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Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland

AnaemiAnaemiaaProf. A. B. Skotnicki M.D. Ph.D.

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AnaemiAnaemiaa

Decreased haemoglobin Decreased haemoglobin concentration and/or PCVconcentration and/or PCV

Decreased haemoglobin Decreased haemoglobin concentration and/or PCVconcentration and/or PCV

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Internal Internal ironiron exchange.exchange.

Absorption - about 1 mg/d is required from the diet in men, 1.4 mg/d in women

transferrin saturation 20 to 60%

Absorption - about 1 mg/d is required from the diet in men, 1.4 mg/d in women

transferrin saturation 20 to 60%

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Iron storage and Iron storage and transporttransport

Tissue ferritinTissue ferritin Serum transferin

20 umol/lSerum transferin

20 umol/l

BoneMarrow

Erythroblasts

BoneMarrow

Erythroblasts

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Classification of Classification of anaemiaanaemia

Morphological Based on red

cell measurement

Morphological Based on red

cell measurement

Aetiological Based on

cause

Aetiological Based on

cause

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Aetiological classification of Aetiological classification of anaemiaanaemia↓ Hb ↓ ER

Excessiveblood lossblood loss

-haemorrhage

Excessive red cell destructiondestruction

Inadequate production production of red cells

- decreased -abnormal

Post –haemorrhagic

anaemia

Haemolitica anaemias

Aplastic anameiaBone marrow infiltrattion

Cytoplasmic defect↓ Fe

Nuclear defect ↓ B12

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Morphological classification of Morphological classification of anaemiaanaemia

↓ B12↓ fol.ac.

↓ B12↓ fol.ac.

↓ Fe↓ Fe Acute blood lossHaemolysis

Bone marrow aplasiaBone marrow infiltration

Acute blood lossHaemolysis

Bone marrow aplasiaBone marrow infiltration

MCV andMCH normalMCV and

MCH normal

Normocytic normochromic

anaemia

Normocytic normochromic

anaemia

↑ MCV↑ MCH↑ MCV↑ MCH

Macrocytic hyperchromic Megaloblastic

anaemia

Macrocytic hyperchromic Megaloblastic

anaemia

↓ MCV↓ MCH↓ MCV↓ MCH

Microcytic hypochromic

anaemia

Microcytic hypochromic

anaemia

Chronicdisease

Chronicdisease

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Anaemia – signs and Anaemia – signs and symptomssymptoms

GeneralGeneral signs and symptoms universal for all anaemias

Signs and symptoms specificspecific for a particular cause

GeneralGeneral signs and symptoms universal for all anaemias

Signs and symptoms specificspecific for a particular cause

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General symptoms of General symptoms of anaemiaanaemia

↓ Hb↓ Hb ↓ O2 carrying capacity of bloodTISSUE HYPOXIA

↓ O2 carrying capacity of bloodTISSUE HYPOXIA

Clinical manifestationsClinical manifestations

PalpitationsTachycardia

Heart murmurs

PalpitationsTachycardia

Heart murmurs

dyspnoeadyspnoea

pallorpallor

Cardiac overactivityCardiac overactivity

Cadiorespiratoryinsufficiency

Cadiorespiratoryinsufficiency

Skin vasoconstriction

redistribution of blood flow(brain, heart)

Skin vasoconstriction

redistribution of blood flow(brain, heart)

Compensatory mechanismsmobilised to contract hypoxia

Compensatory mechanismsmobilised to contract hypoxia

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AnaemiaAnaemia – general signs and – general signs and symptomssymptoms

CSN:•Headaches•Tinnitus


General:•Shortness of breath•Fatigue•Weakness•Susceptibility to infections

General:•Shortness of breath•Fatigue•Weakness•Susceptibility to infections

CVS:•Tachycardia•Functional murmur•Stenocardiac pain

CVS:•Tachycardia•Functional murmur•Stenocardiac pain

Pale skin & mucous membranes

Pale skin & mucous membranes

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Anaemia – major Anaemia – major typestypes

Iron deficiency anaemiaIron deficiency anaemia Megaloblastic anaemiaMegaloblastic anaemia Haemolytic anaemiaHaemolytic anaemia Aplastic anaemiaAplastic anaemia Anaemia of chronic Anaemia of chronic

diseasedisease

Nutritional factor deficiency

Nutritional factor deficiency

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Normal Normal erythropoiesiserythropoiesis

