling Test- Part 1

1 ug B12 (0.5 ug CiCo^57) orally 1000ug B12 IM1 ug B12 (0.5 ug CiCo^57) orally 1000ug B12 IM

Gut normal IF normalGut normal IF normal

AbsorbedAbsorbed

~30%~30%

Urine Blocks all binding sitesUrine Blocks all binding sites

Must collect 24 hr urineMust collect 24 hr urine

(~25% collections inadequate)(~25% collections inadequate)

Schilling test – Part 2Schilling test – Part 2

If absorption reduced in part 1If absorption reduced in part 11ug B12(0.5 CiCo^57) + IF orally 1000ug B12 IM1ug B12(0.5 CiCo^57) + IF orally 1000ug B12 IM

No change normal excretion= IF deficientNo change normal excretion= IF deficient

Gut disease (B12 excretion controls: 11-32%Gut disease (B12 excretion controls: 11-32%

PA part 1: 0-6%PA part 1: 0-6%

PA part 2: 3-30%)PA part 2: 3-30%)

If problems with incontinence or renal failure; collect If problems with incontinence or renal failure; collect plasma sample 8 hours after oral B12 Co^57plasma sample 8 hours after oral B12 Co^57

Folate deficiencyFolate deficiency

Nutritional esp. old age, institutions, povertyNutritional esp. old age, institutions, povertyMalabsorption eg coeliac diseaseMalabsorption eg coeliac diseaseExcess utilisationExcess utilisationPhysiological (pregnancy, lactation)Physiological (pregnancy, lactation)Pathological eg hemolytic anaemiaPathological eg hemolytic anaemiaExcess urinary folate lossExcess urinary folate lossActive liver diseaseActive liver disease CCF CCF Drugs (anti-convulsants, sulphasalazine)Drugs (anti-convulsants, sulphasalazine)AlcoholismAlcoholismITUITU

Serum folateSerum folate

Not sensitive or specificNot sensitive or specific

Spurious low values – anorexiaSpurious low values – anorexia

alcoholismalcoholism

anticonvulsantsanticonvulsants

pregnancypregnancy

Falsely raised values – acute food intakeFalsely raised values – acute food intake

HaemolysisHaemolysis

Red cell folateRed cell folate

Levels are 30x greater than serumLevels are 30x greater than serum

Better longer term measureBetter longer term measure

Raised by – reticulocytosisRaised by – reticulocytosis

haemoconcentrationhaemoconcentration

Lowered by – B12 deficiency (methyl THF Lowered by – B12 deficiency (methyl THF leaks out of RBC)leaks out of RBC)

Response to B12/folate therapyResponse to B12/folate therapy

BM normal by 48 hours but giant BM normal by 48 hours but giant metamyelocytes persist for 14 daysmetamyelocytes persist for 14 daysSerum Iron normal by 48 hrsSerum Iron normal by 48 hrsK drops in first 48 hrsK drops in first 48 hrsUric acid increases and peaks at 96 hrsUric acid increases and peaks at 96 hrsReticulocyte response by D2-D3- peaks by day Reticulocyte response by D2-D3- peaks by day 77Hb increased by 1-1.5 gm per week (If MCV <80 Hb increased by 1-1.5 gm per week (If MCV <80 ?IDA)?IDA)Hypersegmented neutrophils persist for 14 daysHypersegmented neutrophils persist for 14 daysBil/LDH correct over 7 daysBil/LDH correct over 7 days

Response to therapyResponse to therapy

Neurology:Neurology:

If present for < 3/12, usually reverse but If present for < 3/12, usually reverse but may take upto 6/12may take upto 6/12

No improvement after >12/12No improvement after >12/12

Spinal cord damage usually irreversibleSpinal cord damage usually irreversible

Only 30% of optic atrophy pts improveOnly 30% of optic atrophy pts improve

Iron deficiencyIron deficiency

3.1% adult men3.1% adult men

5.3% adult women5.3% adult women

Children upto 14 (non-menstruating Children upto 14 (non-menstruating females) 2-3%females) 2-3%

Menstruating girls upto 14 yrs age 9%Menstruating girls upto 14 yrs age 9%

30% menstruating females have low 30% menstruating females have low ferritinferritin

Symptoms and signsSymptoms and signs

Anaemia – speed of onsetAnaemia – speed of onset

angina/CCFangina/CCF

GlossitisGlossitis

Angular stomatitis (~10%)Angular stomatitis (~10%)

Postural hypotensionPostural hypotension

PalpitationsPalpitations

Mild alopeciaMild alopecia

Iron deficiency- interesting factsIron deficiency- interesting facts

7mg Fe/1000 kcal diet = Poor iron content7mg Fe/1000 kcal diet = Poor iron contentPhytates/phosphates reduce absorption = Phytates/phosphates reduce absorption = reduce Fe availabilityreduce Fe availabilityIron losses males 0.5-1 mg/dayIron losses males 0.5-1 mg/day

females 1-2 mg/dayfemales 1-2 mg/day pregnancy 1.5-3 mg/daypregnancy 1.5-3 mg/day children 1 mg/day (2-3 yrs require 5-children 1 mg/day (2-3 yrs require 5-

