"Courage is the price that life exacts for granting peace. The soul that knows it not, knows no rele

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"Courage is the price that life exacts for
granting peace. The soul that knows it not, knows
no release from little things." - Amelia
Earhart
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Anemia A discussion with Pathologist

• Dr. Venkatesh M. Shashidhar
• Senior Lecturer in Pathology
• Fiji School of Medicine

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Blood Smear - Normal
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White Blood Cells
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RBC disorders (Anemias)

• Anemia is decreased red cell mass affecting
  tissue oxygenation
• Low Hb lt13.5 (males), lt11.5 (females)
• Onset, chronicity, presentation pattern.
• Congenital disorders
• Membrane, Hb enzyme disorders.
• Acquired disorders
• Decreased production
• Increased loss

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Congenital RBC Disorders

• (Hemolysis)
• Membrane Disorders
• Spherocytosis, Elliptocytosis
• Hemoglobin Disorders
• Hemoglobinopathies - Sickle cell, HbC etc.
• Thalassemia Syndromes - ?, ?, ?
• Enzyme disorders
• G6PD, PK deficiency

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Her. Spherocytosis
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Sickle Cells
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ß Thalassemia Major
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G6PD Deficiency Anemia
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Acquired RBC disorders
(Deficiency, Marrow disorder, Blood loss
Hemolytic)

• Decreased Production
• Deficiency anemias Iron, B12, Folate etc.
• Aplastic, Hypoplastic anemias
• Marrow disease, malignancy, radiation
• Increased loss/destruction
• Blood loss anemias - parasites, bleeding
• Hemolytic anemias - Autoimmune (cold warm
  antibody) mechanical, drugs toxins.

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Iron Deficiency Anemia
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Megaloblastic Anemia
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Anemia - Differential diagnosis
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Anemia with Low MCV(Microcytic Hypochromic)

• Microcytes when MCV lt80fl.
• Anemia - Many weeks after Iron store depletion.
• lt6micron diameter IDA (moderate in others)
• RDW Red cell Distribution Width - IDA

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Low MCV and Low Retics

• Differential diagnosis
• Iron deficiency
• Sideroblastic anemia
• Thalassemia trait
• Anemia of chronic disease
• Laboratory evaluation
• Iron, iron-binding capacity, and ferritin
• Blood smear - Target cells, stippling, etc.
• Hb electrophoresis for Thalassemia
• Bone marrow iron stores, ring sideroblasts

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Iron Deficiency Anemia
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Iron Deficiency Anemia
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Iron Deficiency Anemia
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High MCV and Low Retics

• Differential diagnosis
• Megaloblastic anemia
• Vitamin B12 deficiency
• Folate deficiency
• Myelodysplastic syndrome
• Drug-induced anemia
• Nonmegaloblastic anemia
• Liver disease
• Hypothyroidism
• Reticulocytosis

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High MCV and Low Retics

• Laboratory evaluation
• Serum vitamin B12, RBC folate
• Examination of peripheral smear for
• hypersegmented neutrophils, giant platelets
• Thyroid function tests,
• Liver function tests
• Bone marrow aspirate for evaluation for
  myelodysplastic features

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20353-Meg.An
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20353-Meg.An
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Megaloblastic Anemia
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Normal MCV and Low Retics

• Differential diagnosis
• Primary bone marrow failure
• Aplastic anemia
• Constitutional red cell aplasia (Diamond-
  Blackfan)
• Acquired red cell aplasia
• Myelophthisis
• Secondary bone marrow failure
• Uremia
• Endocrinology
• Human immunodeficiency virus infection
• Anemia of chronic disease

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Normal MCV and Low Retics

• Laboratory evaluation
• Iron, iron-binding capacity, and ferritin
• Blood smear for marrow disorders teardrop
• Serum creatinine, thyroid function tests, liver
  function tests, cortisol levels if appropriate
  Erythropoietin level
• Bone marrow aspirate and biopsy.

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Bone Marrow Cellularity
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Anemia with high Retics

• Acute blood loss, Splenic sequestration
• Hemolysis
• Immune hemolytic anemia
• Mechanical hemolysis Valve, Microangiopathic(DIC)
  
• Hereditary hemolytic anemia
• Acquired membrane defects PNH
• Infection-related hemolysis Clostridia, malaria.

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Anemia with high Retics

• Laboratory evaluation
• Blood smear RBC Morphology
• Urinary hemosiderin,
• Direct and indirect Coombs test
• Cold agglutinin titer
• Appropriate further tests as indicated by
• Hemoglobin electrophoresis,
• G6PD, PK, Osmotic Fragility, sucrose lysis test,
• bacterial cultures/ smear for parasites.

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Anemia Problem cases
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Polychromasia - Hemolytic An.
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Problem Cases

• Early cases - Not fully evolved
• Mixed conditions nutritional deficiency
• Chronic disorders nutritional deficiency
• Nutritional bleeding more
• Other diseases/Factors Infections, deficiency,
• Megaloblastic anemia with nutrophilia.

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IDA on Treatment
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Clinical History

• 60Year Fiji Indian female
• Progressive Weakness, fainting attacks since few
  months.
• Had blood transfusion for severe anemia a month
  ago.
• Hypertensive on Methyldopa.
• WBC count 166,000, MCV 110, gt80 lymphs

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Blood Film
High WBC
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Blood Film
Lymphoid cells Smear cells (Fragile)
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Bone Marrow Biopsy

• Highly cellular marrow

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Clinical History

• 27 Year Fiji Indian Male
• Anemia chronic.
• Bilateral arthralgia, Moderate Lymph-node
  enlargement and Hepatosplenomegaly
• 6x2cm Bilateral tumor over outer aspect of
  thighs.
• Hb 11gm, PLT- 400,000, very high WBC count
  256,000.

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Left thigh
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Blood Film

• High WBC
• Myeloid cells
• Mature Neutrophils
• Platelets

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Bone Marrow Trephine Biopsy

• Highly cellular

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Diagnosis

• In this case the diagnosis remains uncertain.
• The high white cell count with mature-looking
  cells and the highly cellular bone-marrow suggest
  that his might be a myeloproliferative disorder,
  however it doesnt fit exactly into any of these
  diseases.
• The masses over the hips probably represent sites
  of extramedullary haematopoesis.

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Case - Severe Anemia

• 70year Indian Female
• Presented with Congestive cardiac failure
• Hb 4gm, MCV 136 fl
• ? B12 deficiency
• Not a vegetarian, gastroscopy normal
• Blood smear and Bone marrow.

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Blood Film
Small lymphocyte Macrocytic RBC (oval)
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Bone Marrow
Giant Metamyelocyte
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Diseases do not read books.!Reference range
not normal values.!Complete Picture!
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C.B.C / FBC / Hemogram

• Haemoglobin - 152.5, 14 2.5 - g/dl
• PCV - 0.47 0.07, 0.42 0.05 - l/l ()
• Haematocrit, effective RBC volume - better
• RBC count - 5.5 1, 4.8 1 x1012/l
• MCHC - Hb/PCV - 30-36 - g/dl
• Hb synthesis within RBC
• MCH - Hb/RBC - 29.5 2.5 pg/l
• Average Hb in RBC
• MCV - PCV/RBC 85 8 - fl

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Microcytic Anemia (IDA)
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Macrocytic Anemia (Meg.)
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Thalassemia Trait
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The real art of conversation is not only to say
the right thing at the right place but to leave
unsaid, the wrong thing at the tempting
moment!-- Dorothy Nevill