Anemia

1
Anemia

• Clinical Pathology
• Kristin Canga, RVT

2
Reading Assignment

• Page 68 Lab Pro book
• Clinical Application box (Iron Deficiency
  Anemia) on pg. 12 of AP book
• Pages 55 57 Lab Pro book (about counting
  reticulocytes)

3
Anemia

• Literally means no blood but clinically means
  an ______________ ____________________below
  normal in any of the following values
• ________________________________________
• ________________________________________
• ________________________________________
• In other words, anemia is a condition of reduced
  oxygen carrying capacity of RBCs
• Rate of RBC ______________________ decreased
• Rate of RBC ______________________ increased

4
Aiding in Classification and Diagnosis of Anemia

• A thorough ___________ must be obtained.
• This helps the doctor know what the patient has
  been ____________ /____________, where they have
  been, how long they have been suffering, and
  possibly _________ the anemia has occurred.
• A physical exam should be completed.
• Put your ____________ on the animal!
• Look for _____________, _____________,
  _____________, active bleeding, elevated
  heart/respiratory rates, etc
• A complete _____________evaluation is a MUST.

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Petechia
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Ecchymosis
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PATIENT HISTORY

• 1. __________________________of clinical signs
• ______________ onset suggests acute
  _________________ or ______________
• ______________ onset suggests chronic
  ______________ or bone marrow depression
• 2. Evidence of blood loss
• ______________
• ______________
• ______________
• Blood in ______________

8
PATIENT HISTORY

• 3. ____________________________
• 4. Existence of an underlying condition or prior
  illness
• ____________________________
• ____________________________
• ____________________________
• 5. Exposure to drugs
• - human ______________ , ______________
• 6. Exposure to toxic ______________ in the
  ______________
• - ______________ , poisonous _________,
  ______________

9
PHYSICAL EXAMINTION

• ______________
• Suspect infection, leukemia, hemorrhage, or
  hemolysis
• Character of ___________________
• ______________
• ______________ liver disease or hemolysis
• ______________ ______________ hemolysis
• ______________ - hypoxia
• ______________ or ______________ platelet or
  vascular defect

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PHYSICAL EXAMINATION

• 3. Palpation
• ______________
• ______________
• ______________
• ______________
• 4. ______________ signs of underlying disease
• 5. External wounds
• ______________
• ______________
• ______________

11
Classification and Dx of Anemia

• Classification is to aid in discovering the
  _______________ and to help guide
  __________________.
• Remember Anemia is not a __________________,
  but a sign of an underlying health concern.
• Anemia may be considered ___________________ or
  ________________________ and is generally
  classified/diagnosed in one of two different
  ways
• By RBC ________ and ____ concentration
• RBC ____________________ (MCV, MCHC)
• By bone marrow response
• ________________________________
• ________________________________

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LABORATORY EVALUATION

• Initial laboratory tests to evaluate the anemic
  patient include (but not limited to)
• ______________ (and color of supernatent plasma)
• Total ______________ protein
• Examination of ______________ and
  ____________________________
• Total ______________ count
• ______________ estimation
• ______________ concentration
• Total ______________ count
• ______________
• ______________ evaluation

13
PCV Test yourself ?

• What is it measuring?
• Normal ranges for dogs?
• Normal ranges for cats
• Plasma (supernatent) colors?

14
Plasma Protein

• What is it measuring?
• How is it measured?
• What is normal range for dogs and cats?

15
How Many Cells should you have?

• As a rule, the following values should be
  considered
• RBC total numbers should be in the ______________
  .
• (106/µL)
• Plt total numbers should be in the ______________
  of ______________ . (200,000 500,000/µL)
• WBC total numbers should be in the ______________
  to ____________________________ . (6,000
  17,000/µL)
• Neutrophils 60 77
• Lymphocytes 12 30
• Monocytes 3 10
• Eosinophils 2 10
• Basophils rare (lt2)

In dogs and cats
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Blood Film Evaluation and WBC Differential

• What area are you evaluating?
• How are cells arranged?
• Are RBCs normal?
• How many WBCs are counted?
• How many fields are counted for plt. estimation?
• What is calculation for plt. estimation?

