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1 ANEMIA & Its Laboratory Diagnosis 1 ANEMIA & Its Laboratory Diagnosis

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1 ANEMIA & Its Laboratory Diagnosis - PPT Presentation

Dr Ahmad Sh Silmi IUGFaculty of Health Science 2 Objectives At The End Of This Lecture You Will Be Able To Define anemia Discuss the causes amp clinical significance of different categories of anemia ID: 909765

iron anemia rbc hgb anemia iron hgb rbc cells blood normal marrow bone deficiency red hemoglobin cell due disease

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Slide1

1

ANEMIA & Its Laboratory Diagnosis

Dr: Ahmad Sh. SilmiIUG-Faculty of Health Science

Slide2

2

ObjectivesAt The End Of This Lecture You Will Be Able To:Define

anemiaDiscuss the causes & clinical significance of different categories of anemiaDescribe the classification of anemiaExplaining:Microcytic anemiaMacrocytic anemiaNormochromic

normocytic anemiaDiscuss the laboratory findings for each category of anemia

Perform basic laboratory tests for the diagnosis of anemia

Slide3

3

Chapter Outline1. Definition of anemias

2. Classification of anemias 2.1. Hematologic Response to Anemia2.2. Signs of Accelerated Bone Marrow Erythropoiesis2.3. Physiologic Response to Anemia 2.4. Methods of classification 2.5. Anemia Diagnosis/Cause2.6. Lab Investigation of

Anemia3. Types of anemia

3.1

microcytic hypochromic anemia

3.2

. macrocytic normocytic anemias

3.3

. normocytic anemias

3.4

. normocytic

anemias

due to

hemoglobinopathies

Slide4

4

1. Definition of AnemiaAnemia

is a decrease in the RBC count, Hgb and/or HCT values as compared to normal reference range for age and sex (Also determined by alteration in plasma volume)True anemia:decreased RBC mass and normal plasma volumePseudo or dilutional anemia:normal RBC mass and increased plasma volumeAn increase in plasma volume can occur in Pregnancy, volume overload (IVs) congestive heart failureLow Hgb and HCT values

Slide5

5

Definition of Anemia cont’d

Slide6

6

Anemia must also relate to the level of hemoglobin the individual normally possesses. If an adult male usually maintains a hemoglobin level of 16g/dl, and over a period of days is noted to have decreased to 14g/dl, this must be considered significant even though both values are within the normal range for an adult male.

Definition of Anemia cont’d

Slide7

7

Definition of Anemia cont’d…..Various diseases and disorders are associated with decreased hemoglobin levels. These include:

Nutritional deficienciesExternal or internal blood lossIncreased destruction of RBCsIneffective or decreased production of RBCsAbnormal hemoglobin synthesisBone marrow suppression by toxins, chemicals, or radiation & replacement by malignant cellsInfection

Slide8

8

Functionally anemia is defined as tissue hypoxia (inability of the body to supply tissue with adequate oxygen for proper metabolic function)There is an abnormal hemoglobin with an increased O2 affinity resulting in an anemia with normal or raised hemoglobin levels, hematocrit, or RBC count.

Generally anemia is not a disease, but rather the expression of an underlying disorder or disease.Definition of Anemia cont’d…..

Slide9

9

Anemia may develop:When RBC loss or destruction exceeds the maximal capacity of bone marrow RBC production orWhen bone marrow production is impaired

Definition of Anemia cont’d…..

Slide10

10

Hematologic Response to AnemiaTissue hypoxia causes increased renal release of erythropoietin (EPO) to accelerate bone marrow erythropoiesis

The normal bone marrow can increase its activity 7-8 times normal Marrow becomes hypercellular

Slide11

11

Signs of Accelerated Bone Marrow ErythropoiesisThe marrow becomes hyper-cellular due to a marked increase in RBC precursors (called erythroid hyperplasia) and the M:E ratio falls.

Nucleated RBCs may be released into the blood circulation along with the outpouring of reticulocytesNRBC number tends to correlate with the severity of anemiaIncreased Polychromasia on the Wright's- stained blood smear is seen due to increased number of circulating Retics.

Slide12

12

If demand exceeds maximal bone marrow activity, RBC production may occur in extramedullary sites, liver, spleen (hepatosplenomegaly).

Slide13

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Physiologic Response to AnemiaAbility to adapt to anemia depends on:

Age and underlying disease.Cardio/pulmonary function.Rate at which anemia develops (BM can compensate easier if the onset of anemia is slow). Underlying disease.

