MSUCOM IM 650

Approach to Anemia

David Minter, DO FACOI

 Approach to Anemia

• Objectives for medical students

– Recite at least 5 items on a differential diagnosis for anemia based on the
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size the red blood cell

– Systematically approach a work up for anemia based a basic complete
blood count, patient history and demographics
– Consistently utilize peripheral smear findings to refine differential
diagnosis of anemia
– Provide at least 5 etiologies of anemia based on MCV
– Provide a work up for a patient to prove hemolysis
– Consistently decide on weather a patient needs a transfusion
 Approach to Anemia

• Life Cycle of Red Blood Cells (RBC)

– Synthesis in bone marrow in response to erythropoietin (EPO) which is
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produced in the juxtaglomerular apparatus in the afferent arterioles of the

kidney
– Last step in synthesis involves creation of reticulocytes
• Reticulocyte = large RBC with some capabilities of protein synthesis
• Reticulocytes live in the bone marrow for ~3 days and finishes maturing
to a RBC in the periphery for one additional day.
– Life span of an RBC is 110-120 days
MSUCOM IM 650

Maturation of RBC
Davidson's Principles and Practice of Medicine. Watson, H.G.; Craig, J.I.O.; Manson, L.M.. Published January 1, 2014. Pages 989-1056. © 2014. Fig. 24.3
 Approach to Anemia
• History
– Dietary habits
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– Medications
– Exposure to chemicals and toxins
– Family history
– Review previous blood tests if available
– Bleeding history (menses, dark stool, recent surgery, etc.)
 Approach to Anemia
• Signs/Symptoms
– The symptoms of anemia are dictated by several factors
• Rate of onset
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– Patients who suffer a gun shot and rapidly loose blood will have more severe
symptoms than a person who looses a few ounces every day with a slow GI bleed
– The faster the onset the less time the body has to adapt to the change
• Severity
– If slow enough, patients can lose ~50% of their blood volume without symptoms (Hgb
of ~6 mg/dl) but below this almost all patients will have some symptoms of anemia
although they may be minor
• Patient’s ability to adapt
– Patients with congestive heart failure or COPD may show signs and symptoms anemia
earlier then other patients as they are unable to tolerate circulating less oxygen
 Approach to Anemia
• Symptoms • Signs
– Fatigue – Skin pallor
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– Muscle weakness – Pale conjunctiva

– Headache – Koilonychia
– Vertigo
– Hypotension/orthostasis
– Tachycardia
– Syncope
– Jaundice
– Dyspnea
– Smooth tongue
– Palpitations – Neurological dysfunction
– Bleeding – Hepatomegaly/Splenomegaly
– Bone deformities
 Approach to Anemia
• Signs/Symptoms
– Jaundice: sclera icterus can indicate hemolysis
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– Thyromegaly: can indicate hypothyroidism

– Lymphadenopathy: diffusely can indicate malignancy
– Enlarged spleen: can indicate chronic malignancy or
portal hypertension from chronic liver disease
MSUCOM IM 650

Koilonychia: spoon-nail typically seen with iron deficiency

MSUCOM IM 650

Pallor: tongue and conjunctiva

 Approach to Anemia
• Physiological adaptations to anemia
– ↑ in oxygenated blood flow
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– ↑ in cardiac rate & output

– Preferential increase in blood flow to vital organs
– ↑ in O2 utilization by tissues
– ↑ in 2,3-DPG (2,3-diphosphoglyceratein) erythrocytes
– Decreased oxygen affinity of hemoglobin in tissues due
to Bohr effect
MSUCOM IM 650

Adaptation to anemia
MSUCOM IM 650

Hemoglobin Oxygen Dissociation Curve

Davidson's Principles and Practice of Medicine. Watson, H.G.; Craig, J.I.O.; Manson, L.M.. Published January 1, 2014. Pages 989-1056. © 2014. Fig. 24.5
MSUCOM IM 650

Approach to Anemia

Work Up
 Approach to Anemia
• Work up = Overview
– Complete Blood Count (CBC)
• Hemoglobin is low, what is low has various limits and can vary with age, gender
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• World health organization (WHO): < 13 g/dl ♂ & < 12 g/dl ♀

– Reticulocyte count and reticulocyte production index
– Peripheral smear
– ? Hemolysis
• Serum bilirubin
• Haptoglobin
• lactate dehydrogenase (LDH)
• Urine hemosiderin
– Bone marrow examination
• depending upon results of other laboratory tests and patient clinical data
 Approach to Anemia
• Work up
– Complete Blood Count: Components
• Hemoglobin (HGB)
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– concentration of the oxygen-carrying pigment in whole blood.

• Hematocrit (HCT)
– % of a sample of whole blood occupied by intact red blood cells
• RBC count
– # of RBCs contained in a specified volume of whole blood
• MCV (mean corpuscular volume Hgb)
– Average weight of Hgb in individual RBC
• MCHC (mean corpuscular Hgb concentration)
– Ratio of Hgb mass to volume
 Approach to Anemia
• Work up
– Complete Blood Count
• Mean Corpuscular Volume (MCV)
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– Average volume of individual RBC

» Normocytic 80.0-100.0 fL
» Microcytic < 80.0 fL
» Macrocytic > 100.0 fL
– Used in the preliminary assessment of anemia pathophysiology

 
MCV =
MSUCOM IM 650

Morphological RBC changes with Anemia

From: Blood Disorders; Pathophysiology of Disease: An Introduction to Clinical Medicine, 7e, 2013; Copyright © 1998 by The McGraw-Hill Companies,
 Normal blood smear
notice that the red blood cell size is
similar to the diameter of the small
lymphocyte nucleus
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 Microcytic Anemia
Smaller sized RBC with less color
Hypochromic microcytic anemia
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of iron deficiency
 Macrocytic Anemia
Enlarged RBCs
Macroovalocytes
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 Approach to Anemia
• Work up
– Complete Blood Count
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• Mean Corpuscular Hgb Concentration (MCHC)

