Med

ANEMIA PRASIT CHANARAT, M.S.(Clin.Path)

Department of Clinical Microscopy Faculty of Associated Medical Sciences, Chiang Mai University PC

ANEMIA

Symptoms : Pallor Jaundice Fatique Palpitation Dyspnea Virtigo Peptic ulcer Glossitis Dysphagia etc

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Classification of Anemia I. Etiologic Classification 1. Impaired RBC production 2. Excessive destruction 3. Blood loss II. Morphologic Classification 1. Macrocytic anemia 2. Microcytic hypochromic anemia 3. Normochromic normocytic anemia III. Kinetic Classification IV. Physiologic Classification PC

Impaired RBC Production 1. Abnormal bone marrow 1.1 Aplastic anemia 1.2 Myelophthisis : Myeloficrosis, Leukemia, Cancer metastasis 2. Essential factors deficiency 2.1 Deficiency anemia : Fe, Vit. B12, Folic acid, etc 2.2 Anemia in renal disease : Erythropoietin 3. Stimulation factor deficiency 3.1 Anemia in chronic disease 3.2 Anemia in hypopituitarism 3.3 Anemia in hypothyroidism

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Excessive Destruction of RBC(cont.) Hemolytic anemia 1. Intracorpuscular defect 1.1 Membrane : Hereditary spherocytosis Hereditary ovalocytosis, etc. 1.2 Enzyme : G-6PD deficiency, PK def., etc. 1.3 Hemoglobin : Thalassemia, Hemoglobinopathies PC

Excessive Destruction of RBC 2. Extracorpuscular defect 2.1 Mechanical : March hemolytic anemia MAHA (Microangiopathic HA) 2.2 Chemical/Physical 2.3 Infection : Clostridium tetani 2.4 Antibodies : HTR, SLE 2.5 Hypersplenism PC

Blood Loss 1. Acute blood loss : Accident, GI bleeding 2. Chronic blood loss : Hypermenorrhea Parasitic infestation

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Macrocytic Anemia MCV > 94 MCHC > 31 1. Megaloblastic dyspoiesis 1.1 Vit. B12 deficiency : Pernicious anemia 1.2 Folic acid deficiency : Nutritional megaloblastic anemia, Sprue, Other malabsorption 1.3 Inborn errors of metabolism : Orotic aciduria, etc. 1.4 Abnormal DNA synthesis : Chemotherapy, Anticonvulsant, Oral contraceptives PC

Macrocytic Anemia MCV > 94 MCHC > 31 2. Non-Megaloblastic dyspoiesis 2.1 Increased erythropoiesis : Hemolytic anemia response to hemorrhage 2.2 Increased membrane surface area : Hepatic disease, Obstructive jaundice, Postsplenectomy 2.3 Idiopathic : Hypothyroidism, Hypoplastic and Aplastic anemia PC

Microcytic Hypochromic Anemia 1.

2. 3. 4.

MCV < 80 MCHC < 31 Fe deficiency anemia : Chronic blood loss, Inadequate diet, Malabsorption, Increased demand, etc. Abnormal globin synthesis : Thalassemia with or without Hemoglobinopathies Abnormal porphyrin and heme synthesis : Pyridoxine responsive anemia, etc. Other abnormal Fe metabolism : PC

Normocytic Normochromic Anemia 1. 2. 3. 4. 5. 6. 7.

MCV 82 - 92 MCHC > 30 Blood loss Increased plasma volume : Pregnancy, Overhydration Hemolytic anemia : depend on each cause Hypoplastic marrow : Aplastic anemia, RBC aplasia Infiltrate BM : Leukemia, Multiple myeloma, Myelofibrosis, etc. Abnormal endocrine : Hypothyroidism, Adrenal insufficiency, etc. Kidney disease / Liver disease / Cirrhosis

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Kinetic Classification of Anemia 1. Insufficient erythropoiesis Stem cells , Hypoplastic marrow, Infiltrated BM 2. Ineffective erythropoiesis - Megaloblastic anemia - Thalassemia - Sideroblastic anemia 3. Uncompensated hemolytic disease with continued bleeding PC