Slide14

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Clinical features:Symptoms

of hypoxia: decreased oxygen delivery to the tissues/organs causes: fatigue , faintness, weakness, dizziness, headaches, dyspnea, poor exercise tolerance, leg cramps.

Slide15

15

Signs of Anemia:General signs include:pallor of mucous membrane, which occur if the

hgb concentration is less than 9g/dl, Specific signs are associated with particular types of anemia, for example, Jaundice in hemolytic anemia, leg ulcer in sickle cell anemia

Clinical

features cont’d….

Slide16

16

Diagnosis of anemiaBefore making a diagnosis of anemia, one must consider:

AgeSexGeographic location

Slide17

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Diagnosis of anemia cont’d……How does one make a clinical diagnosis of anemia?

A. Patient historyDietary habitsMedicationPossible exposure to chemicals and/or toxinsDescription and duration of symptomsTiredness

Slide18

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Patient history

cont…Muscle fatigue and weaknessHeadache and vertigo (dizziness)Dyspnia (difficult or labored breathing) from exertion

G I problemsOvert signs of blood loss such as hematuria (blood in urine) or black stools

Slide19

19

Diagnosis of anemia cont’d….B. Physical exam

General findingsHepato or splenomegalyHeart abnormalitiesSkin pallorSpecific findings In vitamin B12 deficiency there may be signs of malnutrition and neurological changesIn iron deficiency there may be severe pallor, a smooth tongue, and esophageal websIn hemolytic

anemias there may be jaundice due to the increased levels of bilirubin from increased RBC destruction

Slide20

20

C. Lab investigationsA complete blood count, CBCRBC countHematocrit (

Hct) or packed cell volumeHemoglobin determinationRBC indices calculationReticulocyte countBlood smear examination to evaluate:PoikilocytosisLeukocytes or Platelets abnormalities

Diagnosis of anemia cont’d….

Slide21

21

A bone marrow smear and biopsy to observe:Maturation of RBC and WBC seriesRatio of myeloid to erythroid

seriesAbundance of iron stores (ringed sideroblasts)Presence or absence of granulomas or tumor cellsRed to yellow ratioPresence of megakaryocytesLab investigation cont’d……

Slide22

22

4. Hemoglobin Electrophoresis

Diagnosis of anemia cont’d…..

Slide23

23

5. Antiglobulin Testing 6. Osmotic Fragility TestLab investigation cont’d……

Slide24

24

Methods of Anemia ClassificationSeveral Schemes Of Classifying Anemias Exist

Morphologic Based on RBC morphologyAnemia is divided into three groups mainly on the basis of the MCV (RBC indices)Pathophysiologic Anemia is divided using three main causes/mechanisms Impaired erythrocyte formation (Aplastic anemia, IDA, Sidroblastic anemia, anemia of chronic diseases, megaloblastic anemia)Retic count is low

The bone marrow fails to respond appropriately due to disease or lack of essential supplies

Slide25

25

Methods of Classification cont’dIncreased blood loss (Acute, Chronic)Retic

count is typically highAnemia results when red cell loss exceeds the bone marrow’s capacity to increase its activityIncreased destruction of RBCs (hemolytic anemias)Retic count is typically highAnemia results when red cell destruction exceeds the bone marrow’s capacity to increase its activity

Slide26

26

Normocytic Normochromic anemia (normal red cell indices)Blood loss anemia Hemolytic anemia

Aplastic anemiaChronic diseaesRenal insufficciency Morphologic Categories of Anemia

Slide27

27

Microcytic hypochromic ( low red cell indices)Iron deficiency anemia

Sideroblastic anemiaLead poisoning ThallassemiaChronic diseases Morphologic Categories of Anemia

Slide28

28

Macrocytic Normochromic ( high MCV and MCH, normal MCHC)Megaloblastic anemia

Liver diseasePost splenectomyHypothyroidismStress erythropoiesis Morphologic Categories of Anemia

Slide29

29

1 Microcytic/hypochromic

2

1

3

3 Macrocytic/Normochromic

2 Normocytic/Normochromic

N.B. The nucleus of a small lymphocyte (shown by the arrow) is used as a reference to a normal red cell size

Morphologic Categories of Anemia

Slide30

30

1. Microcytic- Hypochromic Anemia

Slide31

31

Microcytic- Hypochromic Anemia

Many RBCs smaller than nucleus of normal lymphocytesIncreased central pallor.Includes Iron deficiency anemiaThalassemiaAnemia of chronic disease Sideroblastic anemiaLead poisoning

Slide32

32

Iron

Protoporphyrin

Heme

Globin

+

Hemoglobin

Iron deficiency

Chronic inflammation or malignant

(ACD)

Thalassemia

(

 or )

Sideroblastic anemia

The Cause of

Microcytic

Hypochromic

Anemia

Slide33

33

RBC maturation in microcytic anemias

Normoblastic

RBC maturation

normocytic red cells

Abbott Manual

Microcytic/Hypochromic

Anemias

Normal RBC maturation is shown for comparison

Slide34

34

A. Iron Deficiency Anemia (IDA) Is a condition in which the total body iron content is decreased below a normal level

This results in a reduced red blood cell and hemoglobin productionMore than half of all anemias are due to iron deficiency.