MCV=90 fl

MCHC=32 g/l

MCH=32 pg

FeFe

B12B12

haemoglobinisation

RBC production

HBNN

E=

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Erythropoiesis in IDA or after Erythropoiesis in IDA or after bleedingbleeding

MCV=70 fl

MCHC=28 g/l

MCH=25 pg

FeFe

B12B12

haemoglobinisation

RBC production

HBN/>N<N

E=

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Iron deficiency anaemia (IDA) - Iron deficiency anaemia (IDA) - causescauses

InadequatInadequate intakee intakeInadequatInadequate intakee intake

Chronic blood Chronic blood lossloss• GI• Urinary Tract

Chronic blood Chronic blood lossloss• GI• Urinary Tract

IncreasedIncreasedrequirementrequirementIncreasedIncreasedrequirementrequirement

IronIronmalabsorbtiomalabsorbtionn

IronIronmalabsorbtiomalabsorbtionn

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IDA – causes of chronic blood IDA – causes of chronic blood lossloss

HaematemesisHaemoptysis

Urinary tract bleeding – haematura:•Renal disorders

•Inflammation•Tumour

•Urinary tract •Calculosis•Polyps

•Urinary bladder tumours

Genital tract bleeding:•Menorrhagiae•Metrorrhagiae•Uterine myoma

Gastrointestinal tract bleeding:•Hiatus hernia•Gastritis haemorrhagica•Peptic ulcer•Gastric cancer•Intestinal polyposis•Colonic cancer •Colitis ulcerosa•Haemorrhoidal varices

•Melaena

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IDAIDA - - signs and signs and symptomssymptoms

Skin:•Dry, cracked•Cheilitis angularis•rhagades

Tongue•Glossitis anaemica

General signs and symptoms PLUS tissue asiderosis

General signs and symptoms PLUS tissue asiderosis

Hair:•Fragility, coming out•Early gray

Nails:•Brittle, spoon nails•Atrophic changes

DysphagiaPlummer-Vinson syndrome

Eyes:•Bluish sclera

Pica

Gastric troubles

Neurovegetative dystonia

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Moderately severe iron deficiency Moderately severe iron deficiency anaemia anaemia

This example of moderately This example of moderately severe iron deficiency severe iron deficiency anaemia shows anisocytosis, anaemia shows anisocytosis, anisochromasia, anisochromasia, hypochromia, microcytosis hypochromia, microcytosis and poikilocytosis. The and poikilocytosis. The poikilocytes include several poikilocytes include several particularly long elliptocytes, particularly long elliptocytes, sometimes referred to as sometimes referred to as 'pencil cells'. Elliptocytes are 'pencil cells'. Elliptocytes are characteristic of iron characteristic of iron deficiency but not deficiency but not pathognomonic. pathognomonic.

This example of moderately This example of moderately severe iron deficiency severe iron deficiency anaemia shows anisocytosis, anaemia shows anisocytosis, anisochromasia, anisochromasia, hypochromia, microcytosis hypochromia, microcytosis and poikilocytosis. The and poikilocytosis. The poikilocytes include several poikilocytes include several particularly long elliptocytes, particularly long elliptocytes, sometimes referred to as sometimes referred to as 'pencil cells'. Elliptocytes are 'pencil cells'. Elliptocytes are characteristic of iron characteristic of iron deficiency but not deficiency but not pathognomonic. pathognomonic.

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Severe iron deficiency Severe iron deficiency anaemiaanaemia

Blood film from Blood film from a patient with a patient with severe iron severe iron deficiency anaemia. deficiency anaemia. The film shows The film shows anaemia, anaemia, microcytosis, microcytosis, hypochromia, hypochromia, anisocytosis, anisocytosis, anisochromasia and anisochromasia and poikilocytosis.poikilocytosis.

Blood film from Blood film from a patient with a patient with severe iron severe iron deficiency anaemia. deficiency anaemia. The film shows The film shows anaemia, anaemia, microcytosis, microcytosis, hypochromia, hypochromia, anisocytosis, anisocytosis, anisochromasia and anisochromasia and poikilocytosis.poikilocytosis.

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Pallor in iron deficiency Pallor in iron deficiency anaemia anaemia

The hand of a patient The hand of a patient with iron deficiency with iron deficiency anaemia showing anaemia showing pallor. The hand of a pallor. The hand of a non-anaemic person is non-anaemic person is pictured for pictured for comparison. Pallor is a comparison. Pallor is a non-specific feature of non-specific feature of anaemia. anaemia.