– Ratio of Hgb mass to volume
– Normochromic 32.0-36.0 g/dL
– Hypochromic < 32.0 g/dL
– Hyperchromic > 36.0 g/dL

 
MCHC (g/L) =
 Approach to Anemia
• Work up
– Complete Blood Count
• Mean Corpuscular Hgb Concentration (MCHC)
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– Low MCHC < 32.0 g/dL

» Typically indicative of the same differential diagnosis as those with low MCV
– High MCHC > 36.0 g/dL
» The only erythrocyte that is hyperchromic = Spherocyte.
» Spherocytes have a ↓ surface-to-volume ratio due to a loss of membrane but
have not much of their hemoglobin
» MCHC can be ↑ in some cases of sickle cell anemia and hemoglobin C disease
» Falsely ↑ MCHC
» hemolysis, cold agglutinins, and/or insufficient blood in relation to EDTA in
the collection tube.
 • Spherocytosis
– Small hyperchromatic cells
that lack central pallor
– Formed by loss of RBC
membrane converting
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biconcave appearance to a
sphere
– Hereditary spherocytosis,
immune hemolytic
anemias, and
microangiopathic hemolytic
anemias
 Approach to Anemia
• Work up
– Complete Blood Count
• Red Cell Distribution Width (RDW)
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– Reference interval for RDW is 11.5-14.5%

– Standard deviation of cell size and the mean MCV
– ↑↑ commonly seen in reticulocytosis

 
RDW =
 Approach to Anemia
• Work up
– Reticulocytes count (Retic count)
• Asses the bone marrow’s response to anemia
• Normal = 0.5-2% in adults
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• High levels
– Increased levels of premature RBC seen in the blood stream in response to blood loss
– Hemorrhage & hemolysis
• Normal levels in the face of anemia = decreased RBC production
– Deficiencies: b12, folate, iron
– Chronic disease: renal disease, liver disease, chronic infections, autoimmune disease
– Bone marrow disease: Myelodysplastic disease (MDS), Aplastic Anemia, Red Cell
Aplasia, Myelofibrosis,
– Lymphoma, Marrow Metastasis
– Bone marrow suppression: alcohol, medications, hypothyroid, etc.
• Very Low levels (< 0.1%)
– Aplastic anemia or pure red cell aplasia
MSUCOM IM 650

Reticulocytes contribution to the differential of anemia

MSUCOM IM 650

Reticulocytes: Beaded chains of ribosomes seen on RBCs stained with methylene blue
 Approach to Anemia

• Work up
– Peripheral Blood Smear
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• Test that looks for abnormalities in morphology of red blood cells

• Results typically take > 24hrs to return
• Anisocytosis
– Nonspecific variation in the size of the cells.
– Some variation in size is normal because of the variation in age of the
erythrocytes, younger cells being larger and older cells smaller
• Poikilocytosis
– Nonspecific variation in the shape of erythrocytes
 Approach to Anemia
• Acanthocytes (spur cells)
– Spherical cells with thorny projections
– Increased cholesterol in RBC
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membrane
– Severe liver disease,
abetalipoproteinemia, splenectomy
• Echinocyte (Burr cell)
– Spiculated red cells with small uniform
even distributed membrane projections

– Membrane alteration related to

increased lipids, calcium
– Liver disease, uremia, pyruvate kinase
deficiency
 Approach to Anemia
• Codocyte (Target cell)
– Target/ bull's eye
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appearance
– Excess RBC membrane
cholesterol and decreased
hemoglobin
– Hemoglobinopathies,
thalassemia, obstructive
liver disease, splenectomy
 Approach to Anemia
• Dacryocyte (Teardrop)
– Tennis racquet
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appearance, elongated
with point
– Extension of RBC
cytoplasm
– Myelofibrosis
 Approach to Anemia
• Elliptocyte (oval cell)
– Ellipsoid cell with central
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pallor
– RBC cytoskeletal defects
– Hereditary elliptocytosis,
iron deficiency anemia,
thalassemia, leukemia
 Approach to Anemia
• Keratocyte (Helmet
cells)
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– Notched red cells that

look like horns
– Remnants of destroyed
RBCs
– Microangiopathic
hemolytic anemias, heart-
valve hemolysis,
glomerulonephritis
 Approach to Anemia
• Degmacyte (Bite cells)
– Occurs during hemolysis
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where a Heinz body

(denatured hemoglobin) of
RBCs cells is removed by
the spleen
– Precursors to this are
known as “blister cells”
– Hemolysis, Glucose-6-
phosphate dehydrogenase
(G6PD) deficiency,
Asplenia
 Approach to Anemia
• Schistocytes
– Fragmented cell RBCs of
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various shapes including

triangles
– Microangiopathic hemolytic
anemias, heart-valve
hemolysis, Disseminated
intravascular coagulation
(DIC), severe burns
 Approach to Anemia
• Basophilic Stippling
– Red cells with bluish-
black granular
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inclusions distributed
across their entire cell
area that are
precipitated ribosomes
– Lead poisoning,
thalassemia
 Approach to Anemia
• Sideroblast
– Nucleated erythrocytes that contain
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stainable iron granules

