Diagnostic Approach to Anemia Prof. Dr. Teoman SOYSAL

Definition of anemia Anemia: A reduction in red cell mass O2-carrying capacity of blood It is expressed in terms of reduction in the concentration of Hb (or RBC or Hct%) compared to values obtained from a reference population. (2 SD below normal)

Reference values (adults) (I) Parameter Female Male RBC (x1012/L) 4.8+0.6 5.4+0.9 Hb (g/dL) 14+2 16+2 Htc (%) 42+5 47+5

Definition of anemia Hb level of a patient which is below the normal ranges of that age and sex. For adults: WHO criteria define anemia as hemoglobin <12 g/dL in women and <13 g/dL in men But: The reference values for red cells ,Hb or Hct may difer according to sex/age Race Altitude Socioeconomical changes Study/reference etc

BEUTLER andWAALEN BLOOD, 1 MARCH 2006 VOLUME 107, NUMBER 5

Age and blood count changes WBC Neutrophyls Eos. Baso Lenfo Mono Hb 12 mo 6-17.5 1.5-8.5 0.05-0.7 0-0.20 4-10.5 0.05-1.1 11.1-14.1 4 y 5.5-15 0.02-0.65 2-8 0-0.8 11.2-14.3 6 y 5-14.5 1.5-8 0-0.65 1.5-7 11.4-14.5 10 y 4.5-13 1.8-8 0-0.60 1.5-6.5 11.8-15 21 y 4.5-11 1.8-7.7 0-0.45 1-4.8 E: 16 K: 14 WBC: x10E3/mm3 Hb:g/dL

Reference values (II) Ret (% / n) 0.5-2.5 / 50-100x109/L MCV (fl) 90+7 MCH (pg) 29+2 MCHc (g/dL) 34+2 RDW (%) 11.5-14.5

RBC % RBC % 50 50 fl fl 100 100 200 200

RBC % RDW: Red cell distribution width 50 fl 100 200

RBC % 50 fl 100 200

Reticulocyte Normal Ranges Male: % 0.8 - 2.5 Female: % 0.8 - 4.1 Increased counts Hemolysis Acute bleeding Response to treatment Normal Ranges Male: % 0.8 - 2.5 Female: % 0.8 - 4.1 Corrected Rtc: Patient Hb/Normal Hb x Rtc % Reticulocytosis: > 100.000 /mm3

Diagnosis and investigation: Is the patient anemic? What is the type of anemia? What is the cause of anemia?

Classification of anemia Morphologic Normocytic: MCV= 80-100fL Macrocytic: MCV > 100 fL Microcytic : MCV < 80 fL Pathogenic (underlying mechanism) Blood loss (bleeding) Decreased RBC production Increased RBC destruction/pooling

!!!!! Plasma volume changes have to be considered before determining a diagnosis of anemia . Volume contraction:Underestimation of anemia Volume overload: Underestimation of Hb level

Volume changes/acute bleeding and anemia 1 2 3 4 5 Increased plasma volume Hct: Low Dehydration Hct:Increased normal Hct:Normal Acute blood loss(early) Hct:unchanged Chronic anemia Hct: Low

!!!!! A normal Hb in a patient in whom an elevated Hb level is expected may represent anemia .(eg:COPD + Hb:N)

!!!!!! Low Hb, high RBC, low MCV,normal RDW Hb: 10 g/dL (anemia) Different red cell measures of a patient may give discordant values in special conditions. eg:Thalassemia trait Low Hb, high RBC, low MCV,normal RDW Hb: 10 g/dL (anemia) RBC: 6.5 million/mm3 (erythrocytosis) MVC : 65 fL RDW: Normal

!!!! Anemia is rarely a disease by itself, It is mostly a manifestation or consequence of an underlying (genetic or acquired) disease. The finding of anemia has to start attempts to disclose an underlying disease . What is the cause of anemia ?