Physiologic Classification of Anemia 1. RPI (Reticulocyte Production Index) < 2 (Ineffective erythropoiesis) 1.1 Hypoproliferative anemia 1.2 Maturation disorder 2. RPI > 3 (Effective erythropoiesis 2.1 Hemolytic anemia 2.2 Blood loss anemia PC

Physiologic Classification of Anemia 1. RPI (Reticulocyte Production Index) < 2 (Ineffective erythropoiesis) 1.1 Hypoproliferative anemia (normocytic normochromic, N/N) - Hypoplastic anemia - Idiopathic/ Chemical/ Infectious / Drug --> Maturation arrest - Myelophthisic anemia (Marrow infiltration) - Refractory anemia (Dysmyelopoietic syndrome) PC

Physiologic Class. of Anemia RPI < 2

1.1.1 N/N and normal RDW a) BM failure b) Decrease marrow stimulation - Endocrine disease - Anemia of chronic disease - Renal disease 1.1.2 Abnormal RBC morphology & RDW a) Oval macrocyte :- Refractory dysmyelopoietic b) Dacrocytes/ tear drops :- Myelophthisic PC

Physiologic Class. of Anemia RPI < 2

1.2 Maturation disorder 1.2.1 Microcytic, high RDW a) Siderblastic (Microcytic dimorphic RBC) b) Fe def. (Microcytic hypochromic RBC) 1.2.2 Microcytic, normal RDW a) Heterozygous, thalassemia syndrome b) Anemia of chronic disease 1.2.3 Macrocytic a) Liver disease b) Folate def. c) Vit. B12 def. d) Hemolytic anemia (Normocyte polychromasia)

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Physiologic Classification of Anemia 2. RPI > 3 (Effective erythropoiesis) 2.1 Hemolytic anemia - Intrinsic hereditary disorder - Extrinsic acquired disorder 2.2 Blood loss - Acute blood loss - Chronic blood loss (without treatment --> microcytic, hypochromic anemia) PC

Evaluation of Anemia A. Hematologic 1. Hematocrit (VPRC preferred) 2. Hemoglobin concentration 3. RBC indices : MCV, MCH, MCHC 4. Leukocyte count 5. Reticulocyte count 6. Platelet count 7. ESR (Erythrocyte sedimentation rate) 8. Stained blood smear : RBC morphology PC

Evaluation of Anemia B. Urine analysis 1. Appearance : Color, pH, Clarity, sp gr 2. Test for protein, Bence Jones protein 3. Bilirubin, Uribilinogen 4. Occult blood 5. Microscopic examination C. Stool 1. Appearance : Color, consistency 2. Occult blood 3. Examination for ova, parasites PC

Evaluation of Anemia D. Serum or Plasma 1. BUN 2. Creatinine, if urea N is abnormal 3. Bilirubin : Direct, indirect 4. Protein 5. SI (Serum iron), TIBC (Total iron binding capacity) E. Special tests in hematology Hb typing / Ham acid test / Coombs’ test, G-6PD, Ferritin, Sucrose test, Autohemolysis test, Haptoglobin, et c. PC

DDx of Common Anemia in Thailand Hb < 9-10 gm/dL

1. Acute anemia 1.1 Acute blood loss BP , Pulse --> Acute hemorrhage 1.2 No acute blood loss • Jaundice, hemoglobinuria --> G-6-PD def. • Jaundice, No hemoglobinuria --> AIHA (NCNC), HS (Spherocycyte), hemoglobin H disease (HCMC) • Jaundice, fever --> Malaria • No jaundice --> G-6-PD def., Hb H, Acute leukemia

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DDx of Common Anemia in Thailand Hb < 9-10 gm/dL

2. Chronic anemia 2.1 No hepatosplenomegaly • No petichiae and purpura --> Fe def. Anemia, anemia of chronic disease, folate def. • Petichiae & purpura --> ITP + Fe def., Acute leukemia (Blast cell), Aplastic anemia • Chronic disease --> Chronic renal failure, rheumatoid arthritis, infective endocarditis, hypothyroidism, etc. PC

DDx of Common Anemia in Thailand Hb < 9-10 gm/dL

2. Chronic anemia 2.2 Hepatosplenomegaly • Mongoloid face --> Thalassemia • No Mongoloid face with lymphadenopathy --> Acute leukemia, lymphoma, TB lymph node • Liver disease