– Identified with Perl's Prussian blue iron stain
– Hereditary
• Myelodysplastic disease (refractory anemia with
ringed sideroblasts), idiopathic
– Secondary
• leukemia, myeloma, myelofibrosis, Lead,
Alcoholism, Drugs/toxin (isoniazid, lead, alcohol).
• Most common acquired = lead and alcohol
 Approach to Anemia
• Howell-Jolly Bodies
– Dark purple or violet
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spherical granules in the

erythrocyte that are DNA
remnants
– Usually filtered by the
spleen and increased
levels are a result of
splenectomy or
functional asplenic
 Approach to Anemia
• Nucleated RBC
– Dark purple or violet
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spherical granules in the

erythrocyte that are DNA
remnants
– Severe hemolysis,
hemoglobinopathies,
splenectomy,
myelofibrosis
 Approach to Anemia
• Work up
– Bone Marrow Biopsy
• Aspiration of liquid bone marrow examined with smears, flow
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cytometry, cytogenetic, molecular diagnostics, and

microbiological studies
• Indications
– Circulating immature cells on peripheral smear
– Severe pancytopenia
– Very Low Retic Count ( < 0.1%)
– Evidence of bone marrow infiltration
– Possible monoclonal paraproteinemia (Example: multiple myeloma)
– Suspicion of myelodysplasia
 Approach to Anemia

• Differential diagnosis for anemia based on work up

– A more common way of creating a differential diagnosis is
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based on mean corpuscular volume (MCV) and reticulocyte

count
– Not all patients will need a peripheral smear but can be helpful
if etiology is unknown
 Normocytic
MCV 80-100
ANEMIA Macrocytic
MCV >100

RETIC <3%
Nutritional Deficiency Megaloblastic
• Iron Microcytic B12 Deficiency
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• B12 MCV <80 Folate Deficiency

• Folate
Chronic disease
Kidney Disease Non-Megaloblastic
Drugs RETIC <3%
Bone Marrow Disease Alcoholism
• MDS Liver disease
• Aplastic Anemia Hypothyroid
RETIC <3%
• Red Cell Aplasia MDS
Fe Deficiency
• Myelofibrosis Lymphoma
Chronic Disease
• Lymphoma
Sideroblastic RETIC >3%
• Marrow Metastasis
Lead Poisoning Hemorrhage
RETIC >3% RETIC >3% Hemolysis
Hemorrhage Hemorrhage
Hemolysis α-Thalassemia (Hg-H)
• DIC β-Thalassemia
• TTP/HUS
• Spherocytosis
• G6PD
• Sickle Cell
MSUCOM IM 650

Possible approach to working up of anemia

Blueprints Medicine, Sixth Edition; Copyright © 2016 Wolters Kluwer; Chapter 63: Anemia; Fig. 63-15 Copyright © Lippincott Williams & Wilkins - All Rights
Reserved
 Approach to Anemia

• Differential diagnosis for anemia based on work up

– Mixed disorders
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• Unfortunately patients can have multiple etiologies for their

anemia. Which can make diagnosis tricky.
• Examples of mixed disorder
– Alcoholism effects on anemia
» Bone marrow suppression
» Chronic liver disease can promote sequestration of blood
» Malnutrition from alcohol can cause nutritional deficiencies (B12, folate)
» Alcohol can induce sideroblastic anemia
MSUCOM IM 650

Approach to Anemia

MICROCYTIC ANEMIA
 Approach to Anemia
• MICROCYTIC ANEMIA (MCV<80)
– Step 1 = Rule Out Iron Deficiency Anemia
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• Ferritin, serum iron, Total iron binding capacity (TIBC)

– Step 2
• Preexisting condition? Congenital = Check Hemoglobin Electrophoresis
• α-thalassemia trait & hemoglobin H disease = normal electrophoresis
– Step 3
• Anemia of Chronic Disease? May need bone marrow biopsy
• DM, connective tissue disease, chronic infections, and malignancy
 Approach to Anemia
• MICROCYTIC ANEMIA (MCV<80)
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• RETIC <3% • RETIC >3%

– Fe Deficiency – Hemorrhage
– Chronic Disease – α-Thalassemia
• Normocytic or Microcytic – β-Thalassemia
– Sideroblastic
– Lead Poisoning
MSUCOM IM 650

Deficiencies associated with microcytic anemia

MSUCOM IM 650

Approach to Anemia

MICROCYTIC ANEMIA
Iron Deficiency
 Approach to Anemia
• Microcytic Anemia
• Iron Deficiency
– Pathology
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• ↑ Iron Loss
– Hemorrhage (GI/GU/menstrual), Hemolysis
• ↓ Iron in Diet
– Vegetarian, Malnutrition, Dementia, psychiatric illness
• ↓ Iron Absorption
– Medication: Proton pump inhibitors, H2 blocker, Quinolones and tetracycline antibiotics
– Bowel disease: Celiac disease, Inflammatory bowel, Gastrectomy
– Dietary: Coffee, tea, milk, cereals, fiber, phosphate containing carbonated beverages,
Multivitamins (calcium, zinc, manganese, or copper)
• ↑ Iron Need
– Pregnancy, Lactation
 Approach to Anemia
• Microcytic Anemia
• Iron Deficiency
MSUCOM IM 650

– What factors can help absorb more ingested iron?

