Anemia

I m RBC moss: Ha <41% or Hb < 13.5 g dl (men); Hct <36% or Hb < 12 g dl (women) Clinical manifestations

• Symptoms: A O2 delivery fatigue, exertional dyspnea, angina (if CAD)

• Signs: pallor (mucous membranes, palmar creases), tachycardia, orthostatic hypotension

• Other findings: jaundice (hemolysis), splenomegaly (thalassemia, neoplasm, chronic hemolysis), petechiae/purpura (bleeding disorder), glossitis (iron, folate, vitamin B12 defic.). koilonychia (iron defic.). neurologic abnormalities (B12 defic.) Diagnostic evaluation

• History: bleeding, systemic illness, drugs, exposures, alcohol, diet (including pica). FHx

• CBC w differential; RBC parameters incl. reticulocyte count. MCV. RDW

• Reticulocyte index (Rl) [reticulocyte count • (Pt's Ha nl Ha)] maturation factor maturation factors for a given Hct: 45% 1.35% 1.5.25% - 2.20% 2.5 Rl »2% — adequate marrow response; Rl - 2% — hypoproliferation

• Peripheral smear seiea area where RBCs evenly spaced and very few touch each other

Peripheral Smear Findings

Feature

Abnormalities and diagnoses

Size

normocytic vs. microcytic vs. macrocytic — see below

Shape

anisocytosis unequal RBC size; poikilocytosis irregular RBC shape spherocytes -» HS.AIHA; sickle cells sickle cell anemia stomatocyte • central pallor appears as curved slit liver disease. EtOH tear drop cells dacryocytes -» myelofibrosis, myelophthisic anemia, megaloblastic anemia, thalassemia schistocytes. helmet cells - MAHA (eg. DIC.TTP HUS). mechanical valve echinocytes burr cells (even, regular projections) -» uremia, artifact acanthocytes spur cells (irregular projections) liver disease target cells — liver disease, hemoglobinopathies, splenectomy bite cells (removal of Heinz bodies by phagocytes) -* G6PD deficiency rouleaux hyperglobulinemia (eg. multiple myeloma)

Intra-

findings

basophilic stippling (ribosomes) -» abnl Hb. sideroblastic, megaloblastic Heinz bodies (denatured Hb) G6PD deficiency, thalassemia Howell-jolly bodies (nuclear fragments) spleneaomy, sickle cell nucleated RBCs — hemolysis, extramedullar hematopoiesis

findings

hypersegmented (>5 lobes) PMNs: megaloblastic anemia (B12 folate def.) toxic granules (coarse, dark blue) and Dohle bodies (blue patches of dilated endoplasmic reticulum) -» sepsis, severe inflammation pseudo-Pelger^Huet anomaly (bilobed nucleus."pince-nez") -♦ MDS blasts - leukemia, lymphoma; Auer rods . acute myelogenous leukemia

(NEJM 200S;JSJ:498>

(NEJM 200S;JSJ:498>

• Additional laboratory evaluations as indicated: hemolysis labs (if Rl >2%). iron, folate, B12.

LFTs, BUN and Cr.TFTs, Hb electrophoresis, enzyme analyses, gene mutation screens

• Bone marrow (BM) aspirate and biopsy (bx) with cytogenetics as indicated

Figure 5-1 Approach to anenna

Anemia

Rl <2%

m>2%

| UNDERPRODUCTION |

] INCREASED DESTRUCTION or LOSS]

J 1 V

t LDH / T bilirubin Í haptoglobin

s/sof bleeding

microcytic normocytic macrocytic anemia anemia anemia

hemolysis

recent acute blood loss

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