Normocytic Anemias Acute post-hemorrhagic anemia Hemolytic anemia (except thalassemia and some other Hb disorders) Aplastic anemia Pure red cell aplasia Bone marrow infiltration Endocrin diseases Renal failure Liver disease Chronic disease anemia Protein malnutrition Hypovitaminosis C

Microcytic anemias Iron deficiency anemia Thalassemia Sideroblastic anemia Lead poisoning Anemia of chronic diseases (some cases)

Macrocytic anemias Megaloblastic Oval macrocytes Non-megaloblastic

Megaloblastic Macrocytic Anemias Vit B12 deficiency Folic acid deficiency Other.

Non-megaloblastic Macrocytic Anemias Anemia of acute bleeding Hemolytic anemias Leukemias (esp: acute) Myelodysplastic syndromes Liver disease Aplastic anemia Diseases infiltrative to the bone marrow Alcoholism Hypothyroidism Scurvy

Pathogenic classification (Causes of anemia) Relative (increased plasma volume) Decreased RBC production Blood loss Anemia due to acute bleeding Increased RBC destruction

Pathogenic classification (Causes of anemia) Decreased RBC production Decreased Hb production Defective DNA synthesis Stem cell defects Pluripotent stem cell Erythroid stem cell(progenitors) Other less defined reasons Blood loss Anemia due to acute bleeding Increased RBC destruction Relative(increased plasma volume)

Decreased Hb production Iron deficiency anemia Thalassemia Sideroblastic anemia Lead poisoning

Defective DNA synthesis Vit B12 deficiency Folic acid deficiency Other.

Pluripotent stem cell defects Aplastic anemia Leukemia or myelodysplastic syndromes Defective erythroid stem cell Pure red cell aplasia Anemia of chronic renal failure Endocrin disease anemia Congenital dyserythropoetic anemias

Decreased RBC production due to multipl or undefined mechanisms Anemia of chronic diseases Bone marrow infiltration Anemia due to nutritional defects

Anemias caused by increased RBC destruction (hemolytic anemias) Can be classified as; Hemolysis due to intracorpuscular defects Hemolysis due to extracorpuscular defects Or Hereditary hemolytic diseases Acquired hem. diseases Intravascular hemolysis Extravascular hemolysis etc.

A Very Simple Classification of Hemolytic Anemias Intracorpuscular 1- Abnormalities of RBC interior a. Enzyme defects b. Hemoglobinopathies & Thalassemia M 2-RBC membrane abnormalities a. Hereditary spherocytosis, elliptocytosis etc b. Paroxysmal nocturnal hemoglobinuria c. Spur cell anemia 3- Extrinsic factors a. Hypersplenism b. Antibody : immune hemolysis c. Traumatic & Microangiopathic hemolysis d. Infections , toxins , etc Hereditary Extracorpuscular Acquired

Is the patient anemic ? RBC count HB level Hct level Volume status

What is the type of anemia? History and physical exam. RBC,HB,Hct , MCV, MCH,RDW Red cell morphology ( peripheral smear) Reticulocyte count Incresed ? Other Lab. investigations

Lab. investigation of anemia(1) WBC count and differential Platelet count and morphology ESR Biochemistry, special tests and others Bone marrow exam.(only when indicated)

Lab. investigation of anemia(2) Serum values of Iron TIBC Ferritin Bilirubins Proteins / electrophoresis LDH Vit B12 and /or Folic acid (None of these tests are routine screening tests)

Lab. Investigation of Anemia(3) Liver, renal, endocrin functional tests Urinalysis Hemosiderin Occult GIS bleeding / parasites etc (tests should be chosen individually-do not order routinly ) Tests to diagnose the type of hemolytic anemia If hemolytic anemia is considered

Normocytic anemia Retic. count normal/low Secondary anemia Renal, Hepatic, Endocrin , Chronic disease (Normal marrow) Hypoplastic Marrow AA, pure red cell aplasia Bone marrow infiltrative diseases Leukemia , Myelofibrosis Metastatic disease Dysplastic marrow: MDS Retic. count increased Response to treatment Hemolytic anemia Acute bleeding No sign of secondary anemia Other signs of bone marrow disease may be +

Microcytic anemia Serum iron high Serum iron normal /high Bone marrow iron content and sideroblasts Sideroblastic anemia Serum iron normal /high Hemoglobin studies Thalassemia , HbC , others Serum iron decreased Ferritin low Iron deficiency Ferritin: Normal or increased Anemia of chronic diseases