• Vitamin C
• Acidic foods (example tomato sauce)
• Take with meat protein (beef, pork, fish)
• Fasting ingestion of iron
 Approach to Anemia
• Microcytic Anemia
• Iron Deficiency
– Signs/Symptoms
MSUCOM IM 650

• Fatigue (most common), cold intolerance, weakness, pallor, dry mouth,

glossitis, hair loss or pica
– Pica: appetite for substances not appropriate as a food source (ice, clay, soil, or paper products)
• Plummer-Vinson (Rarely presents in the developed world)
– Dysphagia
– Esophageal web
– Atrophic glossitis
– Koilonychia (spoon nails)
– Chlorosis: greenish-yellow skin
– Blue sclera
 Approach to Anemia
• Microcytic Anemia
• Iron Deficiency
– Progression of lab changes in iron deficiency over time
MSUCOM IM 650

• ↓Ferritin → ↓Serum Fe→ ↑TIBC→ ↑RDW→ ↓MCV→ Anemia

• Change in MCV is a late finding
– Workup
• CBC
– Microcytic
– ↑ RDW
– Possibly ↑ platelets (secondary thrombocytosis)
 Approach to Anemia
• Microcytic Anemia
• Iron Deficiency
– Iron Studies
MSUCOM IM 650

• Serum Iron
– Circulating Iron level (normal = 60-160 μg/dL)
– Typically LOW in iron deficiency
– Unreliable as diagnostic test as results can be variable from day-to-day
• Total iron binding capacity (TIBC)
– Amount of transferrin able to bind iron (250-460 μg/dL)
– Typically HIGH in iron deficiency
– Low sensitivity: reduced by inflammation, aging, and poor nutrition.
 Approach to Anemia
• Microcytic Anemia
• Iron Deficiency
– Iron Studies
• Ferritin: Spectrum of sensitivity
MSUCOM IM 650

– most efficient and cost-effective test

– < 12mcdl = Definitely iron deficiency
– < 45mcg/dl = Probably Iron deficiency
– > 100mcg/dl = No Iron deficiency
• Transferrin saturation: (saturation = Fe/TIBC x 100)
– Low in iron deficiency (Normal = 25-45% )

TIP: If Transferrin saturation >45% think hemochromatosis (too much iron). Ferritin
is acute phase reactant meaning that it will increase in acute inflammation making
this difficult to interpret in a hospitalized patient.
 Approach to Anemia
• Microcytic Anemia
• Iron Deficiency
– Work up
• Peripheral Smear: Anisocytosis, Poikilocytosis, Elliptocytosis
MSUCOM IM 650

– Endoscopy for Gastrointestinal bleeding

• Esophagogastroduodenoscopy (EGD): can be expected to reveal a cause
of anemia in between 30-50% of patients with GI bleed
– Small bowel biopsies should be taken during this endoscopy as 2–3% of patients presenting
with Iron deficiency anemia with have celiac disease
• Colonoscopy
– Evaluates the patient for angiodysplasia, cancers, etc.
– Dual pathology (lesions in both the colon and upper GI tracts) occurs in around 10–15% of
patients
– Esophagitis, erosions, aphthous ulceration, and peptic ulcer should not at this stage be
accepted as the cause of the iron deficiency.
 Approach to Anemia
• Microcytic Anemia
• Iron Deficiency
– Treatment
MSUCOM IM 650

• Underlying Cause, Search for bleeds, Replace blood as needed.

• Oral replacement therapy = Feosol Sulfate 325mg PO TID
(~180mg iron daily)
– Hgb should ↑ 2g/dl after ~4 weeks later with uncomplicated disease
– 20% experience GI upset and 30% self discontinue the medication
– Side effects
» Dose-related, GI effects (nausea and constipation); can be diminished by
dose reductions and by lengthening the treatment interval
» Esophagitis and gastritis
 Approach to Anemia
• Microcytic Anemia
• Iron Deficiency
– Treatment
• Intravenous replacement therapy
MSUCOM IM 650

– Indications
» Unable to tolerate PO iron
» History of bowel surgery or bariatric procedures
» End stage renal disease
» Inflammatory bowel disease
» Chemo- induced anemia
– Side effects
» Infusion reactions: mild in 1:200 and major in 1:200,000
» Treatment
» Mild: stop infusion and slow rate once reaction has passed
» Severe: fluids and Steroids
» Avoid diphenhydramine as reaction can worsen reaction
MSUCOM IM 650

Approach to Anemia

MICROCYTIC ANEMIA
Thalassemia
 Approach to Anemia
• Normal Hemoglobin
– Adult Hgb (Hgb A) is composed of 2-
Normal Adult Hemoglobin Electrophoresis
α and 2-β subunits bound to a heme
MSUCOM IM 650

group comprised of a protoporphyrin Hgb A1 95-98%

and iron group
Hgb A2 2-3%

– Fetal hemoglobin Hgb F 0.8-2.0%

• HbF = (α2, γ2)
Hgb S 0%
– Normal adult Hgb
• Hgb A = (a2,b2) Hgb C 0%
– Hemoglobin A2
• HbA2 = (α2, δ2), normal variant
 Approach to Anemia
• Microcytic Anemia
• Alpha Thalassemia
MSUCOM IM 650

– Epidemiology
• More common in persons of African and Southeast Asian
descent
– Pathology
• Defect in chromosome 16 that lead to deficient or absent
synthesis of α-globin chains in hemoglobin production
 Approach to Anemia
• Microcytic Anemia
• Alpha Thalassemia
MSUCOM IM 650

– Spectrum of Disease
• Silent carrier
– 1 gene deletion = (-, α /α,α)
– Asymptomatic, normal hematologic findings
• Trait/Minor
– 2 gene deletion = (-, α /- ,α) or (-, - /α,α)
– Causes with microcytosis, mild anemia; NO hemolysis
 Approach to Anemia
• Microcytic Anemia
• Alpha Thalassemia
– Spectrum of Disease
MSUCOM IM 650

• Intermedia or Hemoglobin H disease

– 3 gene deletion (-,-/-, α) results in excessive β-globulin production and β-4 Hgb
tetramers formation otherwise known as Hemoglobin H
– Hemoglobin H can precipitate in RBCs causing damage and hemolysis
– Hemoglobin H has a higher affinity for oxygen making it less efficient as a carrier
– Causes Severe microcytic anemia, hemolysis, and splenomegaly
• Major or Hgb-Bart’s
– 4 gene deletion = (-,-/-,-) results in γ4 tetramer formation (Hgb-Barts)
– result in hydrops fetalis
 Approach to Anemia
• Microcytic Anemia
• Alpha Thalassemia
– Work up
MSUCOM IM 650

