Natural Killer/T-Cell LymphomaIntroduction of Anemia

Ting LiuDepartment of Internal Medicine

2017. 3.

Definition of Anemia

The term of Anemia is functionally defined as an

insufficient RBC mass to adequately deliver

oxygen to peripheral tissues

For practical purposes, any of the three

measures ( Hb, Hct, and RBC ) may be used to

establish the presence of anemia, but the

hemoglobin concentration is often preferred

Anemia is not a disease but a manifestation of

many diseases

NORMAL VALUES FOR RBC

Criteria of Anemia

The criteria depends on the age and gender of

the subjects, as well as their altitude of

residence and race

Men Women Pregnancy

WHO (Hb g/L) <130.0 <120.0 <110.0

China(Hb g/L) <120.0 <110.0 <100.0

The Low Limited of Hb Level in Normal Men and Women of Various Age

80

90

100

110

120

130

140

10 20 30 40 50 60 70

AGE (Years)

HEMOGLOBIN (g/L) Men

Women

The injury of progenitor of erythrocyte:

physical, chemical, biological factors

The lack of hematopoietic factors:

ferritin,vitB12, folic acid,vitB6

The damage of bone marrow tissues:

leukemia, lymphoma,solid tumor infiltrate

Increase of red blood cell destruction & loss:

hereditary and acquied hemolytic anemia

bleeding

Causes and Mechanisms of Anemia

Classification of Anemia

According to the causes and mechanisms of anemia

types:

Decrease of red blood cell production:

AA, IDA, leukemia

Increase of red blood cell destruction:

hemolytic anemia

Acute or chronic blood loss, GI tumor, ulcer,

hypermenorrhea, hemorrhoea

CLASSIFICATION OF ANEMIA（ Accoding to morphology ）

Types MCV( fl ) MCH( pg ) MCHC ( % ) Refer to Diseases

Macrocytic >100 >32 32-35Megaloblastic AnemiaMDSLiver Diseases

Normocytic 80-100 26-32 32-35Acute BleedingAplastic AnemiaHemolytic AnemiaChronic Diseases

Microcytic <80 <26 ≤32IDAThalassemic SyndromeSideroblastic Anemia

This classification provides important cluing information about the possible cause for an anemia.

Normal Red Cells（MCV 80 - 100fL）

Macrocytic Anemia（MCV>100fL）

Macrocytic Anemia (BM)

Macrocytic Anemia

MCV>100 fL

Increased MCV is a normal characteristic of reticulocytes

Abnormal DNA synthesis

Folate, B12 deficiency

Abnormal RBC maturation

MDS, leukemia

Alcohol abuse

Liver disease

Hypothyroidism

Microcytic Anemia（MCV<80fL）

Normal Red Cells（MCV 80 - 100fL）

Microcytic Anemia

MCV<80 fL

Usually hypochromic as well

Reduced iron availability

Iron deficiency

Anemia of chronic disease

Reduced heme synthesis

Lead poisoning

Reduced globin production

Thalassemia, other hemoglobinopathies

Normocytic Anemia with Low Reticulocyte Count

Decreased stimulation of bone marrow Anemia of chronic disease

Chronic renal insufficiency

Metabolic disorders

Isolated decrease in RBC precursors Pure red cell aplastic anemia

Bone marrow damage Fibrosis

Stem cell damage

Infiltration with tumor/infection

Myelodysplasia/sideroblastic anemia

Normocytic Anemia with High Reticulocyte Count

High reticulocyte count may lead to macrocytosis

Hemolysis is the most common reason with

Jaundice, cholelithiasis

Risk of aplastic crisis (Parvovirus B19)

Classification

Hereditary vs. acquired

Extravascular vs. intravascular

Immune vs.non-immune

Bleeding

Mild to moderate elevations (3 to 7%) encountered in myelophthisic anemia

Hematology Inpatient Consults

9%

18%

60%

13%

Macrocytic

Normo/macro High retic

Normocytic low retic

Microcytic

Evaluation of anemia

Clinic Features of Anemia

SYMPTOMS

Fatigue

Headaches

Faintness

Breathlessness

Angina

Intermittent claudicating

Palpitation

Clinic Features of Anemia

SIGNS

Pallor

Tachycardia

Systolic murmur

Cardiac failure

Papilloedema-retinal hemorrhage (rare)

