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Anemia

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									Anemia




     Andres Ferber,MD
     Hematology and Medical Oncology
     Department of Medicine
     Cooper University Hospital
     June 20, 2009
                          Overview
• Introduction
• Diagnosis
• Etiology
• Approach to the patient with anemia
        • The History and Physical Exam
        • The in-complete blood count (CBC)
        • The RETICULOCYTE count
        • The Differential
        • The other labs
• Examples
    – Iron deficiency Anemia
    – Anemia of chronic diseases
    – Hemolytic anemia
                     Cases
• Case 1
  34 year old female with anemia for several
  months. Has no SOB, CP or near syncope. No
  bleeding. Hb 9g/dl, MCV 70. Retic 1.5%

• Case 2
  70 years old female. Generalized weakness for
  several months. No SOB,CP or near syncope.
  Exam PIP nodules. Anemia 10g/dl. MCV 84.
  Retic 1.5%
                       Introduction
• Anemia represents a reduction in the red cell mass
• The amount of red cells produced daily is 1% of the total red cell mass
• The amount of red cells destroyed daily is 1% of the total red cell mass
• The red cell mass is therefore constant
• A reduction in the red cell mass occurs when there is increased
  destruction (including bleeding) or decreased production of red blood
  cells
• The reticulocyte count is the key to differentiate between these two
  mechanisms
                         Diagnosis
• The diagnosis of anemia is easy.
• Hemoglobin concentration (Hematocrit)
       less then 12 g/dl (37%) in women
       less than 14 g/dl (40%) in men

       No spurious (dilutional) “anemia”
       Hemoglobin concentration = Hemoglobin / Volume (grams/dl)
• The diagnostic challenge is to recognize that anemia is a sign of an
  underlying pathology whose recognition requires an approach to the
  whole patient.
        History and Physical Exam
•   History
     – HPI
           • Age and Chronology
           • Symptoms of anemia
               – DOE,SOB,CP,Palpitations.Syncope,weakness,memory loss,leg pain
           • Symptoms of the cause of anemia including BLOOD LOSS
     – Medicines including cytotoxic drugs, radiation exposure.
     – Allergies
     – PMH including conditions that could be aggravated by the anemia
     – OB/GYN
     – PSH
     – SOC including occupational
     – FH including anemia
     – ROS
              Physical Examination
•   Signs of anemia
           • HR,BP,RR
•   Signs of the disease process causing the anemia
           • Temperature
           • HEENT:Icterus, tongue,mouth lesions
           • Lymph:Adenopathy
           • COR:Murmurs,Valves,Rubs
           • Abomen:Hepatomegaly, Splenomegaly,Masses,Rectal Exam
           • Skin:Rashes,petechiae
           • Neuro:Posterior Column Signs
•   Signs of diseases that could be aggravated by the anemia
    The in-complete blood count (CBC)
•    What’s measured
      – Hemoglobin
      – Number of red cells
      – Mean Corpuscular Volume MCV
      – Red cell distribution Width RDW
      – Platelets
      – White blood cells number and differential
•    What’s calculated
      – MCHC
      – MCH
•    What is not there
      – The RETICULOCYTE count
     The RETICULOCYTE count
•   Anemia represents a reduction in the red cell mass
•   The amount of red cells produced daily is 1% of the total red cell mass
•   The amount of red cells destroyed daily is 1% of the total red cell mass
•   Therefore at the steady state 1% of all red cells are going to be “new”
    or RETICULOCYTES
•   If normally there is 4.500.000 red cells per mm3 then normally there is
    1% of 4.500.000 that is 45.000 RETICULOCYTES per mm3
•   The maximum number of RETICULOCYTES that a normal marrow is
    able to produce per day corresponds to about 500.000 per mm3
•   If the bone marrow does not produce any red cells the reticulocyte
    count is 0
•   The absolute RETICULOCYTE count is anything between 0 and
    500.000 mm3
  The RETICULOCYTE count II
• The reticulocyte count has to be always interpreted in relation to the
  red cell mass (Hemoglobin concentration, Hematocrit or Red cell
  number)
• Somebody with a Hemoglobin of 10g/dl (3.000.000 rbc/mm3) and a
  1.3% reticulocyte count (40.000 reticulocytes/mm3) has an abnormally
  low reticulocyte count. In such case it will be expected that because
  the person has a lower than normal Hemoglobin concentration, the
  bone marrow produces more than the “normal” 40.000 /mm3
• Somebody with an Hemoglobin of 19g/dl (6.000.000 rbc/mm3) and a
  0.7% reticulocyte count (40.000) reticulocytes/mm3) has an
  abnormally high reticulocyte count. In this case because of the
  abnormally high Hemoglobin it will be expected that the bone marrow
  will produce less than the “normal” 40.000/mm3
The RETICULOCYTE Count III
• Reticulocyte index = 1 X % reticulocytes X Patient Hematocrit
                         2                               45
• This index accounts for the longer half life of the reticulocytes and
  interprets the reticulocyte count in relation to the red cell mass
  (Normal hematocrit is 45)
• A reticulocyte index more than 2 usually indicates increased red cell
  production in response to the anemia.
 The rest of the CBC, the differential
      and the peripheral smear
• The white cell count and platelet count are useful to determine if there
  is more than one cell line affected
• The white cell count is not meaningful without the differential
• The peripheral smear is many times the only way to point towards the
  right diagnosis.
             Hemoglobin
Hemoglobin   8 g/dl
8 g/dl
             Retic 1%
Retic 1%     40.000
40.000