DDx

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Mechanisms of Anemia Production Disorders: ✹Hematopoietic Cell Damage -Drugs, Radiation, Infections, Toxins

✹Factor Deficiency -Iron (Heme Synthesis) -Vitamin B12 (DNA Synthesis) -Folate (DNA Synthesis)

Mechanisms of Anemia Survival Disorders: ✹Blood Loss - External or Internal ✹Red blood Cell Destruction -Hemolytic Anemias

Anemia Manifestations - Cause & Chronicity Nonspecific Signs and Symptoms ✹Weakness, Malaise, Fatigue ✹CNS hypoxia - Headaches, Faintness, Dimness of Vision ✹Skin Pallor, Thinning and Inelasticity ✹Nail Brittleness ✹Angina Pectoralis (if ASCVD)

Production Disorder - Iron Deficiency ✹Most Common Nutritional Deficiency ✹Required in Hemoglobin Synthesis Heme + Globin Chains = Hemoglobin ✹Occurs in RBC Cytoplasm ⇒ Hypochromic Microcytic Anemia

Iron Metabolism ✹Iron is Absorbed Primarily in Duodenum - 25% of Heme-Bound Iron (Red Meat) - 1-2% of Non-Heme Iron

✹Body Losses of Iron are Limited - 1-2 mg/Day By Epithelial Cell Shedding

✹Mucosal Block - Maintains Balance

Transferrin ✹Transport Protein For Iron In Blood ✹Fully Saturated Transferrin = TIBC 300 - 350ug/dl Fe ✹Normal Transferrin - 1/3 Filled With Iron 100 - 120ug/dl Fe (Serum Iron)

Iron Storage Ferritin - Protein Iron Complex *Found In All Tissues *BM, Liver (Transferrin) *Spleen (RBC Breakdown) Hemosiderin - Breakdown Product of Ferritin

Development of Iron Deficiency ✹Depletion of Stores ⇓ Serum Ferritin ⇓ Stainable BM Iron ⇑ Transferrin (↑ TIBC) Fe

⇓ Serum

⇓ Transferrin Saturation ✹

Iron Deficiency Anemia Laboratory Findings

✹Hypochromic Microcytic Anemia (↓ RBC Count, ↓ MCV) ✹↓ Serum Ferritin Levels ✹ ↓ Transferrin Saturation (↓ Serum Fe, ↑ Transferrin)

Causes of Iron Deficiency ✹External Blood Loss - Most Common Female Genital Tract Gastrointestinal Tract ✹↑ Demand - Infancy, Pregnancy ✹Dietary Deficiency - Rare (Vegetarian Diets) ✹Intestinal Malabsorption Syndrome

Iron Deficiency Clinical Manifestations ✹Anemia - Non-Specific Findings ✹Koilonychia ✹Plummer-Vinson Syndrome -Hypochromic Microcytic Anemia -Atrophic Glossitis -Esophageal Webs (Dysphagia)

Koilonychia - Iron Deficiency

Hypochromic Microcytic Anemia (Iron Deficiency)

Vitamin B12 Absorption B12

Stomach

B12 IF IF B12

Parietal cells produce IF

IF

B12

Ileum IF receptors B12

Vitamin B12 Deficiency ●Western World - Pernicious Anemia Autoantibodies (Serum and Gastric) IF

B12 IF

⇓ IF Function

Parietal Cell

⇓ Gastric Production

Production Disorder Vitamin B12 or Folate Deficiency Megaloblastic Anemias ✹Impaired DNA Synthesis (Nucleus) ✹Function - Transfer of Carbon Groups ✹Affects All Rapidly Dividing Cells -Mouth - Atrophic Glossitis -GI tract - Intestinal Malabsorption

Megaloblastic Anemia Peripheral Blood ✹RBCs - Large Oval Macroovalocytes - MCV > 100u3 ✹Anemia Due To Ineffective Hematopoiesis - Autohemolysis of Megaloblasts (Circulating Large RBCs Destroyed) ✹Hypersegmented Neutrophils ✹Thrombocytopenia, Neutropenia (Severe)