17
Total WBC Count

• Overall count should be in ______________ to
  ____________________________ . (6,000-17,000)
• Total count calculated by machine
• Manual hemacytometer is rare in clinic and
  diluent is no longer available.
• Increased WBCs ______________
• Decreased WBCs ______________

18
Hemoglobin Calculation

• Done by machine.
• Aids us in calculating average ______________ of
  RBCs (_______)
• Aids us in calculating average ______
  concentration within RBCs (_______)
• Can aid in calculating average ______________ of
  Hb within average RBC. (_______)
• MCH is LEAST accurate

19
Classifying Anemia by RBC indices

• MCV ____________________________
• MCHC ____________________________
• MCH ____________________________

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Rules of Thumb (ROTs)

• Hb concentration is _______ of PCV (in g/dL)
• Total RBCs are _______ of PCV (in millions)

21
Classification by RBC Indicies

• Recall that MCV (mean corpuscular volume)
  describes the average volume of the individual
  RBC
• Normal MCV _____________________
• Increased MCV _____________________
• Decreased MCV _____________________
• FORMULA (PCV / Total RBC) X 10 MCV
  (femtoliters)
• Normal MCV canine 60 77 fl.
• feline 40 55 fl.

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Lets do the math

• The MCV of a patient with a PCV of 12 is
• Step 1 Recall the formula
• (_______/ ______________) X 10 MCV
  (femtoliters)
• Step 2 Remember the ROT
• total RBC ? _______ PCV so
• ______________ ______________
• Step 3 plug in the numbers
• ___________________________________
• Is this normal for k9/fel?
• How would you classify this RBC?

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Possible Causes of Abnormal MCV

• Possible causes of Increased MCV
• Increased _____________________activity 1
• Reticulocytosis
• Congenital (____________________________)
• Cats with _______ (/- anemia)
• Possible causes of Decreased MCV
• ______________ deficiency 1
• Congenital disorder (_______and ______________)

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Classification by RBC Indicies

• MCHC (mean corpuscular hemoglobin concentration)
• Describes the ratio of the _______of hemoglobin
  to the ______________in which it is contained
  (concentration of hemoglobin in the avg. RBC)
• Normal MCHC ______________
• Decreased MCHC ______________
• High MCHCs artifact WHY???

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Formula

• (______ / ______) X ______ MCHC (g/dL)
• Normal MCHC canine ______________g/dL
• feline
  ______________g/dL
• Remember the ROTs?
• If you calculate MCHC by estimating Hb, the
  values will always come out the same.
• Lets do the math!

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Using the ROT

• The MCHC of a patient with a PCV of 33 is
• Step 1 Recall the formula
• (_______ / _______) X _______ MCHC (g/dL)
• Step 2 Remember the ROT
• Hb ? _______ of PCV so
• _______ _______
• Step 3 Plug in the numbers
• __________________________________________

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Using actual numbers

• The patients Hb is 9g/dL, and their PCV is 30
• Formula (_______/_______) x _______
• SO ____________________________g/dL
• Is this normal for k9? Fel?
• How would it classify the RBC?

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Low MCHC usually results from

• Severe _______deficiency
• Marked, regenerative anemia
• ____________________________RBCs that do not yet
  have their full complement of Hb.
• MCHC increase
• Presence of ______________, ______________, and
  ___________ can interfere with tests and
  ______________increase MCHC
• True _____________________anemia cannot exist
  the erythrocyte cannot be oversaturated with
  ______.