• CBC (microcytic/hypochromic)
– Low MCV (typically <75)
• RDW: ↑ in 90% of patients with iron deficiency and only 50% of
those with thalassemia
– Thus, if a patient has a microcytic anemia and normal RDW it is more likely thalassemia
• Hemolysis = Present in Hemoglobin H disease & Hgb-Barts
– ↑ Indirect bilirubin, ↑ LDH, ↓ Haptoglobin
– Peripheral smear: Target cells, Basophilic stippling
• DNA Sequencing: can confirm diagnosis
 Approach to Anemia
• Microcytic Anemia
• Alpha Thalassemia
– Work up
MSUCOM IM 650

• Hemoglobin Electrophoresis
– Silent carrier
» Normal electrophoresis
– Minor
» Normal electrophoresis after 3 months of age
» Thus this is a diagnosis of exclusion for microcytic anemia
– Intermedia: Hemoglobin H Disease
» Presence of β-4 Hgb (Hgb-H)
– Major: Hemoglobin Bart's
» Presence of γ4 tetramer formation (Hgb-Barts)
 Approach to Anemia
• Microcytic Anemia
• Alpha Thalassemia
MSUCOM IM 650

– Treatment
• Silent carrier; 1 gene deletion = (-, α /α,α)
– None
• Trait/Minor; 1 gene deletion = (-, α /- ,α) or (-, - /α,α)
– None
• Intermedia or Hgb-H; 3 gene deletion (-,-/-, α)
– Transfusion as needed; possible splenectomy
• Major or Hgb-Barts; 4 gene deletion = (-,-/-,-)
– Most die in utero
 Approach to Anemia
• Microcytic Anemia
• Beta Thalassemia
MSUCOM IM 650

– Epidemiology
• Mediterranean, African, and Southeast Asian descent
– Pathology
• Defect of chromosome 11 results of deficient or absent
synthesis of β globin chains in hemoglobin production
 Approach to Anemia
• Microcytic Anemia
• Beta Thalassemia
– Spectrum of disease
MSUCOM IM 650

• Minor (trait)
– Asymptomatic and results in microcytosis and mild anemia
• Intermedia
– Less transfusion dependence, less severe symptoms than Major
• Major (Cooley’s)
– Synthesis from both genes is severely reduced or absent
– Infants develop symptoms as fetal hemoglobin production drops off ( ~6months old)
– Infantile symptoms include pallor, irritability, growth retardation, organomegaly,
jaundice, bony deformity (hair on end appearance on skull x-ray) and facial
deformity (Chipmunk face).
MSUCOM IM 650

Facial abnormalities seen with Thalassemia

Hematology: Basic Principles and Practice. Giardina, Patricia J.; Rivella, Stefano. Published January 1, 2013. Pages 505-535.e13. © 2013. Figure 38-5
 A & B) “Hair-on-end”
appearance of the skull
C) Distortion of the maxillary
bones & poor development of
the sinus cavities caused by
opaque masses of
extramedullary erythropoiesis.
D) Squaring and convexity
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abnormalities of the hands.

Boney abnormalities in Beta thalassemia

Hematology: Basic Principles and Practice. Giardina, Patricia J.; Rivella, Stefano. Published January 1, 2013. Pages 505-535.e13. © 2013. Figure 38-9
 Approach to Anemia
• Microcytic Anemia
• Beta Thalassemia
– Work up
MSUCOM IM 650

• CBC (microcytic/hypochromic)
– MCV (typically <75)
• Hemolysis (↑indirect bilirubin, ↑ LDH, ↓ haptoglobin)
• Hemoglobin electrophoresis
– Minor: HgbA2 >3.5% (normal is 2-3%)
– Intermedia: same pattern as major; differentiated from β-Thalassemia Major
clinically
– Major: absent or ↓HbA, ↑HbF, and normal or ↑HbA2
• DNA Sequencing: can confirm diagnosis
MSUCOM IM 650

Approach to Anemia

MICROCYTIC ANEMIA
Sideroblastic Anemia
 Approach to Anemia
• Microcytic Anemia
• Sideroblastic Anemia
– Definition: disorders in which Hgb synthesis is reduced because of
MSUCOM IM 650

failure to incorporate heme into protoporphyrin to form hemoglobin

– Etiology: Most common is acquired disease from lead and alcohol
• Hereditary, Myelodysplastic syndrome (refractory anemia with ringed
sideroblasts), idiopathic
• Secondary: leukemia, myeloma, myelofibrosis, Lead, Alcoholism,
Drugs/toxin (isoniazid, lead, alcohol).
– Work up: Hypochromic, microcytic anemia
– Bone Marrow: erythroid hyperplasia + > 15% sideroblasts
MSUCOM IM 650

Approach to Anemia

MACROCYTIC ANEMIA
 Approach to Anemia
• MACROCYTIC ANEMIA (MCV >100)
– Step 1 = Review medication list
• Drugs That Cause Macrocytosis: EtOH, drug (hydroxyurea, methotrexate,
trimethoprim, zidovudine, 5-fluorouracil, etc.)
MSUCOM IM 650

– Step 2 = Rule out nutritional causes

• B12 deficiency
– ↑homocysteine levels & ↑ Methylmalonic acid level
• Folate deficiency: ↓Red cell Folate = chronic
– ↑homocysteine levels and Methylmalonic acid level normal
– Step 3
• Does the patient have history of Liver disease?
• Uncontrolled thyroid disease: check TSH
• Peripheral smear + Bone Marrow Biopsy
 Approach to Anemia