Slide35

35

Iron Deficiency Anemia (IDA)Causes:Nutritional deficiency

Malabsorption (insufficient or defective absorption)Inefficient transport, storage or utilization of ironIncreased needChronic blood loss (GI bleeding, ulcer, heavy menstruation, etc)

Slide36

36

DIETARY SOURCES OF IRON

Inorganic Iron eg lentils

Organic iron

eg

beef

DAILY IRON REQUIREMENT 10-15mg/day (5-10% absorbed)

Slide37

37

Adult men 0.5-1

Post menopausal female 0.5-1Menstruating female 1-2Pregnant female 1.5-3Children 1.1Female (age 12-15) 1.6-2.6

Estimated daily iron requirements

Units are mg/day

Slide38

38

Amount of iron in average adult

Male (g) Female (g) % of total

Hb 2.4

1.7

65

ferritin & hemosiderin

1.0

0.3

30

Myoglobin

0.15

0.12

3.5

Heme enzyme

0.02

0.15

0.5

Transferrin-bound

iron

0.004

0.003

0.1

The distribution of body iron

Slide39

39

Iron Deficiency Anemia (IDA) Sequence of Iron Depletion

When iron loss or use exceeds absorption, there is a sequence of iron depletion in the body:Storage iron decreases/ low serum ferritin; serum iron & TIBC are normal, no anemia, normal red cells.

Serum iron decreases/TIBC increases (increased transferrin); no anemia, normal red cells.

Anemia

with microcytic/hypochromic red cells = IDA.

Slide40

40

CLINICAL FEATURES IRON DEFICIENCYSymptoms eg.

fatigue, dizziness, headache Signs eg. pallor, Tongue atrophy/ glossitis - raw and sore, angular cheilosis (Stomatitis)

Glossitis

Angular

Cheilosis

or Stomatitis

Koilonychia

Slide41

41

Clinical signs and symptomsSpoon‑shaped nails (koilonychia), brittle nails and hair.

Slide42

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Lab Investigation of IDAIron TestsUsed to differentiate microcytic hypochromic anemia's or detect iron overload (hemochromatosis)

Iron circulates bound to the transport protein transferrinTransferrin is normally ~33% saturated with ironIron Tests Include:serum iron, Total Iron Binding Capacity (TIBC), serum ferritin

Slide43

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Lab Investigation cont’dSerum iron level measures the amount of iron bound to transferrinDoes not include the free form of iron

Total Iron Binding Capacity (TIBC)Is an indirect measure of the amount of transferrin protein in the serumInversely proportional to the serum iron levelIf serum iron is decreased, total iron binding capacity of transferrin increased (transferrin has more empty space to carry iron)

Slide44

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Serum ferritin Indirectly reflects storage iron in tissues Found in trace amount in plasma It is in equilibrium with the body stores

Variation in the quantity of iron in the storing compartment is reflected by plasma ferritin concentration e.g. Plasma ferritin is decreases in IDA, Plasma ferritin increases in ACDLimitation: During infection or inflammation Serum Ferritin increases like other acute phase proteins, and then it is not an accurate indicator in such situations.

Lab Investigation cont’d

Slide45

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Bone marrow iron (Tissue iron)Tissue biopsy of bone marrowPrussian blue stain

Type of iron is hemosiderin

Slide46

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ABSENT IRON STORES IN BONE MARROW IN IRON DEFICIENCY

Iron deficiency

Normal control

Slide47

47

Iron Deficiency AnemiaLab findingsLow RBC, Hgb, HctLow MCV, MCH, MCHC

Normal WBC and PLT

Blood smear

Slide48

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Iron Deficiency AnemiaRBC morphologyHypochromia

MicrocytosisAnisocytosisPoikilocytosis Pencil cells (cigar cells)Target cellsno RBC inclusionsIron parametersLow serum iron, High TIBC, Low serum ferritin

Blood smear

Slide49

49

Wright’s stained blood smear

Ovalocytes

- Pencil forms No RBC inclusions

Iron Deficiency

Slide50

50

B. Sideroblastic Anemia (SA)This group of anemias are characterized by:Defective protoporphyrin

synthesis (blocks) resulting in iron loadingA hypochromic anemia due to deficient hemoglobin synthesis.