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Morphologic Classification of Anemia by RBC
Indicies
MCHC normal MCHC decreased
MCV normal Normocytic Normochromic Normocytic Hypochromic
MCV increased Macrocytic Normochromic Macrocytic Hypochromic
MCV decreased Microcytic Normochromic Microcytic Hyprochromic
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Normocytic Normochromic
Macrocytic Microcytic
Hyperchromic Hypochromic
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Calculating MCH

• You will need to know HOW to do this for VTNE,
  even though it is the _______accurate of the
  indices.
• Calculates the average _______of Hb contained in
  average RBC.
• (_______/_______) x _______ MCH in picograms
  (pg)
• Normal ranges
• K9 _______pg
• Fel _______pg

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Lets do the Math

• The MCH of a patient with a PCV of 54 is
• Step 1 Remember the formula
• (_______/_______) x _______ MCH
• Step 2 Remember the ROT
• Hb ? _______ PCV and RBCs ?_______ PCV
• _______ _______ and _______ _______
• Step 3
• Plug in the numbers
• _____________________pg

33
Diagnosis of Anemia According to Bone Marrow
Response

• Most applicable way to differentiate between
• ________________________ and _____________________
  ___ anemia

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Bone Marrow Response

• Regenerative anemia
• Characterized by evidence of increased
  ______________ and delivery of new erythrocytes
  into ______________ (usually within 2-4 days).
• Usually suggests bone marrow is responding
  appropriately to either
• _____________________ (acute or chronic internal
  or external) or
• _____________________ (intravascular or
  extravascular)
• Involves determining whether absolute
  _____________________ numbers are increased in
  the blood.

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Bone Marrow Response

• Non-regenerative anemia
• Lack of circulating ______________ RBCs in the
  face of _______ indicates a nonregenerative
  anemia and likely results from bone marrow
  ______________.
• Either reduced erythropoiesis or defective
  erythropoiesis
• No response evident in ______________blood.
  (usually ______________ ______________)
• _____________________examination may be helpful
  with the diagnosis.

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Regenerative Anemia

• Blood Loss Anemia
• Acute _____________________ relatively large
  amount of blood lost in a brief period.
  (______________ ______________)
• PCV initially ______________
• Reticulocytes should appear _______ hrs (peak
  within 1 week)
• Causes
• ______________
• Internal or external
• Accidental or surgical
• ______________disorders
• Bleeding ______________ or large ______________

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Regenerative Anemia

• Chronic blood loss (_______Deficiency Anemia)
  lost ______________and ______________for a period
  of time.
• a. Parasites
• ______________, _______, blood-sucking _______,
  coccidia spp.
• b. GI ulcers and neoplasms
• c. Inflammatory bowel disease
• Overuse of ______________donors
• Note neonates can become iron deficient due to
  lack of adequate dietary _______ intake.

38
Iron Deficiency Anemia

• Body compensates for anemia by lowering
  _______-_______ affinity, preferential shunting
  of blood to vital _______, increased
  ______________output (tachycardia), and increased
  levels of _____________________.
• With decreasing _______ stores, erythropoiesis is
  limited and RBCs become ______________and
  deficient in _______ (______________and
  _____________________).
• Hallmark of iron deficiency anemia is decreased
  _______.
• Keratocytes schistocytes
• Clinical signs include lethargy, weakness,
  decrease exercise tolerance, anorexia, lack of
  grooming, mild systolic murmur.

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Regenerative Anemia

• 2. _____________________ increased rate of
  erythrocyte _______________________ within the
  body.
• Immune-mediated
• -_____________________
• -_____________________
• - Incompatible _____________________
• Blood Parasites
• -Hemotrophic Mycoplasmas
• - ______________________spp.
• - ________________________

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Cytauxzoon felis inclusions
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Regenerative Anemia

• c. Heinz body anemia
• Plants
• Onions, garlic
• ______________________
• Drugs or Chemicals
• (______________________, Propylene glycol, Zinc,
  Copper, Methylene blue, Naphthalene,
  ______________________, phenothiazine, benzocaine
• Diseases (in cats)
• Diabetes mellitus
• Hyperthyroidism
• Lymphoma

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Regenerative Anemia

• d. ______________________ induced hemolysis
• RBC glycolysis is inhibited by hypophosphatemia
  no glycolysis no ATP (energy) for RBC cell
  lysis
• Diabetic cats
• Enteral alimentation