• Macrocytic Anemia
• Megaloblastic • Non-Megaloblastic
MSUCOM IM 650

• RETIC <3%
–B12 Deficiency
–Alcoholism
–Folate Deficiency –Liver disease
–Medications –Hypothyroid
• Anticonvulsants –Malignancy
• Myelodysplastic syndrome
• Immunomodulators
• Multiple Myeloma
• Antineoplastic • Lymphoma

• RETIC >3%
–Hemorrhage
–Hemolysis
 Approach to Anemia
• Macrocytic Anemia
– Macrocytosis
• Defined as a mean corpuscular volume (MCV) >100 fl
MSUCOM IM 650

• Occurs in approximately 3% of the general population naturally

– Megaloblastic
• Peripheral smear = macro-ovalocytes and hypersegmented neutrophils
• B12/folate deficiencies
• Medications that interfere with use of B12 & Folate
– Non-megaloblastic
• Round macrocytes or macro-reticulocytes
• Alcohol abuse, liver disease, hypothyroid, MDS, hemolysis/hemorrhage,
splenectomy, Medications
MSUCOM IM 650

Megaloblastic anemia with Hypersegmented neutrophil (blue arrow)

 Approach to Anemia
• Macrocytic Anemia
– Medications causing macrocytic anemia
• HIV meds: stavudine (Zerit), lamivudine (Epivir), zidovudine (Retrovir)
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• Anticonvulsants
– Valproic acid (Depakote), phenytoin (Dilantin)
• Immunomodulators
– Azathioprine, mycophenolate mofetil, Leflunomide, Sulfasalazine
• Antineoplastic
– Methotrexate, hydroxyurea, Fluorouracil
• Trimethoprim/sulfamethoxazole (Bactrim)
• Biguanides: metformin (Glucophage)
• Cholestyramine (Questran)
 Approach to Anemia
• Macrocytic Anemia
• Falsely elevated MCV
– Cold agglutinins
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• Cause the RBCs to clump, making them appear larger to the automatic
counter
– Hyperglycemia
• Blood is more concentrated, and when it is diluted to measure the mean
corpuscular volume, the cells swell more than usual, causing a false
elevation
– Leukocytosis
• Increased turbidity of a sample with very elevated WBC can cause the
machine to overestimate the cell size
 Approach to Anemia
• Macrocytic Anemia
• Pathology
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– Megaloblastic
• Folate/b12 deficiency leads defective RNA and DNA
syntheses and the presence of bigger precursors RBCs.
– Non-megaloblastic anemia mechanism is unknown
 Approach to Anemia
• Macrocytic Anemia
• Cobalamin Deficiency (Vitamin-B12)
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– Source =Animal products (meat and dairy products)

– Function
• Cofactor for methionine synthetase in the conversion of homocysteine to
methionine, and as adenosylcobalamin for the conversion of
methylmalonyl-coenzyme A (CoA) to succinyl-CoA
– Absorption
• Bound to intrinsic factor which is produced in the parietal cells of the
stomach and absorbed in the ileum
 Approach to Anemia
• Macrocytic Anemia
• Cobalamin Deficiency (Vitamin-B12)
– Etiology
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• Impaired absorption
– Pernicious anemia (↓Intrinsic Factor)
– Gastrectomy/bariatric surgery
– Gastritis
– Small bowel disease (Ileal resection, Crohn's disease)
– Pancreatic insufficiency
– Congenital (transcobalamin II deficiency)
– Medications (metformin, PPI)
• Decreased intake
– Vegan & vegetarian diet
 Approach to Anemia
• Macrocytic Anemia
• Cobalamin Deficiency (Vitamin-B12)
– Signs/symptoms
• Paresthesia
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• ↓ Proprioception: vibration, position, ataxic gait, limb weakness

• Spasticity (hyperreflexia)
• Autonomic: postural hypotension, incontinence, impotence
• Weakness
• Altered mental status: confusion, paranoia, psychosis
• Optic atrophy
• Anosmia
• ↓ Taste
• Glossitis
• Hyperpigmentation
• Vitiligo
 Approach to Anemia
• Macrocytic Anemia
• Cobalamin Deficiency (Vitamin-B12)
– Work up
• CBC
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– Only 10 % pts Vitamin B12 deficiency are actually anemic

– Possible thrombocytopenia and leukopenia
– MCV generally >110 fL
• Vitamin-B12
– < 200 = low
– 200-400 = low normal
– > 400 = normal
• ↑↑ Methylmalonic acid and ↑↑ Homocystine levels
– Highly sensitive and specific; Early predictors of disease
– Can be help in diagnosing if “low-normal level” is true deficiency however
• Peripheral smear: megaloblastic anemia with hypersegmented neutrophils
 Approach to Anemia
• Macrocytic Anemia
• Cobalamin Deficiency (Vitamin-B12)
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– Treatment = B12 replacement

• Amount of Vit B12 need depends on disease process
• PO: inadequate intake, food-cobalamin malabsorption and
pernicious anemia
– PO 1000-2000 μg/day for 1 month then 125-500 μg/day is recommended
– Preferred as this route is cheaper
• Intramuscular or Subcutaneous: treats any cause
– Example of dossing 1000 μg/week for 1 month and monthly thereafter
 Approach to Anemia
• Macrocytic Anemia
• Folate Deficiency
– Source: greens, vegetables, fruits, grains
– Absorption: absorbed in the duodenum and proximal jejunum
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– Etiology
• Decreased intake
– Malnutrition
– Alcoholism
• Decreased absorption
– Small bowel disease (Celiac disease, tropical sprue)
• Increased demand
– Pregnancy
– Hemodialysis
– Chronic hemolytic anemia
 Approach to Anemia
• Macrocytic Anemia
• Folate Deficiency
– Work up
• Folate level
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– Fluctuate rapidly with dietary intake