Block(s

) in

protoporphyrin

synthesis leads to iron overload and microcytic/hypochromic anemia

Slide51

51

Terms:Siderocytes

are mature RBCs in the blood containing iron granules called Pappenheimer bodies....abnormal.Sideroblasts are immature nucleated RBCs in the bone marrow containing small amounts of iron in the cytoplasm....normal.

Slide52

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Sideroblastic anemia is characterized by theAccumulation of iron in the mitochondria of immature nucleated RBCs in the bone marrow;

Iron forms a ring around the nucleus  these are called ringed sideroblasts....abnormal. Sideroblastic Anemia (SA)

Slide53

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Lab Findings:Microcytic/hypochromic red cells, low MCV and MCHC; variable anemia, low retic.RBC inclusions: Basophilic stippling and

Pappenheimer bodies (siderocytes). (May see target cells).High serum iron and high serum ferritin (stores); low TIBC. Decreased transferrin synthesis occurs in iron overload states.Bone marrow: ringed sideroblasts (Hall mark of Sideroblastic Anemia)

Sideroblastic Anemia (SA)

Slide54

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54

RBC with iron

Wright’s stain

NRBC with iron

Prussian blue stain

NRBC with ring of iron

Prussian blue stain

Pappenheimer bodies

Blood

Bone marrow

Bone marrow

Sideroblast

Ringed Sideroblast

Sideroblastic Anemia (SA)

Slide55

55

Pappenheimer bodies

Wright’s stain

Blood

Basophilic stippling/stippled RBCs

Blood

Pappenheimer bodies

Prussian blue iron stain

Blood

Sideroblastic Anemia (SA)

Slide56

56

100x

Ringed Sideroblasts

Prussian blue iron stain

Bone marrow

10x

Increased stainable iron

Prussian blue iron stain

Bone marrow

Bone

marrow findings (if done):

Ringed

sideroblasts

demonstrated with Prussian blue stain.

Increased stainable iron in macrophages.

Slide57

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C. Anemia of chronic diseaseAnemia of chronic disease (ACD) – inability to use iron and decreased response to EPO Very common anemia

Associated with systemic disease, including chronic inflammatory conditions:Rheumatoid arthritisChronic renal disease Thyroid disease Malignancies Tuberculosis Chronic fungal infections etc

Slide58

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ACD pathogenesisLactoferrin is an iron biding protein in the granules of neutrophils

Its avidity for iron is grater than transferrinDuring infection or Inflammation, neutrophil-lactoferrin released into plasma and Hunts available ironBind to macrophage and liver cells (because they have receptor for lactoferrinCytokines: Produced by macrophages during inflammation and contribute to ACD by inhibiting erythropoiesis

Slide59

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Lab DiagnosisBlood findings

Early stage: normocytic normochromic.Late stage: hypochromic microcytic. LeukocytosisAbundant storage of iron in macrophage (Prussian blue)

Slide60

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60

Target cells/Codocytes

Beta

Alpha

D.

Thalassemias

Inherited decrease in alpha or beta globin chain synthesis needed for Hgb A;

quantitative

defect

All have microcytic/hypochromic RBCs and target cells

Genetic mutations classified by:

↓ beta chains = beta thalassemia…Greek/Italian

↓ alpha chains = alpha thalassemia…Asian

Slide61

61

Haemoglobin

Molecule

Hgb A = 2

α

& 2

β

Hgb A

2

=

2

α

& 2

δ

Hgb F

=

2

α

& 2

γ

Consists of 4 globin chains + 4

heme

groups

Normally

, each individual inherits 2α, 1β, 1γ, and 1δ gene from

each

parent.....so 4α, 2β, 2γ, and 2δ genes are inherited.

97%

2%

1%

Slide62

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Thalassemia Impaired alpha or beta globin synthesis results in an unbalanced

number of chains produced that leads to:RBC destruction in beta Thalassemia majorProduction of compensatory Hgb types in beta thalsFormation of unstable or non-functional Hgb types in alpha thals

Slide63

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ThalassemiaSeverity ranges from lethal, to severe transfusion-dependency, to no clinical abnormalities; severity depends on the number and type of abnormal globin genes inherited.Major

 severe anemia; no α (or β) chains are produced, so cannot make normal hemoglobin (s).Minor/trait  mild anemia; slight decrease in normal hemoglobin types made.