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Regenerative Anemia

• e. Other Microorganisms
• ______________________
• Clostridium spp. and Leptospirosis (cattle)
• ______________________
• ______________________
• f. ______________________intoxication (usually
  calves)
• can also occur as a result of inappropriate
  administration of ______________________ therapy.
• g. ______________________ RBC defects
• ______________________ (shortened RBC lifespan)
• RBC membrane transport defects
• Chronic intermittent hemolytic anemia (Abyssinian
  and Somali cats)

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Regenerative Anemia

• h. Miscellaneous
• Metabolic disorders (anything that interferes
  with synthesis of ______________________, RBC,
  etc. or anything that interferes with
  ______________________processes of RBC)

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Non-regenerative Anemia

• Most non-regenerative anemias are
  ______________________
• Further sub-classified based on whether
  ______________________ (neutrophil production)
  and ______________________ (platelet production)
  are also affected.
• Animals with non-regenerative anemia in
  conjunction with ______________________
  (neutropenia and thrombocytopenia) usually have
  ____________ cell injury.
• Possible causes drugs, toxins, viruses (FeLV),
  radiation, and immune-mediated stem cell injury.

46
Non-regenerative Anemia

• Reduced ______________________
• Chronic ______________________ disease
• Endocrine deficiencies
• Inflammation and neoplasia
• Cytotoxic damage to the ______________________
• Estrogen toxicity
• Cytotoxic cancer drug therapy
• Chlormphenicol (cats)
• Radiation
• Other drugs

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Non-regenerative Anemia

• e. Infectious agents
• FeLV
• ______________________ spp.
• ______________________
• f. Immune-mediated
• Continued treatment with recombinant
  erythropoietin
• ______________________ aplastic anemia
• g. Congenital/inherited
• h. ______________________ and other
  ______________________ disorders

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Non-regenerative Anemia

• 2. Defective ______________________
• Disorders of ___________ synthesis
• Iron, copper, and pyridoxine deficiencies lead
  toxicity drugs
• Folate and ____________ deficiencies
• Abnormal ______________________
• can be inherited, drug-induced or idiopathic

49
Reticulocyte Count

• Probably the most important diagnostic tool used
  in the evaluation of anemia.
• Fewer _____________ erythrocytes are present in
  anemic animal more ______________________are
  present.
• Expressed as a _____ of the RBCs present.
• The lifespan of a normal RBC is about 110 days
  (dogs) and 68 days (cats).
• Bone marrow should replace ___ of the RBCs
  daily so the reticulocyte count should be
  _____-______.

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Reticulocyte Count

• Gently mix 4 drops of blood with 4 drops of new
  methylene blue in a test tube.
• Let mixture stand for 15 minutes
• Use 1 drop of mixture to prepare a diagnostic
  blood film and observe under high-power,
  oil-immersion field.
• Count 1,000 RBCs while separately keeping track
  of the number of reticulocytes (only aggregate
  form)
• Divide the reticulocyte number by 1,000 and
  convert to a percentage. (Multiply by 100)

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Example Reticulocyte count

• If you see 10 retics on slide 1 and 15 on slide
  2, your total is 25 reticulocytes.
• 25/1000 0.025 x 100 2.5

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Corrected Reticulocyte Count

• Performed to take in account the reduced number
  of circulating RBCs in the anemic animal.
• Called CRC or Corrected Reticulocyte Count
• FORMULA
• Observed retics x PCV / normal PCV
• (Normal PCV use 45 for dogs and 35 for cats)
• Ex 2.5 X 30 / 45 1.67

Note This calculation is necessary because the
reticulocyte count is misleading in anemic
patients. The problem occurs because the
reticulocyte count is not really a count but
rather a percentage it reports the number of
reticulocytes as a percentage of the number of
red blood cells. In anemia, the patient's red
blood cells are reduced, creating an elevated
reticulocyte count.
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