Hemoglobin
8 g/dl       Hemoglobin
             8 g/dl
Retic 15%
300.000      Retic 10%
             150.000




Hemoglobin
8 g/dl
Retic 2%     Hemoglobin
30.000       8 g/dl
             Retic 2%
             30.000
Hemoglobin
8 g/dl

Retic 1%
20.000
    Other laboratories that are useful in the
    initial evaluation of the anemic patient
•   Sma12
     – Creatinine
     – Total protein
     – Albumin
     – Calcium
     – LDH
•   Serum Protein Electrophoresis

•   Iron Studies                Iron Deficiency   Anemia Chronic Diseases
      – Iron                        low                    low
      – TIBC                        high                   low
      – Feritin                     low                    normal/high

     – ESR/CRP                      normal                 high
     – Soluble transferrin          high                   normal
       receptor
Approach to Anemia with LOW Reticulocytes and Normal MCV
Approach to Anemia with LOW Reticulocytes and High MCV
Approach to Anemia with LOW Reticulocytes and Low MCV
Approach to Anemia with HIGH Reticulocyte count
               Iron deficiency Anemia
                                                                 Anemia, Thrombocytosis
                                                                 Low Reticulocyte Count
•    History                                                     Low MCV
      – Age and sex                                              Hypochromia and mycrocytosis
      – Chronology
                                                                 Anisocytosis and Poikilocytosis
      – Bleeding
                                                                 Iron       Low
      – Mouth pain
      – Dysphagia                                                TIBC       High
      – Pagophagia and Pica                                      Ferritin   Low
      – Brittle nails
•    Physical                                                        Increase in the reticulocyte
      – Glositis                                                     count with no or modest
      – Coilonichia                                                  increase in Hb after 7 to 10
      – Rectal exam                                                  days of Iron Therapy


    The MOST important issue in this type of anemia is to determine the source of bleeding
    There is no nutrional iron deficiency in the United States
         Anemia of Chronic Disease
                                                               Anemia, Normal, low or high Plt
                                                               count
                                                               Inappropriately low Reticulocyte
•    History                                                   Count
      – Age and sex
                                                               Normal MCV
      – Chronology
      – Bleeding                                               Normochromic Normocytic
      – Other Medical Problems                                 Anisocytosis
      – Inflamatory                                            Iron       Low
      – Malignancy screening
                                                               TIBC       Low
•    Physical
      – Look for signs of other diseases                       Ferritin   Normal or high




    The MOST important issue in this type of anemia is to determine the underlying disease
    and treat it rather than the anemia per se
                                  Cases
• Case 1
  34 year old female with anemia for several months. Has no SOB, CP
  or lightheadness. No bleeding. Hb 9g/dl, MCV 70. Retic 1.5%


         Fe 10, IBC 500, Iron Saturation 2 % Ferritin 1
         Gyn workup negative
         Von Willebrand Disease Workup negative
         Colonoscopy negative
         Tissue transglutaminase Antibody +
         EGD biopsy diagnostic of celiac disease
         Gluten Free Diet resulted in resolution of the anemia
                                Cases
•   Case 2
    70 years old female. Generalized weakness for several months. No SOB,CP or
    lighheandeness. Exam PIP nodules. Anemia 10g/dl. MCV 84. Retic 1.5%
End

								
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