Anemia 101- Case Studies

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Anemia 101-Case Studies

• Peter A. Kouides MD
• Associate Professor of Medicine,
• University of Rochester School of Medicine
  Attending Physician,
• The Rochester General Hospital

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Anemia classification based on the mechanism

• Kinetic Classification (based on retic count)
• Decreased production
• Morpholgical classification (based on MCV)
• Microcytic
• Normocytic
• Macrocytic
• Increased destruction
• Immunological classification (based on Coombs
  test)
• Immune-mediated
• Non-immune mediated

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The Medical Students Approach to Anemia

• Check the reticulocyte count to determine if the
  anemia is from decreased production
  (hypoproliferative, reticulocytopenic) or
  increased destruction (hemolytic)/acute blood
  loss (reticulocytosis)
• 2. If decreased production, narrow down the
  causes in terms of the MCV-
• If the MCV is low, then do iron studies then Hb
  electropheresis
• If the MCV is normal, check the serum creatinine
  and TSH, if they are WNL then consider bone
  marrow exam
• If the MCV is high check a folate and vitamin B12
  level
• 3. If the the reticulocyte count is increased-
• Check a direct Coombs test
• 4. Look at the peripheral blood smear to
  confirm/support the diagnosis

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Anemia Algorithm

• Patient with anemia and decreased reticulocyte
  count-

What is the MCV ??
Microcytic
Normocytic

• Macrocytic
• Vitamin-related
• B12, Folate
• Non-vitamin
• MDS
• EtOH/Liver Disease
• Hypothyroidism

Fe def.
Systemic Diseases
Thal

• Diseases in Bone Marrow
• MDS
• Solid Tumor
• Myeloma
• Aplastic anemia

Renal vs. Liver vs. Endocrine vs. Anemia
of Inflammation
Other sideroblastic anemia (meds,PB,Zn
excess,Cu def)
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Anemia Algorithm, continued

• Patient with anemia and increased reticulocyte
  count HEMOLYTIC ANEMIA

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Anemia Algorithm, continued

• Patient with anemia and increased reticulocyte
  count-

What is the result of a Coombs test ??
Negative
Positive (autoimmune hemolytic
anemia)
Intrinsic red cell defect
Extrinsic red cell defect
Warm
Cold
Membrane
Cytoplasm
Vessel
Valve
Hemoglobin
Toxin
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The Attendings Approach to Anemia

• 1. Stool guiacs x 3
• 2. If the MCV is low, then prescribe iron
• 3. If the MCV is high, then check a folate level
  and vitamin B12 level
• if folate level returns low or indeterminate,
  then begin folic acid 1 mg po qd
• if B12 level returns low or indeterminate, then
  begin IM vitamin B12

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The Pharmacologists Approach to Anemia
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Case 1-A 67-year-old man is referred for
evaluation of dyspnea. The hematocrit is 28,
white blood cell count 4500/mm3, platelet count
550,000/mm3, and reticulocyte count 4. The MCV
is 78 and the blood smear reveals basophilic
stippling and a small population of hypochromic
microcytic red cells. Serum Fe 225, TIBC 260,
Ferritin 490
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Case 2-Patient H.M.

• A 57-year-old woman presents to the clinic for
  evaluation of ataxia, weakness, and parathesias.
  The patient has been taking a multivitamin
  preparation.
• Hematocrit is 38
• white blood cell count 4,000 platelet count
  100,000
• What tests would you order next ?

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• Case 3- A 65-year-old man with a Hematocrit of
  33 and a reticulocyte count of 7 is admitted to
  the hospital with right upper quadrant abdominal
  pain. Peripheral blood smear reveals occasional
  spherocytes.

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Case 4- Patient R.B.

• A 26-year-old woman presents to the hospital
  with pleuritic chest pain. She gives a history
  of episodic arthralgias for a number of months,
  plus one episode of frank arthritis involving the
  small joints of both hands occurring 2 months
  prior to admission. The patient has a hematocrit
  of 29, a white blood cell count of 4000, and a
  reticulocyte count of 12. The smear reveals
  normocytic, normochromic red blood cells with
  polychromatophilia, and occasional spherocytes,
  occaisonal NRBC.

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Case 5- Patient F.D.

• A 60-year-old woman is hospitalized because of
  severe fatigue and dyspnea of 2 weeks' duration.
  Five years ago, the patient had a total
  hysterectomy and bilateral salpingo-oophorectomy
  for ovarian adenocarcinoma. She received a
  course of oral melphalan as adjuvant chemotherapy.

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Patient F.D. continued

• Three years ago a restaging laparotomy reveals no
  evidence of tumor, and blood counts were normal.
  
• Now, except for a temperature of 38.4C (101.1F)
  and pallor, she has normal findings.
• Laboratory studies Hematocrit 17, MCV 108 fL.
  , WBC 4,500, platelet count 50,000, reticulocyte
  count 0.8

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MDS vs. Folate/B12 Deficiency

• Think of MDS when the anemic patient is elderly
  and the MCV is increased
• in one study of the elderly, MDS was the fourth
  most common cause of anemia after
• acute blood loss/Fe Deficiency
• anemia of chronic disease
• anemia of renal insufficiency
• the B12 level can be borderline low in elderly
  patients but it is not true B12 deficiency if-
• a serum total homocysteine level is normal
• a urine methylmalonic acid level is normal

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Case 6- Patient G.D.

• A 28 year-old black man plans a trip to India and
  is advised to take prophylaxis for malaria.
  Three days after beginning treatment, he develops
  dark urine, pallor, fatigue, and jaundice
• Hematocrit is 26 (it had been 43), MCV 100 WBC
  3.4, Platelets 199,000

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Patient G.D. continued

• Reticulocyte count 13
• What test should be diagnostic?
• And, why do I say should instead of is
  diagnostic?

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Drugs Causing Anemia
LESS COMMON- Decreased Production Anti-Tb drugs
Sideroblastic Anemia Chloramphenicol, Valproic
acid Pure Red Cell Aplasia AZT,
Dilantin Macrocytic Anemia
MORE COMMON- Increased Destruction
(Hemolytic) Qunidine, PCN, Aldomet
Auto-immune Hemolytic Anemia Primaquine,Nitrofuran
toin, Dapsone, Pyridium G6PD
Deficiency
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Case 7

• A 21-year-old woman with sickle cell anemia has
  had a fever and severe pain in the right shin for
  3 weeks. The painful area is hot, swollen,
  tender and indurated.

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Case 8

• A 66-year-old-man presents with increased fatigue
  and anemia. Hypothyroidism was detected 3 years
  ago and thyroid hormone therapy was administered.
  Anemia was diagnosed 2 years ago, but findings
  on bone marrow examination were normal, and there
  was no response to oral therapy with iron.
  Sexual function has diminished during the last 2
  years. He has a blood pressure of 90 Hg systolic
  and 60 mm Hg diastolic, pallor, absence of
  axillary hair, and sparse pubic hair. There is
  no gynecomastia, but the testicles are soft, and
  the prostate gland is small. The result of an
  examination of the stool for occult blood is
  negative. Laboratory studies hematocrit 36,
  leukocyte count 5800/µL, platelet count
  255,000/µL, peripheral blood film - normochromic
  normocytic erythrocytes with anisocytosis or
  poikilocytosis, MCV 86 fl, serum creatinine -
  normal.