Slide64

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Heinz bodies

Excess alpha chains

Supravital stain

Beta

Thal

Major (Homozygous)

Both beta genes abnormal

Marked decrease/absence of beta chains leads to alpha chain excess…no Hgb A is produced

Rigid RBCs with Heinz bodies destroyed in bone marrow and blood (ineffective erythropoiesis)

Slide65

65

Stippled NRBC

NRBC

Target cell

Wright’s stained blood smear

HJB

Beta

Thal

Major (Homozygous)

CLINICAL FINDINGS

Lab Findings

Severe anemia, target cells, nucleated red cells

RBC inclusions

No hemoglobin A; compensatory Hgb F

Slide66

66

Hypercellular Bone Marrow

(10x)

Pap bodies

NRBC

Transfused RBC

Target cell

Blood smear

Howell-Jolly body

Target cells

Blood smear

Transfused RBC

Beta

Thal

Major (Homozygous)

Treatment

Transfusion

Splenectomy

Iron chelation

Slide67

67

Wright’s stained blood smear

Stippled RBC

Target cell

Beta

Thal

Minor (Heterozygous)

One abnormal beta gene

Slight decreased rate of beta chain production

Blood picture can look similar to iron deficiency

Lab findings

Mild anemia, target cells, no

nRBCs

, stippled RBCs

No Heinz bodies

Normal iron tests

Compensates with Hgb A2

Ovalocytes

Slide68

68

Alpha Thal Major/Homozygous

Deletion of all 4 alpha genes results in complete absence of alpha chain productionNo normal hemoglobin types madeKnown as Barts Hydrops FetalisDie of hypoxia….Bart’s Hgb

Slide69

69

Target cells

Wright’s stain blood smear

Heinz bodies E

xcess beta chains

Supravital stain

Alpha

Thal

Intermedia = Hgb H Disease

Three alpha genes deleted

Moderate decrease in alpha chains leads to beta chain excess…unstable Hgb H

Moderate anemia

Slide70

70

Alpha Thal Minor (Heterozygous)

One or two alpha genes deleted (group)Slight decrease in alpha chain production Mild or no anemia, few target cellsEssentially normal electrophoresis; many undiagnosed

Slide71

71

Beta Thalassemias

Slide72

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Alpha Thalassemias

Slide73

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+

HGB Synthesis Defects

Differential Diagnosis of Microcytic Anemia

Slide74

Distinguishing features between iron def (IDA) and thalassemia Mentzer index: MCV/RBC <13 favors thalassemiaThe RBC count in thalassemia is more than 5.0 x 106

/μL (5.0 x 1012/L) and in IDA is less than 5.0 x 106/μL

(5.0 x 1012/L) MCV usually less than 70 in TT, more than 70 in IDA The red cell distribution width (RDW) in IDA is more than 17% and in TT is less than 17%.

74

Slide75

75

2. Macrocytic Normocytic Anemias

Slide76

76

Macrocytic Normocytic Anemias

Wright’s stained blood smear

Slide77

77

A. MEGALOBLASTIC ANEMIAVitamin B12 deficiency

Folate deficiencyAbnormal metabolism of folate and vit B12B. Non megaloblastic anemiaLiver diseaseAlcoholism

Post splenoctomy

Neonatal

macrocytosis

Stress erythropoiesis

Slide78

78

A. Megaloblastic Anemia

Macrocytosis due to a deficiency of vitamin B12 or folic acid that causes impaired nuclear maturation Vitamin B12 & folate are DNA coenzymes necessary for DNA synthesis and normal nuclear maturationResults in megaloblastic maturation…nucleus lags behind the cytoplasm and leads unbalanced growth called maturation asynchronyBoth deficiencies cause enlarged fragile cellsMany cells die in the marrow (ineffective)Show a similar blood picture and clinical findingsOnly vitamin B12 deficiency causes neurological

symptoms…required for myelin synthesis

Slide79

79

RBC maturation in microcytic anemias…IDA

Normoblastic RBC maturation

normocytic red cells

Megaloblastic RBC maturation

macrocytic red cells

Megaloblastic

Anemia

Slide80

80

Lab FindingsMild To Severe Anemia, Increased MCV & MCH, normal MCHC

Low RBC, HGB, WBC and PLT counts (fragile cells) due to ineffective hematopoiesis.Low reticulocyte count Macrocytic ovalocytes and teardrops; Marked anisocytosis and poikilocytosis Schistocytes/microcytes - due to RBC breakage upon leaving the BM Erythroid

hyperplasia - low M:E ratio (1:1) Iron stores increased.