7 mg/day)7 mg/day)Breast milk/Toddlers diet often don’t keep up Breast milk/Toddlers diet often don’t keep up with Iron demandwith Iron demand

Iron deficiency- Points to rememberIron deficiency- Points to remember

1 Aspirin /day – average gut loss 2-3ml/d = 2-3 1 Aspirin /day – average gut loss 2-3ml/d = 2-3 mg Ironmg Iron1 Hookworm – average gut blood loss 0.03 1 Hookworm – average gut blood loss 0.03 ml/dayml/dayLiver disease– get Iron deficiency with a normal Liver disease– get Iron deficiency with a normal MCV; ferritin likely to be normal or increased, MCV; ferritin likely to be normal or increased, therefore difficult to diagnosetherefore difficult to diagnose1/31/3rdrd of patients with Fe deficiency have low/ of patients with Fe deficiency have low/ borderline B12borderline B12After partial gastrectomy, 50% of patients will be After partial gastrectomy, 50% of patients will be Iron deficient at 5 yearsIron deficient at 5 years

4% myoglobin (4%)4% myoglobin (4%)

transferrin(0.1%)transferrin(0.1%)

29% enzymes(0.2%)29% enzymes(0.2%)

Ferritin Ferritin

66% Haemoglobin66% Haemoglobin

Total body Iron 3-4 gmsTotal body Iron 3-4 gms

6 gms of Hb made per day = 20 mg Fe6 gms of Hb made per day = 20 mg Fe

Plasma Fe pool= 4 mg, hence large turnoverPlasma Fe pool= 4 mg, hence large turnover

Iron deficiency – helpful film Iron deficiency – helpful film commentscomments

MicrocytesMicrocytesAnisocytosisAnisocytosisPoikilocytosisPoikilocytosisPencil cellsPencil cellsTarget cells: few, not manyTarget cells: few, not manyPolychromasia = reticulocytes ?bleedingPolychromasia = reticulocytes ?bleedingNeutropenia ; reverts with Iron therapyNeutropenia ; reverts with Iron therapyThrombocytosisThrombocytosis

DiagnosisDiagnosis

Serum Ferritin measures Fe storesSerum Ferritin measures Fe storesSensitive SpecificSensitive SpecificFerritinFerritin Causes of low ferritinCauses of low ferritin Fe deficiency Fe deficiency CV <4% HypothyroidCV <4% HypothyroidDiurnal variation <10%Diurnal variation <10%Serum FeSerum Fe Causes of low serum FeCauses of low serum Fe Fe def. Fe def.CV >20% InflammationCV >20% InflammationDiurnal variation> 50% Infection Diurnal variation> 50% Infection malignancymalignancy trauma trauma Causes of high TIBCCauses of high TIBC Fe def. Fe def.

Plasma FerritinPlasma Ferritin

Low plasma ferritin: Iron deficiencyLow plasma ferritin: Iron deficiency

HypothyroidismHypothyroidism

Vitamin C Vitamin C deficiencydeficiency

High plasma ferritin: Iron overloadHigh plasma ferritin: Iron overload

Acute phase responseAcute phase response

Liver damageLiver damage

Sensitivity 0.23 and specificity 1.0 for diagnosis of Sensitivity 0.23 and specificity 1.0 for diagnosis of IDAIDA

Haemolytic anaemiaHaemolytic anaemia

Immune Immune

Non-ImmuneNon-Immune

Evidence of haemolysisEvidence of haemolysis

FBCFBC

ReticulocytesReticulocytes

LFTLFT

LDHLDH

HaptoglobinHaptoglobin

Blood film – SchistocytesBlood film – Schistocytes

-- Spherocytes-- Spherocytes

Spherocytes Spherocytes SchistocytesSchistocytes

Immune vs non-ImmuneImmune vs non-Immune

Direct Coomb’s TestDirect Coomb’s Test

Causes of false positive DCTCauses of false positive DCT

Autoimmune conditions Autoimmune conditions

Paraproteinemias e.g myelomaParaproteinemias e.g myeloma

Post allogeneic transplantPost allogeneic transplant

Causes of Immune haemolysisCauses of Immune haemolysis

AutoimmuneAutoimmune

Allo-immune (blood transfusion, Allo-immune (blood transfusion, mismatched bone marrow transplants)mismatched bone marrow transplants)

Drug-inducedDrug-induced

Autoimmune haemolysisAutoimmune haemolysis

Cold AIHACold AIHA

Warm AIHAWarm AIHA

Paroxysmal cold haemoglobinureaParoxysmal cold haemoglobinurea

Practical problemsPractical problems

Difficulties in blood groupingDifficulties in blood grouping

Difficulties in cross-matching bloodDifficulties in cross-matching blood

ManagementManagement

Blood transfusionBlood transfusion

SteroidsSteroids

IVIG – less effectiveIVIG – less effective

RituximabRituximab

Chemotherapeutic agentsChemotherapeutic agents