Signs and Symptoms of Anemia

CNS

Debilitating fatigue

Dizziness, vertigo

Depression

Impaired cognitive function

Immune system

Impaired T cell and macrophage function

Cardiorespiratory system

Exertional dyspnoea

Tachycardia, palpitations

Cardiac enlargement, hypertrophy

Increased pulse pressure, systolic ejection murmur

Risk of life-threatening cardiac failure

Gastro-intestinal system

Anorexia

Nausea

Genital tract

Menstrual problems

Loss of libido

Vascular system

Low skin temperature

Pallor of skin, mucous membranes and conjunctivae

Factors Influencing Symptoms of Anemia

The rapidity of onset and severity of anemia

The ability of patients to make cardiovascular

compensations

Age: old person with severe symptoms

Sex: female with severe symptoms

Diagnosis

History: Nutrition,Reproduction,Bleeding,Drugs,

Occupation, Family History, Underlying

disease

Physical Examination: Skin, Eye ground, Mouth,

Heart, Abdomen, Lymph nodes, Nervous System

RBC Indices: Blood Smear, CBC, Ret. MCV, MCHC

History Taking in Anemia

What is the complaint

Duration

Age of onset

History of bleeding disorder

Family history of bleeding disorder

Family history of anemia

History of recent bleed

History of menorrhagia

History Taking in Anemia

Is anemia episodic

History of drug intake

Dietary habits

History of worm infestation

Abdominal complaints

History of fever

History of swelling in the neck/axila/groin

Examination of Anemic Patient

Demeanor

Dyspnoea

Pallor

Jaundice

Glositis/stomatitis

Shape of skull

Lymph nodes palpable

Hepatomegaly

Splenomegaly

Leg ulcers

Who is patient? Why?

Caspar Netscher

“spoon-shaped nails”;

Koilonychia

Specific signs in IDA

“Beefy red” tongue

Specific signs in Megaloblastic Anemia

“mirror tongue”

Specific signs in megaloblastic anemia

Jaundice (Scleral icterus)

Specific signs in hemolytic anemia

Specific Signs in thalassaemia

Lab. Investigations

Begin with

Complete blood count (CBC)

Peripheral blood smears

Mean corpuscular volume (MCV)

Reticulocyte count (Retic count)

Special Tests

Bone marrow smear, biopsy

FCM, Immunology

Genetics…

Shape Abnormalities of Erythrocytes

Terminology Description Condition

Target cells Central hemoglobin; target-shaped Liver disease; thalassemia:

Abnormal Hgb; iron deficiency

Echinocyte Short spicules, equally-spaced Uremia, hypokalemia, artifact

Acanthocyte Spiculated, irregular Liver disease (alcohol),

Post-splenectomy

Spherocyte Spherical, no central pallor HS, Immune hemolytic anemia

Schistocyte Fragmented RBC, helmet cells MAHA, burns

Ovalocyte Oval/elliptical shaped Hereditary elliptocytosis,

Megaloblastic anemia

Sickle cell bipolar spiculated shape Hgb S-containing

“banana” shaped hemoglobinopathy

Teardrop cell single elongated extremity Myelophthistic changes

Bite cells Irregular gap in membrane G6PD deficiency

Target cell

Liver disease, postsplenectomy, thalassemia,

hemoglobin disease StomatocyteHereditary stomatocytosis,

immunohemolytic anemia.

Ovalocyte (elliptocyte)

Hereditary elliptocytosis

Sickle cell (drepanocyte)

Specific in Sickle Cell Anemia

Burr cell (echinocyte) Uremia, bleeding ulcers, gastric carcinoma

SpherocyteHereditary spherocytosis, immunohemolytic anemia.

Heinz Body

G-6-PD, drug-induced oxidant hemolysis

Bite cell

G-6-PD, drug-induced oxidant hemolysis.

Spherocytes: Autoimmune Hemolytic Anemia

Diagnosis Approach

Step One:

Is there a anemia? and how is the severity?

Step Two:

What’s kind of anemia?

Step Three:

What’s reason caused anemia?

Severity of Anemia

Severity Hb（g/L） Symptomes

Mild Low limit--91 Mild

Moderate 90--61 Exertional dyspnoea

Tachycardia

Severe 60--31 DyspneaPalpitation

Very Severe ≤30 Congestive heart failure

Treatment

The most important is to treat the underlying

disease which caused anemia

Treatment for anemia

RBC product transfusion, Hb≤60g/L

Supplement: EPO, folate acid, iron,

VitB12

Stem cell transplantation: AA, PNH, MDS,

Leukemia

Immunosuppressive therapy: AIHA, AA

Operation: HS, AIHA

Learn from yesterday, live for today, hope for tomorrow. The important thing is to not stop questioning.

Albert Einstein