Megaloblastic Anemia

Slide81

81

Macrocytic Ovalocytes

Blood

NRBC

Blood

Howell-Jolly body

Teardrop

Schistocyte

Stippled RBC & Cabot Ring

Giant Platelet

Pap bodies

Hypersegmented Neutrophil

>5 lobes

Slide82

82

Vitamin B12 deficiencyOccur as a result of one of the following conditionsNutritional Coballamin

deficiencyAbnormal intragasteric events ( i.e. inadequate proteolysis of food Coballamin)Loss or atrophy of gastric mucosa ( deficient IF)Abnormal events in the small bowel lumenInadequate pancreatic proteaseCompeting agents like fish tape worms

Slide83

83

Folate (Folic acid) Deficiency: Deficient intake. Increased needs: pregnancy

, infant, rapid cellular proliferation, and cirrhosis Malabsorption (congenital and drug-induced) Inherited DNA Synthesis Disorders: Deficient thiamine and factors (e.g. enzymes) responsible for folate metabolism.

Two RBC populations

Dimorphism

Macrocytic RBCs

Microcytic RBCs

Slide84

84

1. Pernicious AnemiaIt is defined as anemia resulting from defective secretion of IF associated with autoimmune attack on the gastric mucosa leading to atrophy of the stomach or abs that block IF action.

Abs block the site of if where vit b12 binds.The diagnosis is confirmed by low serum b12 level and typically abnormal results of schilling test

Slide85

85

Schilling testUsed to diagnose pernicious anemia and determine if IF is available.

If absorbed a portion of oral dose of vit B12 (not used by the body) ---- excreted in urineIf not absorbed (malabsorption)…….. Not detected in urine but pass out in feces

Slide86

86

Polychromatophilic

RBCs Wright’s stain

NRBC

B. Non-

Megaloblastic

Anemia

Macrocytosis

that is NOT due to vitamin B12 or folate deficiency

Accelerated erythropoiesis

Regenerating marrow or marked reticulocyte response following recent blood loss

Slide87

87

Stomatocytes, Alcoholic

Echinocytes

Acanthocytes

Target cells

Non-

Megaloblastic

Anemia

Liver disease and alcoholism

Complex & multiple problems

Degree of anemia varies, round

macrocytes

Target cells/

acanthocytes

- due to abnormal lipid metabolism.

Echinocytes are also commonly found on the smear in liver disease.

Slide88

88

Blood smear

Differential Diagnosis of Macrocytic Anemia

Megaloblastic

and non-

Megaloblastic

Perform B12 and folate levels

Specific morphology

Slide89

89

3. Normocytic Normochromic Anemia

Slide90

90

3. Normocytic Normochromic AnemiaIt includes

Aplastic anemia due to BM failureBlood loss anemia Hemolytic anemia

Is a condition in which the size & Hgb content of RBCs is normal but the number of RBCs is decreased.

Slide91

91

A. Aplastic AnemiaCondition of blood pancytopenia caused by bone marrow failure…decreased production of all cell lines and replacement of marrow with fat.

Due to damaged stem cells, damaged bone marrow environment or suppressionNo extramedullary hematopoiesis

Slide92

92

Types of aplastic anemiaPrimary/idiopathic = 50%

Secondary/acquired….chemicals, drugs, infections, radiation = 50%Congenital….Fanconi’s Aplasia plus dwarfism, skeletal abnormalities, mental retardation, abnormal skin pigmentation.

Slide93

93

Bone marrow, decreased # precursor cells

10X

Normal RBCs No Platelets

Blood

Lab diagnosis of Aplastic Anemia

Normochromic

–Normocytic

RBC

(normal MCV & MCH)

Low

reticulocyte count & Hgb

Pancytopenia

No

abnormal cells

Hypoplasia

Bone marrow

Normal Serum iron, vitamin B12 and folate levels

Slide94

94

B. Hemolytic anemia Result from an increase in the rate of pre mature red cell destruction. Compensated hemolytic disease

Uncompensated hemolytic diseaseIt leads toErythropoietic hyperplasia BM produces red cells 6 to 8X the normal rateMarked reticulocytosis

Slide95

95

Two main mechanisms for RBC destruction in HAIntravascular hemolysis: in the circulationExtravascular hemolysis: in RE system (reticuloendothelial system)