The hand of a patient The hand of a patient with iron deficiency with iron deficiency anaemia showing anaemia showing pallor. The hand of a pallor. The hand of a non-anaemic person is non-anaemic person is pictured for pictured for comparison. Pallor is a comparison. Pallor is a non-specific feature of non-specific feature of anaemia. anaemia.

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Pale conjunctiva in iron deficiency Pale conjunctiva in iron deficiency anaemia anaemia

The best places to The best places to check for pallor that check for pallor that may indicate may indicate anaemia are the anaemia are the conjunctiva, the nail conjunctiva, the nail beds and the palms beds and the palms of the hands. This of the hands. This patient with iron patient with iron deficiency anaemia deficiency anaemia has conjunctival has conjunctival pallor. pallor.

The best places to The best places to check for pallor that check for pallor that may indicate may indicate anaemia are the anaemia are the conjunctiva, the nail conjunctiva, the nail beds and the palms beds and the palms of the hands. This of the hands. This patient with iron patient with iron deficiency anaemia deficiency anaemia has conjunctival has conjunctival pallor. pallor.

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Pallor in iron deficiency Pallor in iron deficiency anaemia anaemia

Pallor in a patient Pallor in a patient with iron with iron deficiency deficiency anaemia. The anaemia. The patient's hand is patient's hand is pictured together pictured together with the hand of a with the hand of a healthy person.healthy person.(Courtesy of Dr D. (Courtesy of Dr D. Samson.) Samson.)

Pallor in a patient Pallor in a patient with iron with iron deficiency deficiency anaemia. The anaemia. The patient's hand is patient's hand is pictured together pictured together with the hand of a with the hand of a healthy person.healthy person.(Courtesy of Dr D. (Courtesy of Dr D. Samson.) Samson.)

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Oral changes in iron deficiency Oral changes in iron deficiency anaemia anaemia

Angular cheilosis and Angular cheilosis and atrophic glossitis in atrophic glossitis in iron deficiency iron deficiency anaemia. These anaemia. These features are typical of features are typical of moderately severe iron moderately severe iron deficiency anaemia deficiency anaemia and indicate the effect and indicate the effect of iron deficiency on of iron deficiency on tissues other than the tissues other than the bone marrow.bone marrow.(Courtesy of Dr D. (Courtesy of Dr D. Samson.) Samson.)

Angular cheilosis and Angular cheilosis and atrophic glossitis in atrophic glossitis in iron deficiency iron deficiency anaemia. These anaemia. These features are typical of features are typical of moderately severe iron moderately severe iron deficiency anaemia deficiency anaemia and indicate the effect and indicate the effect of iron deficiency on of iron deficiency on tissues other than the tissues other than the bone marrow.bone marrow.(Courtesy of Dr D. (Courtesy of Dr D. Samson.) Samson.)

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Cheilitis Angularis in Cheilitis Angularis in IDAIDA

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Koilonychia in iron deficiency Koilonychia in iron deficiency anaemia anaemia

Koilonychia or spoon-Koilonychia or spoon-shaped nails in iron shaped nails in iron deficiency anaemia. deficiency anaemia. Koilonychia has a Koilonychia has a high degree of high degree of specificity for iron specificity for iron deficiency but it is a deficiency but it is a relatively uncommon relatively uncommon feature, occurring feature, occurring only in severe chronic only in severe chronic iron deficiency. iron deficiency.

Koilonychia or spoon-Koilonychia or spoon-shaped nails in iron shaped nails in iron deficiency anaemia. deficiency anaemia. Koilonychia has a Koilonychia has a high degree of high degree of specificity for iron specificity for iron deficiency but it is a deficiency but it is a relatively uncommon relatively uncommon feature, occurring feature, occurring only in severe chronic only in severe chronic iron deficiency. iron deficiency.