Myelodysplastic syndrome Bone marrow infiltration Macrocytic anemia Peripheral smear Retic. count Retic. count Increased Hemolysis Acute bleeding Retic. count Normal/ decreased Megaloblastic Deficiencies of VitB12 ,Folic acid or other causes Non-Megaloblastic Liver diseases Myelodysplastic syndrome Bone marrow infiltration Acute leukemia Aplastic Anemia, Alcoholism Hypothyoidism etc

Case I 38 years old, ♀ Tiredness, hair loss, nail changes

Microcytic anemia Serum iron high Serum iron normal /high Bone marrow iron content and sideroblasts Sideroblastic anemia Serum iron normal /high Hemoglobin studies Thalassemia , HbC , others Serum iron decreased Ferritin low Iron deficiency Ferritin: Normal or increased Anemia of chronic diseases

Microcytic anemias May change None Iron deficiency Normal N Diagnosis (type of anemia) MCV RDW Serum Iron Iron binding capacity Ferritin ESR/acute phase signs Hemogl. changes Iron deficiency May change None Thalassemia N Normal May be diagnostic Chronic disease anemia Elevated RBC count: Thalassemia minor >Iron deficiency

Case I 38 years old, ♀ Tiredness, hair loss, nail changes

What is your diagnosis? What is the next step? Prove iron deficiency Serum iron, TIBC, Ferritin Find out the cause of iron deficiency Chronic blood loss / excessive need-inadequate intake Menstruel bleeding, Pregnancy GI bleeding Inadequate intake or malabsorbtion etc Treat both iron deficiency and the cause

Case II 26 y o Slight symptoms Decreased excercise tolerence Paleness Long history of being anemic on routine CBC’s ,non responsive to iron RBC:5.500.000/mm3 Hb: 10 g/dL MCV: 60 fL RDW: 14.3 Retic: %2 WBC: 5000/mm3 Plt: 200.000/mm3 Name the blood picture. Further questions to ask to the patient? Further tests to do ? Ferritin : slightly elevated HbA2: slightly elevated, Hb F: normal Final Diagnosis ?

Case III WBC: 2.300/µl Hgb: 11 g/dL Hct: %33 MCV: 122 fL MCH: 39pg 70 y o, male Fatigue, weakness Sore tongue, poor taste sensation Papill. atrophy-beefy tongue Paresthesias Loss of position sense, ataxia Decreased deep tendon reflexes 3 units of red cell transfusion made before admission WBC: 2.300/µl Hgb: 11 g/dL Hct: %33 MCV: 122 fL MCH: 39pg MCHC: %34 RDW: 30.5 Plt: 100.000/µl Retic: 1% Macrocytosis Anisocytosis, neutrophyl hypersegmentation, oval macrocytes

Retic. count Increased Macrocytic anemia Peripheral smear Retic. count Retic. count Increased Hemolysis Acute bleeding Retic. count Normal/ decreased Megaloblastic Deficiencies of VitB12 ,Folic acid or other causes Non-Megaloblastic Liver diseases Myelodysplastic syndrome Bone marrow infiltration Acute leukemia Aplastic Anemia, Alcoholism Hypothyoidism etc

What is the blood picture ? (The type of the disorder) What is your diagnosis? Why?

Normocytic anemia Retic. count normal/low Secondary anemia Renal, Hepatic, Endocrin , Chronic disease (Normal marrow) Hypoplastic Marrow AA, pure red cell aplasia Bone marrow infiltrative diseases Leukemia , Myelofibrosis Metastatic disease Dysplastic marrow: MDS Retic. count increased Response to treatment Hemolytic anemia Acute bleeding No sign of secondary anemia Other signs of bone marrow disease may be +

? ? ? 60 y o Normocytic anemia Reticulocytes: 1% Hoarse voice Lethargy Hair loss Dry skin Weight gain Poor memory Bradycardia Pale, pruritus, hypertension Urea + creatinin elevated Symmetric polyarthritis Morning stiffness Sc nodules ? ? ?