B. Hemolytic anemia

Slide96

96

Extravascular hemolysisAged RBC 120 dayAbnormal RBC

During destruction RBC releases Hgb Hgb

Exstravascularly

removed

by Macrophage (RES)

in BM, liver and spleen

Iron

reabsorbed

Globin

Amino acid

Protein synthesis

Protoporphyrin

Unconjugated bilirubin

liver (glucuronic acid)

conjugated bilirubin

gut reabsorbed &

Excreted as

urobilin

& urobilinogen

Slide97

97

Extravascular hemolysisLab Features Increased RBC break down

Serum bilirubin increaseStool urobilinogen increaseBlood urobilinogen increaseUrine urobilinogen increase

Slide98

98

Intravascular hemolysis Red cells are destroyed in blood vessels and Hgb is released into the circulation:

Free Hgb

Saturates plasma

haptoglobin

Excess free Hgb is filtered by the

glomerules

(kidney)

(if rate of hemolysis saturates renal reabsorption capacity)

Free Hgb enters urine

Fe is released in bladder tubule

Renal tubule loaded with hemosiderin

Slide99

99

Intravascular hemolysisLab FeaturesHemoglobinemia and hemoglobinuria

Hemosiderin uriaReduced/absent serum haptoglobin

Slide100

100

1. Hereditary hemolytic anemiaThis is a congenital hemolytic anemia. some of which present at birth and other later in life, while still others may remain silent unless a physiological stress is super imposed

Result of intrinsic red cell defects Membrane defect (Hereditary Shperocytosis, Elliptocytosis and sickle cell anemia)Metabolic defect : G6PDH and PK defic Hgb chain defect (

hemoglobinopatheis) : sickle cell anemia

Slide101

101

Spherocytes

A. Hemolytic

Anemias

due to Membrane Defects

Most common is Hereditary Spherocytosis (HS)

Membrane defect is decreased

spectrin

and increased permeability of membrane to sodium ions

Lab findings

Anemia varies

Few to many

spherocytes

on smear, high MCHC

Increased OF test

Slide102

102

H Ovalocytosis

Normocytic ovalocytes

H.

Ovalocytosis

/

Elliptocytosis

Membrane defect is polarization of cholesterol or hemoglobin at ends and increased sodium permeability

Over 25%

ovalocytes

Most asymptomatic

Mild anemia in 10-15%

Slide103

103

H Stomatocytosis

Hereditary Stomatocytosis

Membrane defect is abnormal permeability to sodium and potassium

Caused by edema

20-30%

stomatocytes

on blood smear

Mild to severe hemolytic anemia

Slide104

104

H Acanthocytosis = Abetalipoproteinemia

Hereditary

Acanthocytosis

Defect is increased membrane cholesterol due to abnormal plasma lipids

Numerous

acanthocytes

on smear

Mild anemia

Also known as

abetalipoproteinemia

Slide105

105

PK Deficiency

Echinocytes

PK deficiency

↓ATP impairs

cation

pump

Severe hemolytic anemia

Echinocytes

G-6-PD Deficiency

Unable to protect Hgb due to decreased NADPH

No clinical problems unless exposed to oxidants

Exposure to oxidants induce Heinz body formation and RBC destruction

Normal RBCs

if no exposure to oxidant

G-6-PD Deficiency

B. Hemolytic Anemias due to Enzyme Defects

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G-6-PD deficiency after exposure to oxidant

Heinz bodies -

denatured Hgb

Supravital

stain

G-6-PD deficiency Hemolytic episode

Damaged RBCs Wright’s stain

G-6-PD Deficiency

Blood findings after oxidant exposure:

Mod to severe anemia

Schistocytes

,

spherocytes

due to pitting out of Heinz bodies by spleen

Enzyme assay

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Target cells/Codocytes

C. Normocytic

anemias

due to

hemoglobinopathies

Inherited hemoglobin defect with production of structurally abnormal globin chains;

All have target cells

Beta chain amino acid substitution = variant Hgb

Hgb S = valine substituted for glutamic acid @ 6th of ß

Hgb C = lysine substituted for glutamic acid @ 6th of ß

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HGB S Disease (Hgb SS)

Sickle cell

Target cell

Hemoglobin S Disorders

Two sickle cell genes inherited (both beta chains are abnormal)

Symptomatic after 6 months of age

Lab findings

Severe anemia

Targets, sickle cells

NRBCs, inclusions

No Hgb A, >80% Hgb S, ↑ F

A.

Hemoglobin S disease/Sickle cell anemia/

Hgb

SS

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Target cells only

NO Sickle cells

HGB S Trait (Hgb SA)

Hemoglobin S Disorders

One sickle cell gene inherited

Lab Findings

Asymptomatic, targets only

No anemia or sickle cells

~60% Hgb A, ~40% Hgb S

Potential problems if hypoxic

B. Hemoglobin S trait/Sickle cell trait/

Hgb

SA

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C crystals

HGB C Disease (Hgb CC)

Target cell

Hemoglobin C Disorders

Lab findings

Mild anemia

Many target cells

Intracellular C crystals

No Hgb A, >90% Hgb C

Decreased OF

A.