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Typical changes in blood count Typical changes in blood count in IDAin IDA

Normal Blood Normal Blood CountCount

Hb Hb 14 g/dl14 g/dl RBC RBC 4,50 x 10^12/l4,50 x 10^12/l PCVPCV 40 %40 % MCVMCV 90 fl90 fl MCH MCH 30 pg30 pg RetRet 0,5 %0,5 % WBC WBC 7,5 x 10^9/l7,5 x 10^9/l Differential normalDifferential normal PlateletsPlatelets

400x10^9/l400x10^9/l

Normal Blood Normal Blood CountCount

Hb Hb 14 g/dl14 g/dl RBC RBC 4,50 x 10^12/l4,50 x 10^12/l PCVPCV 40 %40 % MCVMCV 90 fl90 fl MCH MCH 30 pg30 pg RetRet 0,5 %0,5 % WBC WBC 7,5 x 10^9/l7,5 x 10^9/l Differential normalDifferential normal PlateletsPlatelets

400x10^9/l400x10^9/l

Blood Count in IDABlood Count in IDA Hb Hb 7,5 g/dl7,5 g/dl RBC RBC 4,05 x 10^12/l4,05 x 10^12/l PCVPCV 26%26% MCVMCV 64 fl64 fl MCH 18,5 pgMCH 18,5 pg RetRet 2,6%2,6% WBC WBC 7,5 x 10^9/l7,5 x 10^9/l Differential normalDifferential normal PlateletsPlatelets

530x10^9/l530x10^9/l

Blood Count in IDABlood Count in IDA Hb Hb 7,5 g/dl7,5 g/dl RBC RBC 4,05 x 10^12/l4,05 x 10^12/l PCVPCV 26%26% MCVMCV 64 fl64 fl MCH 18,5 pgMCH 18,5 pg RetRet 2,6%2,6% WBC WBC 7,5 x 10^9/l7,5 x 10^9/l Differential normalDifferential normal PlateletsPlatelets

530x10^9/l530x10^9/l

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Iron deficiency is Iron deficiency is NOT NOT a a diagnosis but a symptomdiagnosis but a symptom

Clinical & laboratory

findings

Clinical & laboratory

findings

IronDeficiencyanaemia

IronDeficiencyanaemiaAetiology

?Aetiology

?

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Iron deficiency Iron deficiency anaemiaanaemia 53 old male53 old male

Tiredness Hb 7 g/l MCV 69 fl Serum ferritin 8ug/l Occult faecal blood test positive

(+) Colonoscopy

53 old male53 old male Tiredness Hb 7 g/l MCV 69 fl Serum ferritin 8ug/l Occult faecal blood test positive

(+) Colonoscopy

•Carcinoma of the colon

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22 years old patient with ACD (Hodgkin’s 22 years old patient with ACD (Hodgkin’s lymphoma)lymphoma)

0

5

10

15

20

25

30

XI 2000 XII 2000 IV 2001 V 2002TIME

Hb (g/l)

Fe (umol/l)

Fe (umol/l) - normal values

Hb - normal values

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Megaloblastic Megaloblastic AnaemiaAnaemia

Abnormal changes in blood cell formation leading to macrocytic anaemia and varying degrees of pancytopenia as a result of abnormal DNA synthesis because of single or combined deficiency of folate and/or vitamin B12

Abnormal changes in blood cell formation leading to macrocytic anaemia and varying degrees of pancytopenia as a result of abnormal DNA synthesis because of single or combined deficiency of folate and/or vitamin B12

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Normal Normal erythropoiesiserythropoiesis

MCV=90 fl

MCHC=32 g/l

MCH=32 pg

FeFe

B12B12

haemoglobinisation

RBC production

HBNN

E=

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Erythropoiesis in B12 Erythropoiesis in B12 deficiencydeficiency

MCV=100 fl

MCHC=32 g/l

MCH=40 pg

FeFe

B12B12

haemoglobinisation

RBC production

HB<NN

E=

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Megaloblastic anaemia Megaloblastic anaemia - - causescauses

Inadequate intake

Disturbed metabolism

Increasedrequirement

Malabsorbtion

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Megaloblastic anaemia Megaloblastic anaemia - - causescauses

COBALAMIN DEFICIENCY. Inadequate intake:

vegetarians (rare) Malabsorption: Defective

release of cobalamin from food:Gastric achlorhydria, Partial gastrectomy, Drugs that block acid secretion

Inadequate production of intrinsic factor (IF): Pernicious anemia; Total gastrectomy: Congenital absence or functional abnormality of IF Disorders of terminal ileum

Competition for cobalamin Other

COBALAMIN DEFICIENCY. Inadequate intake:

vegetarians (rare) Malabsorption: Defective

release of cobalamin from food:Gastric achlorhydria, Partial gastrectomy, Drugs that block acid secretion