– Unreliable test
– < 4 mg/L = Low
– 4-8 mg/L = borderline
• RBC Folate levels
– Unaffected by recent dietary changes; Comment on longer term folate stores
– Low levels are also seen with b12 deficiency
• ↑↑ Homocystine & normal Methylmalonic acid
– Helpful for low borderline patients
– Treatment
• Folate 1-5mg PO q24hr; short term until clinical response
MSUCOM IM 650

Approach to Anemia

NORMOCYTIC ANEMIA
 Approach to Anemia
• NORMOCYTIC ANEMIA (MCV 80-100)
– Step 1 = Rule Out Readily Treatable Causes
• Iron + vitamin B12/folate deficiencies
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• Check Kidney function for Chronic Kidney Disease

– Mild-Moderate anemia
– Typically with CKD stage 3 (creatinine clearance < 60 ml/min)
• Check TSH = if High consider hypothyroidism
 Approach to Anemia
• NORMOCYTIC ANEMIA (MCV 80-100)
– Step 2 = Anemia of Chronic Disease or Primary bone
marrow disorder?
MSUCOM IM 650

• Anemia of Chronic Disease = ↑ Erythrocyte Sedimentation

Rate (ESR) + an unremarkable peripheral blood smear study
support the diagnosis
– Differential: Connective tissue disease, chronic infections, and malignancy
• Bone Marrow disorder: Peripheral smear + Bone Marrow
Biopsy
– Especially consider if patient has multiple cell lines decreased (pancytopenia)
• Other: drug effect, alcoholism, radiation/chemical exposure,
and trauma or surgery
 Approach to Anemia
• RETIC <3%
• RETIC >3%
• Nutritional Deficiency
–Iron
• Hemorrhage
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–B12
–Folate
• Chronic disease • Hemolysis
• Chronic Kidney Disease
• Drugs • DIC
• Bone Marrow Disease
–MDS • TTP/HUS
–Aplastic Anemia
–Red Cell Aplasia • Spherocytosis
–Myelofibrosis
–Lymphoma • G6PD
–Marrow Metastasis
MSUCOM IM 650

Approach to Anemia

NORMOCYTIC ANEMIA
Anemia of Chronic Disease
 Approach to Anemia
• Normocytic Anemia
• Anemia of Chronic Disease
– Pathology
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• Inflammation causes changes in iron homeostasis

• ↑ Hepcidin = iron trapping in macrophages
• Bone marrow suppression
• ↓ Erythropoietin production
• ↓ Life span of RBC
– Etiology
• Infections (acute and chronic)
• Cancer
• Autoimmune
• Also: diabetes mellitus, critical illness
 Approach to Anemia
• Normocytic Anemia
• Anemia of Chronic Disease
MSUCOM IM 650

– Work up
• CBC = Normocytic or Microcytic
• ↓ Serum Fe+3, ↑ TIBC, normal or ↑ Ferritin
• ↓ Retic count

• No specific test for this condition thus it is a diagnosis of

exclusion
 Approach to Anemia
• Normocytic Anemia
• Anemia of Chronic Disease
– Treatment
• Typically doesn’t require specific treatment outside of the underlying cause
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• Transfusion: severe & symptomatic anemia (in which the hemoglobin < 8.0 g/dl)
– Long term blood transfusion can have adverse effects on mortality
• Intravenous Iron
– if iron deficiency is present (Ferritin <100mcg/mL)
– if Ferritin >100mcg/dl and Iron treatment is given, it may lead to bacteremia and cardiovascular
damage
• Erythropoietin (Epogen) indications
– Ruled out iron deficiency
– Cancer + Chemo
– Chronic Kidney Disease
– HIV + myelosuppressive therapy
MSUCOM IM 650

Approach to Anemia

Hemolysis
 Approach to Anemia
• Hemolysis
– Can be microcytic, normocytic or macrocytic depending on
MSUCOM IM 650

the cause
– Normal destruction
• RBCs that are older or damaged are taken up in the extravascular
space of the spleen, where they are engulfed by macrophages
• The resulting hemoglobin is broken down into Iron and biliverdin
• A minority of blood is broken down in the intravascular space where
hemoglobin bound to haptoglobin in order to be cleared by the liver
 Approach to Anemia
• Hemolysis
• Non immune mediated: Mechanical
MSUCOM IM 650

– Physical trauma to red blood cells within blood vessels

– Examples: Microangiopathic hemolytic Anemia
• Mechanical heart valve
• Disseminated intravascular coagulation (DIC)
• Thrombotic thrombocytopenic purpura (TTP)
• Hemolytic uremic syndrome (HUS)
• Pre-eclampsia/Eclampsia
• Systemic infections: Malaria, babesiosis, Clostridium
• Vasculitis
 Approach to Anemia
• Hemolysis
• Hereditary hemolysis
– Alteration in hemoglobin results in shorter half-life of RBC and
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chronic anemia
– Examples
• Enzymopathies
– Glucose-6-phosphate dehydrogenase (G6PD) deficiency
• Membranopathies
– Hereditary spherocytosis
• Hemoglobinopathies
– Sickle cell disease
– Thalassemia (α & β minor in adults)
 Approach to Anemia
• Hemolysis
• Immune mediated
– Autoantibodies interact with red blood cells resulting in them being
marked for destruction in either the intravascular or extravascular spaces.
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– Autoantibodies can be subdivided based on their maximum binding

temperature
• Warm Agglutinin: temperature (37°C or 98.6°F)
– Mediated by auto-IgG tagging RBCs for extravascular macrophage destruction in the spleen or
mediating complement C3 fixation for intravascular hemolysis
– Most common type; 65-70% of autoimmune hemolytic anemia
• Cold Agglutinin: temperature (0-4°C or 32-39.2°F)
– Mediated by auto-IgM mediated fixation of compliment to RBCs surface for intravascular
hemolysis
– Less common: ~20-25%
 Approach to Anemia
• Hemolysis
• Immune mediated
• Most cases are idiopathic but etiology should be explored
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– Warm Disease – Cold Disease