Hemoglobin C disease/

Hgb

CC

Two C genes inherited (

both β chains are abnormal)

C crystals polymerize differently and look like blocky Hgb packed rods

in

the red cells....intracellular

.

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HGB C Trait (Hgb CA)

Target cells only

NO C crystals

Hemoglobin C Disorders

B.

Hemoglobin C trait/

Hgb

CA

One C gene inherited

Lab findings

Asymptomatic, no anemia

Targets, no C crystals

~60% Hgb A, ~40% Hgb C

Normal Hgb A2 and F

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SC Crystals

Target cells

HGB SC Disease (Hgb S & Hgb C)

Hemoglobin SC Disease

Lab findings

Intermediate in severity between Hgb SS & SA

Several target cells

Many SC crystals

No Hgb A, ~50% Hgb S, ~50% Hgb C, ↑ F

Hemoglobin SC disease/

Hgb

SC

One sickle gene and one C gene inherited

Double heterozygote‑ inherit sickle gene (S) from one parent and C gene from other parent;

Both β chains are abnormal

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2. Acquired hemolytic anemiaA variety of acquired conditions result in shortened survival of previously normal red cells. These include immune mediated destruction, red cell fragmentation disorders, acquired membrane defects, spleen effects

Result of extrinsic causesImmune HA; warm HIHA, cold AIHADrug associatedInfection associated

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Spherocytes & polychromasia

Blood

Warm Autoimmune HA (WAIHA)

Altered immune response causes production of an

IgG

warm autoantibody against ‘self’ RBC antigens

Antibody/complement attaches to RBC antigen…partially

phagocytosed

(loss of membrane) 

spherocytes

Cause

:

Primary (idiopathic) or secondary to disease

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Ingestion of coated RBC

RBC

Electron Microscopy

Blood

Monocyte with ingested RBC

RBC

Warm Autoimmune HA (WAIHA)

Lab findings

Mod to severe anemia,

spherocytes

, high MCHC

Erythrophagocytosis

Looks similar to H spherocytosis but positive DAT

Increased OF, bilirubin

Erythroid hyperplasia

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50x

RBC Agglutination

100x

Cold Autoimmune HA (CAIHA)

Altered immune response causes production of an

IgM

cold autoantibody against ‘self’ RBC antigens

Antibody/C3 attaches to RBC antigen  agglutination (

lysis

by complement or macrophage)

Primary (idiopathic) or secondary to disease

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Cold Autoimmune HA (CAIHA)Lab findingsAgglutination of red cells in extremities....ears, toes, nose

 tissue damage  gangre Severity varies with seasons….avoid the coldIgM antibodies cause RBC agglutinationReticulocytosisPositive Direct Antiglobulin

Test (detects complement)

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Hemolytic Transfusion ReactionIncompatible blood transfusionRecipient has antibodies to antigens on the donor red cells received

Donor cells are destroyedABO worstIntravascular hemolysis that is complement-induced lysis…immediateCan be life-threatening

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Hemolytic Disease of the Newborn Caused by maternal IgG

antibodies directed against baby RBC antigensAntibodies cross placenta and destroy fetal red cellsHDN due to Rh incompatibilityRh negative mother forms Rh antibody after exposureHDN due to RhSever anemiaMany nucleated red cellsHDN due to ABO incompatibility Mother’s ABO blood type is O; baby is type A or B

HDN due to ABOMild, no anemia

Spherocytosis

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Schistocytes

Fibrin Strands

RBC

RBC fragmentation on fibrin strands

Hemolytic

Anemias

due to Trauma

Fragmentation syndromes…most common finding on smear are

schistocytes

; anemia varies

Types of trauma

Mechanical…prosthetic heart valves/cardiac abnormalities

Microangiopathic

(MAHA)…small vessels (DIC.........bleeding)

March

hemoglobinuria

…forceful contact….

Schistocytes

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Schistocytes

& Spherocytes

Hemolytic

Anemias

due to Infectious Agents, and Thermal Burns

Anemia varies, with severe hemolysis

Schistocytes

and

spherocytes

on blood smear

Parasitize RBC, elaborate lytic toxins or cause direct damage to red cell membrane

Malaria fever

Closteridal

infections..release

toxins

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END OF ANEMIA