Inadequate production of intrinsic factor (IF): Pernicious anemia; Total gastrectomy: Congenital absence or functional abnormality of IF Disorders of terminal ileum

Competition for cobalamin Other

FOLIC ACID DEFICIENCY

Inadequate intake: unbalanced diet (common in alcoholics, teenagers, some infants)

Increased requirements: Pregnancy, Infancy, Malignancy, Increased hematopoiesis, Chronic exfoliative skin disorders

Malabsorption: Tropical sprue, Nontropical sprue, others

FOLIC ACID DEFICIENCY

Inadequate intake: unbalanced diet (common in alcoholics, teenagers, some infants)

Increased requirements: Pregnancy, Infancy, Malignancy, Increased hematopoiesis, Chronic exfoliative skin disorders

Malabsorption: Tropical sprue, Nontropical sprue, others

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Megaloblastic anaemia - Megaloblastic anaemia - causescauses

Cause B12 deficiency Folic acid deficiency

1. Dietary deficiency: 2. Malabsorbtion:

•Atrophic gastritis•Hipochlorchydria•Lack of intrisinc factor•Small bowel diseases•Post gastrectomy

3. Increased demands:

•Pregnancy 4. Disturbed metabolism:

•anticonvulsives•cytostatics

rarely

++++++

++ − −+

often (alcohol abuse, parenteral nutrition, age)

−−

++-

++ ++

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Megaloblastic anaemia– symptoms and Megaloblastic anaemia– symptoms and signssigns


• Glossitis Hunteri • smooth• Reddened• Burning• Reduced in size

• Loss of appetite• Loss of taste• Loss of body weight• Abdominal pains• Atrophic gastritis• Diarrhoea• Achlorchyrdia

•Visual disturbances•Optic nerve disturbances•Psychiatric disturbances

•Irritability•Sleepiness•Dementia

•Peripheral neuropathy•Paresthesia•Pins and needles•Unsteady gait•Reduced Sensation•Imbalance•Dysuria•Reduced heat and cold sensibility

Average age – 60 Often - womenSpecific PLUS

General signs and symptoms

Specific PLUSGeneral signs and symptoms

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Blood film in megaloblastic Blood film in megaloblastic anaemiaanaemia

In megaloblastic anaemia the most characteristic features in the peripheral blood film are hypersegmented neutrophils and macrocytes, particularly oval macrocytes [arrow]. The neutrophil shown has six lobes and is therefore classified as hypersegmented

In megaloblastic anaemia the most characteristic features in the peripheral blood film are hypersegmented neutrophils and macrocytes, particularly oval macrocytes [arrow]. The neutrophil shown has six lobes and is therefore classified as hypersegmented

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Haemolytic Haemolytic anaemiaanaemia

Decrease in the total number of circulating erythrocytes that is caused by premature premature destruction or removaldestruction or removal of red cells from the circulation

Decrease in the total number of circulating erythrocytes that is caused by premature premature destruction or removaldestruction or removal of red cells from the circulation

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Haemolytic Haemolytic anaemiaanaemia

Classifications of HA according toClassifications of HA according to Type of defectType of defect Site of defectSite of defect Site of haemolisisSite of haemolisis

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Classification of HA Classification of HA according toaccording to

Type of defectType of defect

Hereditary Membrane defect Metabolic defect Hemoglobinopathie

s

Hereditary Membrane defect Metabolic defect Hemoglobinopathie

s

Acquired Immunologic defect Mechanical defect Intravascular

coagulopathy March hemoglobinuria Infection Membrane abnormality

Acquired Immunologic defect Mechanical defect Intravascular

coagulopathy March hemoglobinuria Infection Membrane abnormality

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Classification of HA Classification of HA according toaccording to

Type of defectType of defect Hereditary

Membrane defect• HS• Hereditary

elliptocytosis Metabolic defect

• GdPD deficiency • PK deficiency

Hemoglobinopathies• Thalassemias • Sickle cell diseases • Other

hemoglobinopathies

Hereditary Membrane defect

• HS• Hereditary

elliptocytosis Metabolic defect

• GdPD deficiency • PK deficiency

Hemoglobinopathies• Thalassemias • Sickle cell diseases • Other

hemoglobinopathies

Acquired Immunologic defect

• Drug-induced hemolysis• Isoimmune and alloimniune hemolysis

(neonatal and delayed transfusion reactions)