• Cancers • Infections
– Lymphomas and – Mycoplasma pneumoniae
lymphoproliferative disorders – Mononucleosis (CMV)
• Connective Tissue diseases • Cancers
– Systemic lupus erythematosus – Lymphomas, Leukemia
• Viral infections – Waldenström's Macroglobulinemia,
• Drugs: (many) procainamide, • Drugs: (many) isoniazid, tetracycline,
methyldopa, interferon hydralazine, quinidine, sulfonamides
 Approach to Anemia
• Hemolysis
• Immune mediated
– Work up
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• MCV may be high to reticulocytosis

• Retic Count > 3%
• ↑ LDH
• ↑ Indirect bilirubin Common lab findings to all
forms of hemolysis
• ↓ Haptoglobin
• Urinary Urobilinogen
• Peripheral smear findings
– Nonimmune-mediated: schistocytes, burr cells, helmet cells, and microspherocytes
– Immune-mediated: spherocytes, acanthocytes, bite cells, or RBC clumping
 Approach to Anemia
• Hemolysis
• Immune mediated
– Work up
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• Hemosiderin, Urine
– Tests for intravascular hemolysis
– During massive intravascular hemolysis haptoglobin can become overwhelmed.
Left over hemoglobin can be taken up in the renal tubules as hemosiderin. This
can be detected in the urine
– Urinalysis will show large blood on dipstick and no RBCs seen on urine microscopy
 Approach to Anemia
• Hemolysis
• Immune mediated
– Work up
MSUCOM IM 650

• Direct Antiglobulin test (DAT) or Direct Coombs test

– Detects the presence of antibody or compliment on the surface of red blood cells
– How the test is done: patients blood is mixed with coombs reagent which is rabbit
or mouse antibodies directed against Auto-IgG or auto-C3. If these autoantibodies
are present patients blood will agglutinate and the test is positive for autoimmune
hemolytic anemia
» If auto-IgG is agglutinated then the testis (+) Warm disease
» If auto-C3 is agglutinated then the testis (+) Cold disease
» Auto-C3 can also be weakly (+) in warm disease with (+) auto-IgG
 Approach to Anemia
• Hemolysis
• Immune mediated
– Treatment
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• Warm antibody
– Treat any underlying cause
– Corticosteroids
» Prednisone 1-1.5/kg/d until hemoglobin stabilized then lower dose x 3-6months
» Response rate f ~82%
– Splenectomy
» Indicated for non-responders to steroids; Not indicated in Cold antibody disease
– Rituximab: monoclonal antibody
– Immunomodulators
» Azathioprine
» Cyclophosphamide
 Approach to Anemia
• Hemolysis
• Immune mediated
– Treatment
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• Cold antibody
– Treatment of underlying cause
– Avoidance of cold (hat, gloves, etc.)
– Rituximab: monoclonal antibody
– Prednisone: less effective
 Approach to Anemia
• When to Transfuse PRBC in Hospitalized Patients?
– Hemodynamically UNSTABLE due to anemia
• Transfuse immediately
– Hemodynamically STABLE
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• Based on hemoglobin number and symptoms

• ICU patients (adult/pediatric) Hgb <7mg/dL
• Postoperative patients: Hgb <8 g/dL (or for *symptoms)
• Stable + Cardiovascular disease: Hgb <8g/dL (or for *symptoms)
– *symptoms (chest pain, orthostatic hypotension or tachycardia unresponsive to fluid
resuscitation, or congestive heart failure).

– One unit of RBC ↑Hgb ~1g/dL or ↑ HCT ~3%

MSUCOM IM 650

Approach to Anemia

The END
 Approach to Anemia
• Work Cited
– Hematology Am Soc Hematol Educ Program. 2012;2012:183-90
– Shirlyn B. McKenzie, PhD. 2010. Clinical Laboratory Hematology - 2nd
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Ed. Upper Saddle River, New Jersey. Pearson Education, Inc.

– Mayo Clin Proc. 2003;78:1274-1280
– Ann Intern Med. 2012;157:49-58.
– N Engl J Med. 1999 Jul 8;341(2):99-109.
– Am Fam Physician. 2009;79(3):203-208
– N Engl J Med 2013;368:149-60
– Clin Med Res. 2006 Sep;4(3):236-41
– Hematol Oncol Clin N Am 26 (2012) 205–230
 Approach to Anemia
• Work Cited
– Gut 2000;46(Suppl IV):iv1–iv5
– The American Journal of Medicine (2008) 121, 943-948
– Am Fam Physician. 2007 Mar 1;75(5):671-678.
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– Hematology Am Soc Hematol Educ Program. 2010;2010:338-47.

– N Engl J Med 2005;352:1011-23.
– Mayo Clin Proc. 2005;80(7):923-936
– Am Fam Physician. 2009;80(4):339-344, 371.
– Am Fam Physician 2004;69:2599-2606.
– N Engl J Med 2015;373:1649-58.
– Med Clin N Am 101 (2017) 263–284
– Med Clin N Am 101 (2017) 319–332
– Med Clin N Am 101 (2017) 297–317