Case IV 65 y o , male One month history of fever, cough and hemoptysis ESR: 80mm/h; high CRP Sputum + for TBC bacteria; chest x-ray shows right apical infiltrate Normocytic anemia, MCV normal, RDW ↑, What is the type of anemia? What is the diagnosis? This case could also present as a microcytic anemia .What would you expect from the iron studies in that situation? Low iron, Low TIBC, High Ferritin Retic.: 2%

Normocytic anemia How to decide the next step? History PE Smear Retic. count normal/low Secondary anemia Renal, Hepatic, Endocrin , Chronic disease (Normal marrow) Hypoplastic Marrow AA, pure red cell aplasia Bone marrow infiltrative diseases Leukemia , Myelofibrosis Metastatic disease Dysplastic marrow: MDS Retic. count increased Response to treatment Hemolytic anemia How to decide the next step? History PE Smear Other tests Acute bleeding No sign of secondary anemia Other signs of bone marrow disease

Case IX 67 y o, male Anemia symptoms Severe bone pain CBC Normocytic anemia What is your possible diagnosis? What is the next step? ESR:>100mm/h Hypercalcemia Hyperglobulinemia Renal failure

Morphologic abnormalities in hemolytic anemias Sickle cell: Target cels: Schistocytes: Agglutination: Heinz bodies: Sickle cell anemia Thalassemia, HbC disease, liver disease, splenectomy Microangiopathic hem anemia, uremia, DIC, malignant hypertesion, eclampsia, disseminated vasculitis or malignancy, Cold agglutinin disease Unstable Hb, G6PD deficiency and oxidant stress

Special Lab. Examinations Coombs antiglobulin test - immune hemolysis Osmotic fragility test - spherocytosis Autohemolysis- G6PD,PK, spherocytosis Red cell enzyme assays- RBC enzyme defects Membrane protein analysis- membrane defects Red cell sickling, HbS- sickle cell anemia Hemoglobin electrophoresis and HbA2, Hb F , HHb,etc - Hemoglobinopathies and thalassemias HAM and sucrose lysis tests and GPI-linked protein analysis by flow cytometry- PNH Oxygen dissociation curve- High oxygen affinity Hb

Case V 18 y o , male Weakness, paleness, slight icterus, splenomegaly, bile stones Family history + Normal RBC WBC: 5600/µl Hgb: 9,6 g/dL MCHC: %37 Plt: 300.000/µl Retic: %9 ? spherocyte Ind Bil: slightly elevated LDH: elevated Haptoglobin : low Red cell osmotic fragility increased ?

Case VI 38 y o Cough , fever WBC: 12.000/µl Hgb: 11 g/dL Hct: 22 % MCV: 130 MCH: 40 MCHC: 36 RDW:28 Plt: 160.000/µl

Case VII CBC WBC: 33.000/mm3 Hb: 7 g/dL Retic: 1% Plt: 12.000/mm3 34 y o, male 2-3 weeks history of Decreased exercise capacity Paleness Headache, sore throat 2 days history of Cough and fever Red spots on the skin CBC WBC: 33.000/mm3 Hb: 7 g/dL Retic: 1% Plt: 12.000/mm3

Case IX 60 y o, female Sudden onset CBC Hb: 8 g/dL WBC: 10.000/mm3 Pallor, palpitation Slight scleral icterus splenomegaly CBC Hb: 8 g/dL WBC: 10.000/mm3 Plt: 450.000/mm3 Retic: 10% What is your diagnosis? What is your next step? Indirect bilirubin: high LDH: high Haptoglobin: low D/I: Coombs +

Case X 70 y o , male +One month history of WBC: 8000/mm3 Hb: 8 g/dL Under examination for prostat enlargement +One month history of Bone pain Symptoms of anemia WBC: 8000/mm3 Hb: 8 g/dL MCV: 88 fL RDW: 14 Retic: 2% Plt: 220.000/mm3

Morphologic abnormalities in hemolytic anemias Polychromasia: Spherocyte : Elliptocytes: Stomatocytes: Acanthocytes: Echinocytes: Reticulocytes Hereditary spherocytosis, immune hem. anemia, burns, chemical injury to RBC Hereditary ovalocytosis, Hereditary stomatocytosis, alcoholism Spur cell anemia with liver disease, abetalipoproteinemia Pyruvate kinase deficiency, uremia