Mechanical defect• Rapid turbulent flow of blood, tumors,

hypertension, aortic stenosis, Prosthetic valve leaks

Intravascular coagulopathy March hemoglobinuria Infection Membrane abnormality

(stem cell abnormality)

Acquired Immunologic defect

• Drug-induced hemolysis• Isoimmune and alloimniune hemolysis

(neonatal and delayed transfusion reactions)

Mechanical defect• Rapid turbulent flow of blood, tumors,

hypertension, aortic stenosis, Prosthetic valve leaks

Intravascular coagulopathy March hemoglobinuria Infection Membrane abnormality

(stem cell abnormality)

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Classifications of HA Classifications of HA according toaccording toSite of defectSite of defect Intracorpuscular factors

Red cell membrane abnormalities (HS and related abnormalities PNH)

Hemoglobinopathies (Thalassemias, Sickle cell disease and related hemoglobinopathies, Methemoglobinemia, Unstable hemoglobin diseases )

Enzymopathies (G6PD deficiency Others)

Extracorpuscular factors Antibodies (Autoimmune

hemolytic anaemia, transfusion-related haemolytic reactions, Drug-related hemolytic reactions)

Mechanical or traumatic factors (Prosthetic heart valves, High-flow red cell damage, Intravascular coagulopathy)

Infections (Bacterial, Parasitic)

Cell membrane lipids (Liver disease, Lipid disorders)

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Classifications of HA Classifications of HA according toaccording to

Site of HaemolysisSite of Haemolysis Intravascular

hemolysis Traumatic hemolysis Immune hemolysis Infections

Intravascular hemolysis

Traumatic hemolysis Immune hemolysis Infections

Extra vascular hemolysis

Autoimmune hemolytic anemia

Red cell membrane defects

Spur cell anaemia Red cell metabolism

defect Unstable

haemoglobin diseases

Extra vascular hemolysis

Autoimmune hemolytic anemia

Red cell membrane defects

Spur cell anaemia Red cell metabolism

defect Unstable

haemoglobin diseases

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Clinical signs and Clinical signs and symptoms symptoms

of haemolytic anaemiaof haemolytic anaemia

GeneralGeneral signs and symptoms universal for all anaemia

Signs and symptoms specificspecific haemolysis Jaundice Increased billirubin (unbound) Increased reticulocitosis

GeneralGeneral signs and symptoms universal for all anaemia

Signs and symptoms specificspecific haemolysis Jaundice Increased billirubin (unbound) Increased reticulocitosis

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Example of blood film in Example of blood film in HAHA

Microangiopathic haemolytic anaemia

Blood film showing the features of microangiopathic haemolytic anaemia in haemolytic uraemic syndrome. There are schistocytes including one microspherocyte

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Aplastic Aplastic anaemiaanaemia

AcellularAcellular or hypocellularhypocellular marrow that causes bone marrow failure and lower level of cell production, leading to pancytopeniapancytopenia.

Etiology: Idiopathic Secondary

AcellularAcellular or hypocellularhypocellular marrow that causes bone marrow failure and lower level of cell production, leading to pancytopeniapancytopenia.

Etiology: Idiopathic Secondary

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Causes of Secondary Aplastic Causes of Secondary Aplastic AnaemiaAnaemia

Drugs and toxins Chloramphenicol Cancer

chmotherapy Chemicals

Infections Viral hepatitis CMV Infectious

mononucleosis Parvovirus 19

Drugs and toxins Chloramphenicol Cancer

chmotherapy Chemicals

Infections Viral hepatitis CMV Infectious

mononucleosis Parvovirus 19

Proleukaemic and leukaemic conditions

Paroxysmal nocturnal haemoglobinuria

Genetic or constitutional conditions

Proleukaemic and leukaemic conditions

Paroxysmal nocturnal haemoglobinuria

Genetic or constitutional conditions

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Normal Bone Normal Bone marrowmarrow

Normal Bone Normal Bone marrowmarrow

Fat cells

WBCRBC

PLT

Bone marrow in Bone marrow in AAAA



Fat cells

Residual haemopoesis

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Signs and symptoms of Signs and symptoms of AAAA

The results of pancytopenia Anaemia (general signs) Thrombocytopenia (bleeding tendency)