Macroovalocytes and Hypersegmented Neutrophil

Vitamin B12 Deficiency - Cause Western World - Pernicious Anemia ✹Autoimmune Disorder -Autoantibodies to IF and Parietal Cells -Chronic Atrophic Gastritis -Achlorhydria - Absent HCL ✹⇑ Incidence of Other Autoimmune Disorders

Vitamin B12 Deficiency Additional Causes: ✹Inadequate Diet - Rare (>20yr Stores) -Foods Containing Animal Protein -Microorganisms Synthesize -Stored in Liver, Reabsorbed in Bile ✹Gastrectomy, Ileal Resection ✹Malabsorption States, Gastric Atrophy ✹Diphyllobothrium Latum - Fish Tapeworm

Megaloblastic Anemia - Bone Marrow Nuclear- Cytoplasmic Asynchrony: ✹Erythroid Series (Hallmark Changes) -Megaloblasts -Erythroid Hyperplasia ✹Myeloid Series ✹Megakaryocytic Series - (Infrequent)

Normal Erythroids (Left); Megaloblasts (Right)

B12 and Folate in DNA Synthesis dUMP

dTMP

DNA

Thymidylate Synthetase

FH4 (Folate)

N5 - Methyl FH4

Methyl Cobalamin Cobalamin (Vitamin B12)

Vitamin B12 Deficiency ✹Clinical - Similar to Folate Deficiency But Demyelinating Neurologic Disorder - Affects Both Sensory and Motor Tracts - Lack of Correlation With Anemia ✹Parenteral B12 - Improves Anemia, +/- Resolution of Neurologic Symptoms ✹Caution! Anemia of B12 Deficiency Also Improves With Folate Supplementation

Vitamin B12 Deficiency Laboratory Findings: ●Low Serum Vitamin B12 Levels ●Normal RBC Folate Levels ●Abnormal Schilling Test - Impaired Absorption of Radioactive Vitamin B12 Correctable by Addition of IF ●Anti-Intrinsic Factor Antibodies (AntiParietal Antibodies Less Sensitive)

Causes of Folate Deficiency ✹Dietary Deprivation - Widely Distributed in Foods (Uncooked Vegetables, Fruits, Liver) - Limited Body Stores (Wks-Months) - Chronic Alcoholics, Elderly, Indigent ✹Malabsorption (Upper 1/3 Intestine) - Intestinal Disease (Sprue, Celiac Dx) - Chronic Drugs (Dilantin)

Folate Deficiency ✹Increased Requirements - Pregnancy ✹Impaired Utilization - Folic Acid Antagonists (Chemotherapy Drugs) Laboratory Findings: ✹Red Blood Cell Folate - Reflects Tissue Content of Folate Throughout Body ✹Serum Folate - Levels Fluctuate Based on Recent Intake, Do Not Reflect Stores

Anemia of Chronic Disease ✹Normochromic Normocytic Anemia (or Hypochromic Microcytic) ✹Chronic Disorders (Inflammation or Tissue Necrosis) -Chronic Microbial Illnesses -Chronic Immune Disorders -Neoplasms ✹Often ↓ TIBC, ↑ Ferritin

Anemia of Chronic Disease Defect Storage Iron IL-1 TNF γ IFN

α

Erythroid Precursors (Insufficient Erythropoietin)

Bone Marrow Storage Iron (Blue)

Hematopoietic Cell Damage Aplastic Anemia Bone Marrow Aplasia (Lack of Cells) ✹Failure of Multipotent Stem Cell - T-cell Mediated Suppression or - Genetic Damage ✹Bone Marrow - Markedly Hypocellular ✹Peripheral Blood - Pancytopenia - Normochromic Normocytic RBCs

Markedly Hypocellular BM - Aplastic Anemia

Aplastic Anemia Causes of Stem Cell Failure ✹Idiopathic (>50%) - Poor Prognosis Especially If < 40 Years Old ✹Whole Body Irradiation ✹Viral Infections - Most Common After Non-A/Non-B Hepatitis ✹Chemical Agents and Drugs Reversible and Non-Reversible

Myelophthisic Anemia BM Replacement ⇒ BM failure: ●Metastatic Carcinoma Most Common ●Destruction By Non-Neoplastic Process is Less Common i.e. Fibrosis, Infection ●Peripheral Blood Cytopenias, Immature Circulating Cells

Breast Cancer Replacing BM

ANEMIA

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