Granulocytopenia (infections)

The results of pancytopenia Anaemia (general signs) Thrombocytopenia (bleeding tendency)

Granulocytopenia (infections)

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Normal bone marrow (right) and in aplastic anaemia (left) Normal bone marrow (right) and in aplastic anaemia (left) trephine biopstrephine biopsiesies

normalnormal AAAA

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Anaemia of chronic disease Anaemia of chronic disease (ACD)(ACD)

Common type of anaemia that occurs in patients who present with any of several chronic inflammatory and malignant diseases

Common type of anaemia that occurs in patients who present with any of several chronic inflammatory and malignant diseases

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Anaemia of chronic disease Anaemia of chronic disease (ACD)(ACD)

Anaemia of chronic diseaseAnaemia of chronic disease caused by a defect in incorporation of caused by a defect in incorporation of

iron into haemoglobin as a iron into haemoglobin as a consequence of infection, inflammation consequence of infection, inflammation or malignant disease. or malignant disease.

Bone marrow iron stores are usually Bone marrow iron stores are usually normal or increased. The anaemia is normal or increased. The anaemia is initially normocytic and normochromic initially normocytic and normochromic but when it becomes severe is but when it becomes severe is hypochromic and microcytic. hypochromic and microcytic.

Anaemia of chronic diseaseAnaemia of chronic disease caused by a defect in incorporation of caused by a defect in incorporation of

iron into haemoglobin as a iron into haemoglobin as a consequence of infection, inflammation consequence of infection, inflammation or malignant disease. or malignant disease.

Bone marrow iron stores are usually Bone marrow iron stores are usually normal or increased. The anaemia is normal or increased. The anaemia is initially normocytic and normochromic initially normocytic and normochromic but when it becomes severe is but when it becomes severe is hypochromic and microcytic. hypochromic and microcytic.

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Signs and symptoms of Signs and symptoms of ACDACD

General signs and symptoms of anaemia

Blood film as in IDA No tissue asiderosis

General signs and symptoms of anaemia

Blood film as in IDA No tissue asiderosis

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ACD & IDA: clinical & laboratory ACD & IDA: clinical & laboratory differencesdifferences

Feature ACD IDA

Severity + ++

Tissue asiderosis - +++

Chronic disorder +++ +

↑ ESR: fever; ↑WBC; ↑PLT; pain; lymph nodes ↑

++ -

Serum iron ↓ ↓↓

Serum ferritin ↑ ↓

Serum transferin ↓ ↑

TIBC ↓ ↑

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Signs and symptoms in Signs and symptoms in anaemiaanaemia

Anaemia Signs and symptoms

Aplastic Marrow failure

Iron deficiency Tissue asiderosis

B12 &

follic acid deficiencyNeuro & gastrointestinal

Chronic diseaseWithout tissue asiderosis

Haemolytic Haemolysis

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Anaemia of chronic Anaemia of chronic disease -disease -

bone marrowbone marrow

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Comparison of blood films in Comparison of blood films in anaemiasanaemias

NormalNormal

HaemolyticHaemolyticIDAIDA

MacrocyticMacrocytic

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Fe, TIBC and Fe, TIBC and UIBCUIBCTIBC

60 umol/l

TIBC60 umol/l

Fe20 umol/l

Fe20 umol/l UIBCUIBC

NORMALNORMAL

Fe overload

Fe overload

IDA, pregnancy

IDA, pregnancy

Infectionscancers

Infectionscancers

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Oral iron absorbtion Oral iron absorbtion testtest

0

10

20

30

40

50

1 3 6

hours

Fe s

erum

conce

ntr

atio

n

(um

ol/

l)

upper limit of thenormal valuelower limit of thenormal valueimpaired absorbtion(flat curve)iron deficiency withincreased absorbtion

YOURLOGOHERE


MCV in MCV in anaemiaanaemia

Microcytic Microcytic (MCV<N)(MCV<N)

NormocyticNormocytic

(MCV=N)(MCV=N)MacrocyticMacrocytic

(MCV>N)(MCV>N)Iron deficiency

Fe<N, Ferritin<N, TIBC>N

AplasticReticulocytes < N

B12 <N

Chronic diseaseFe>N, Ferritin=,>N

HaemolyticReticulocytes > N

Folic acid <N

TalasemiaFe >N, Ferritin >N

Acute blood loss

Reticulocytes > N

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